Towards a Research Tradition in Gestalt Therapy [1 ed.] 9781443857345, 9781443807340

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Towards a Research Tradition in Gestalt Therapy

Towards a Research Tradition in Gestalt Therapy Jan Roubal (Executive Editor) Philip Brownell, Gianni Francesetti, Joseph Melnick and Jelena Zeleskov-Djoric (Contributing Editors) Philip Brownell (Series Editor)

Towards a Research Tradition in Gestalt Therapy Edited by

Jan Roubal

Towards a Research Tradition in Gestalt Therapy Series: The World of Contemporary Gestalt Therapy Edited by Jan Roubal This book first published 2016 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2016 by Jan Roubal and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-0734-6 ISBN (13): 978-1-4438-0734-0

TABLE OF CONTENTS

Preface ...................................................................................................... viii Leslie Greenberg Introduction ................................................................................................. 1 Bridging Practice and Research in Gestalt Therapy Jan Roubal, Gianni Francesetti, Philip Brownell, Joseph Melnick, Jelena Zeleskov-Djoric Part I: Theoretical Ground Chapter One ............................................................................................... 18 Warrant, Research, and the Practice of Gestalt Therapy Philip Brownell Chapter Two .............................................................................................. 35 Research in Gestalt Therapy: a Way of Developing our Model Margherita Spagnuolo Lobb Chapter Three ............................................................................................ 45 Critical Realism as an Ontology for Gestalt Therapy Research Alan Meara Chapter Four .............................................................................................. 64 Research from a Relational Gestalt Therapy Perspective Ken Evans Chapter Five .............................................................................................. 79 Looking Back: Reflections on Research Joseph Melnick

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Part II: Introducing Methods Chapter Six ................................................................................................ 92 An Adventure in Grounded Theory Method: Discovering a Pattern in the Flow of a Therapy Process Jan Roubal, Tomáš ěiháþek Chapter Seven.......................................................................................... 116 A Guide to Conducting Case-Based, Time-Series Research in Gestalt Therapy: Integrating Research and Practice in a Clinical Setting Albert J. Wong, Michael R. Nash, Jeffery J. Borckardt, Michael T. Finn Chapter Eight ........................................................................................... 130 The Construction of a Gestalt-Coherent Outcome Measure: Polarities and the Polarization-Integration Process Pablo Herrera Salinas Chapter Nine............................................................................................ 151 Stress and Organizational Well-Being: A Gestalt Organizational Consulting Method Supported by Grounded Theory Margherita Spagnuolo Lobb Chapter Ten ............................................................................................. 167 Strategic Research: Using CORE to Establish an Evidence Base for Gestalt Therapy Christine Stevens, Katy Wakelin Chapter Eleven ........................................................................................ 178 A Gestalt Process/Action Based Theory of Depression and Test Construction Validation Ida Babakhanyan, Todd Burley Chapter Twelve ....................................................................................... 203 An Invitation to Engage in Relational-Centred Phenomenological Research Linda Finlay, Ken Evans Chapter Thirteen ...................................................................................... 223 A Phenomenology-Based Way to Assess Change in Psychotherapy Rolf Sandell

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Part III: Projects for Inspiration Chapter Fourteen ..................................................................................... 244 Measurement of Interpersonal Power Relations between the Client and the Therapist in Gestalt Therapy Session using Metaphor Laima Sapezinskiene, Julius Burkauskas, Kaylyn Kretschmer Chapter Fifteen ........................................................................................ 271 Parallel Processes in Counseling for Schools Liv Heidi Mjelve Chapter Sixteen ....................................................................................... 290 Action Research: A Case of Writing as Inquiry Rob Farrands Chapter Seventeen ................................................................................... 314 Emerging Beauty beyond Freedom: Gestalt Therapy Approach with Offenders using CORE and CHAP Instruments Jelena Zeleskov Djoric, Michele Cannavo, Janko Medjedovic Chapter Eighteen ..................................................................................... 335 Comparative Naturalistic Study on Outpatient Psychotherapeutic Treatments including Gestalt Therapy Peter Schulthess, Volker Tschuschke, Margit Koemeda-Lutz, Agnes von Wyl, Aureliano Crameri Chapter Nineteen ..................................................................................... 356 Organizational Well-being and Vitality of the Working Group: A Qualitative Study on a Business Consultation Model Floriana Romano Contributors ............................................................................................. 370

PREFACE LESLIE GREENBERG

To psychotherapists, the word “research” is a highly emotionally charged term. Therapists of all orientation have very rapid and strong gut reactions to the term. To Gestalt therapists the term often has a very negative connotation implying, among other things, oppression, violation and distortion. To therapists of other dominant orientations, like cognitive behavior therapy, it has the opposite connotation. It has the ring of true gold, and is experienced as something that is valued and validating. Such a strong polarity! Imagine we could replace the term “research” with the term “investigation”, defined by the Oxford dictionary as: “The action of investigating something or someone; formal or systematic examination.” This puts the processes involved in investigation of examination, and of searching again and again (re-search), in a different context. For me it evokes notions of discovery; “to seek to find and not to yield”, and the narrative of a quest. Now investigation or research can be seen as exciting, desirable and possibly even heroic. To explore, discover and become aware are valued processes in the Gestalt approach as opposed to holding beliefs dogmatically without question. Beliefs that are held as absolute truths are a trap. This is especially relevant in relation to the development of theories of therapy and about therapy itself. Openness and investigation in pursuit of understanding, rather than dogma, are crucial for development, both in therapy and about therapy. There has been a welcome growth of interest in research in the Gestalt community in the last few years. Successful research conferences have been held in Rome in 2014, and two research meetings have been held at Cape Cod in 2013 and 2015 and more are planned. This volume is most timely in promoting this trend towards more rigorous investigation of Gestalt therapy. This is a most needed development. The survival of Gestalt therapy as a legitimate psychotherapeutic treatment modality depends upon developing a base of evidence. Gestalt therapists however are usually unimpressed with research methods that objectify clients, and fail to address the dialogical dimension

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of Gestalt therapy. Outcome research and the statistics on which they rely are viewed skeptically, often because they are unfamiliar and feared, mainly because they disempower. Dogmatic beliefs against the value of objectifying research, based often on this fear, develop in reaction to the pressures of positivist dogma. I say this so strongly, based on my own experience of having initially felt all these things myself. This volume attempts to overcome this polarity, and the dogmatic attitudes accompanying either side of this polarity, to promote inquiry and investigation to aid in the development and recognition of Gestalt therapy as an effective and recognized approach. It provides a full array of possible ways of engaging in research. Hopefully it will encourage Gestalt therapists to pose questions such as: Does Gestalt therapy work (outcome research)? How does it work (process research)? With whom is it effective (research on individual differences)? And when does what work and how (change process research)? Gestalt therapists need to acknowledge that the professional world in which we now live has clearly become more outcome oriented, evidence based, pragmatic and socio-economically driven than ever before. The evidence-based movement which began in medicine has spread to psychotherapy in all countries. As Brownell, in this volume notes, funders and consumers of psychotherapy alike simply demand that providers, of all sorts of treatments, offer something that works, and provide credible evidence to this effect. Public policy, best practice, and treatment guidelines based on empirical evidence increasingly impacts the licensing of providers and the provision of continuing education. Research can help Gestalt therapists demonstrate the efficacy of their approach (usually via outcome research), and to improve their understanding of which dimensions and aspects create change in psychotherapy (process research and qualitative research). Research can also help build models to support and enhance clinical models. In 1975, when I graduated from my Gestalt training, I proposed two research projects to my institute to investigate if and how change took place in our training, but the zeitgeist did not support research and certainly not anything that went beyond asking people about their experience (qualitative research). To try to describe or measure anything (quantitative research) was seen as antithetical to Gestalt values. It is important for Gestalt therapists to rigorously review their treatment cases in order to determine what the underlying mechanisms of Gestalt therapy are, how to improve their own treatment success with Gestalt therapy, and when, how, and under what circumstances Gestalt therapy works. There is a growing sentiment in the setting of guidelines

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for treatment that there is not a lot of credible evidence that any one therapy is significantly superior to any other, at least for depression, and possibly for most disorders. Even the usefulness of disorder specific treatment is under review. Hopefully this will move the field toward process oriented evidence based therapy and the study of processes that lead to change. Gestalt, which is process oriented, could fare well in studying how people change, and the use of multiple single cases designs to demonstrate both efficacy and processes of change would fit with practice based research. In addition, the adoption of a critical realist epistemology, proposed by a number of the authors in this volume, would lessen the divide between proponents of phenomenological and empiricist approaches. Critical realism supports the use of empirical research methods by recognizing that there is something real out there but that our descriptions of it are constructions - ones that can move in successive approximations closer to capturing some of the features of reality but will never be able to describe things as fully knowable. This is so whether one engages in qualitative or quantitative methods. In my view the polarity between qualitative and quantitative in the field sets up a false dichotomy, and the split between these methods, as an author of this volume points out, simply becomes a distraction. In investigating a phenomenon one needs to use all methods that help you describe, understand, explain and possibly predict whatever one is studying. A Gestalt therapist should not get stuck in polarities between qualitative and quantitative, between positivism and post-modern social constructionism or with some forms of research being inherently Gestalt friendly and others not. Different types of research are best suited for differing kinds of purposes, and all of them are appropriate to support Gestalt therapy. So, ultimately, research needs to be done in a manner that does not deny complexity, nor the spontaneity of the psychotherapist’s work, but also does capture the reliable regularities that can and do occur across people and across psychotherapy sessions. I am sure this book will help promote such efforts. Kudos to the editors for pulling together this important book Towards a Research Tradition in Gestalt Therapy. Toronto, April 2016

INTRODUCTION BRIDGING PRACTICE AND RESEARCH IN GESTALT THERAPY JAN ROUBAL, GIANNI FRANCESETTI, PHILIP BROWNELL, JOSEPH MELNICK, JELENA ZELESKOV-DJORIC1

This book offers another step forward in establishing a research tradition in our approach. For quite a while there has been a growing awareness of the need for research in the Gestalt community. Gradually, the energy for research activities became mobilized and we are now in the “action” phase. This book is part of a larger active movement in Gestalt therapy, which strives to get Gestalt therapy clinically and academically well established and recognized. As the title suggests, the book captures the actual phase of the process that we are in. We are striving for high research standards that are meaningful for practice, and this book helps clarify our current position in our quest for these. We would like to express our appreciation to the authors, who enthusiastically crafted their chapters for this book, took the risk to become visible with their research activities and used the chance to learn both from the process of writing and from the feedback of their readers. We hope that their courage will inspire other Gestalt practitioner1

These five authors became editors of this book after being organizers of the Cape Cod research conference 2013 and Rome research seminar 2014, which both together included presentations that underset most of the chapters of this book. During the process of the book creation they distributed the tasks and so Jan Roubal became the executive editor; Phil Brownell became series editor; Joe Melnick, Gianni Francesetti and Jelena Zeleskov-Djoric became contributing editors.

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researchers to use their naturally active and creative experimental approach within the field of psychotherapy research and that they too will not hesitate to present their research activities to the community. Indeed, as Gestalt therapists we have a certain predisposition to become researchers. In our daily psychotherapy practice we carefully explore the phenomena of the psychotherapy process and we are constantly evaluating the effect of our work. Then we flexibly adjust our approach according to our findings. If we understand research as systematic curiosity, we can recognize ourselves as being very good at being curious about raising awareness and experimenting with new possibilities. What we need to develop further is the systematic part of research. In our approach there is a historical legacy favouring the spontaneity of the here and now experience over that of systematic conceptual thinking. However, we need both these polarities, because they support each other in their mutual figure and ground dynamics, which enables a bridge between practice and research in our approach.

Motivation to research Why do we need to develop a research tradition? What could be our motivation? First of all, there are clear benefits for a practitioner to be involved in a research process. Using research we start to understand our work in a new way, we allow new insights to come into awareness. Research provides us with a clearer understanding of our work and allows us to describe it in more detail and in a more informed way. This leads to the development of both an individual working approach and an overall global Gestalt approach to theory and practice. Another motivation is the awareness of a risk of being excluded from future developments in psychotherapy. Psychotherapy is rapidly developing through research and publications in scientific journals, where psychotherapists try to describe what they are doing and what they understand about the therapeutic process. If we miss the chance to participate in this dialogue and to belong to this community, we risk becoming more and more isolated. In many countries there is already a crisis concerning Gestalt therapy. In some, insurance companies do not recognize Gestalt therapy as an established method; in some others Gestalt therapy may even have a doubtful reputation as a clinical approach. So, there is the real risk that Gestalt therapy will become more and more isolated. And as we know, an isolated organism cannot live and grow. Growth happens at the contact boundary. The movement to establish a research tradition in Gestalt therapy is a movement towards the contact

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boundary of our community. Our intentionality is to support Gestalt therapists to enter into increasing contact with the wider social and scientific field. Today, research is a way of existing at the contact boundary within the community of psychotherapists. There is yet another reason for our motivation: the richness of our approach. We can be proud of or even be in love with our theory and practice. And at the same time we may feel both satisfaction and some disappointment when we see that many of the actual developments in psychotherapy, in psychotherapy research and in neurosciences are confirming or developing concepts that have been cornerstones of our approach for sixty years. We have given and we have a lot to give to psychotherapy as well as to the wider world in terms of understanding human suffering, social analysis, political vision. We are and can be proud of our approach. But to be proud does not mean to be self-sufficient. No organism is self-sufficient. In this regard we have to be able to balance our pride in knowing how good our method can be, with the humility of belonging to this actual world. If we want to be recognized by the world we have to be citizens of this world. Citizen is a word etymologically meaning “to be rooted on a land and belong to a group”. To be humble literally means to be close to “humus”, to the land. In order to be rooted we need to be humble. In order to belong we have to understand and to speak the language of the community that we want to belong to, we have to be able to describe what we are doing in the same way as the others do, we have to be able to speak the language that the psychotherapy community speaks. Gestalt therapy’s language has some elements of a dialect. Dialects are important, interesting and cherish history, understanding and tradition, but often do not survive the world’s changes. We need to be aware of this and open ourselves to communicating in the common language of psychotherapy and research in order to survive the changes today.

The rise of interest in research among Gestalt therapists Gestalt therapists worldwide have awakened and are moving towards the creation of a research tradition for Gestalt therapy, but it was not always so. For years research was disdained as being positivist and too rigidly simplistic to be compatible with a Gestalt therapy ethos. While the larger fields of clinical psychology and psychotherapy moved relentlessly and increasingly towards an evidence-based practice, Gestalt therapy as a field did not. Occasionally a research project appeared in the literature, but this was more a random event than part of a movement.

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Over the past few years there have been emerging signs of the tensions and the drift that could leave Gestalt therapy disadvantaged and sidelined. For example, in Germany Gestalt therapists were left out when the government sanctioned cognitive behavioural therapists but not Gestalt therapy and other humanistic experiential therapies. This happened due to the extensive research tradition in the cognitive behavioural therapy modality. It became a warning shot across the bow of Gestalt therapy world wide. A shift began to occur when in many European countries psychotherapists began to need a Master's Degree to practice. Many also began to pursue Ph.Ds. As a result they were required to undertake research. They began to be trained in quantitative and qualitative approaches and slowly began to publish. When we call for the establishment of a research tradition, it must be said that we are not at the very beginning. Research in Gestalt therapy is relatively young, but it is not a newborn baby anymore. Besides scattered journal articles and book chapters there are also whole books focused either entirely or partially on research (e.g., Barber, 2006; Strümpfel, 2006; Brownell, 2008), Gestalt therapists interested in research have also started to gather at research conferences (for a recent review of research in Gestalt therapy see Brownell, 2016). We can possibly say that research in Gestalt therapy is in its adolescence now. An adolescent does not know clearly who s/he is, and is searching for a clear identity. Her/his body does not have a coherent shape and does not coordinate all the different parts well. S/he sometimes has a tendency to polarize and simplify in order to confirm her/his own identity. On the other hand, s/he has a lot of energy, a lot of ideas, a lot of potential and ambition. Such adolescent processes resemble today´s Gestalt therapy research movement. This book aims to support Gestalt therapy research in its adolescent period and to support the huge potential of thousands of Gestalt practitioners using our approach in many countries and in many different contexts. This book itself is a risky “adolescent” endeavour. The chapters have different weak points and it would not be easy for them to fulfill really high academic standards. However, we decided not to allow ourselves to become discouraged by overly high demands. We believe it is worth making active steps and to risk being visible. We are on the way and the book reflects our current position. For these reasons the book is quite inclusive and gives voice to different perspectives, which can even offer competing arguments. We hope that the inner dynamics between chapters can foster dialogue and development. It is a part of our “adolescence” that we explore our “preferences” to figure out to which philosophies we are

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attracted. It is a part of the developmental phase in which we find ourselves and any given gestalt practitioner-researcher might wonder, “Who am I?". The methods of research are dependent on the kind of philosophy of science a person adopts, and that relates to ontology and epistemology. It may be that as a whole field we will never come to one position. What is important is that Gestalt therapy provides a space for such a debate and also for a practical research activity. There is a concrete example that demonstrates how the potential of “adolescent” energy can be released and what resonance it could have in the Gestalt therapy community. There exists a project that is focused on developing a fidelity scale for Gestalt therapy (Fogarty, 2015). Its creation presents an essential step in establishing concrete foundations for Gestalt therapy research. Treatment Fidelity rater scales indicate the extent to which a therapeutic treatment has been implemented as intended. The Treatment Fidelity concept operationalizes the theoretical basis of a treatment orientation by describing the key therapist behaviours that both represent the orientation, and distinguish that orientation from others. Without an adequate Treatment Fidelity procedure, it is impossible to know whether the results reflect the intended methodology (i.e., treatment as designed) or the implemented intervention (i.e., treatment as actually delivered) or whether other variables (such as treatment settings, patients, therapists) account for therapeutic change. Treatment Fidelity scales operationalize the observable therapist behaviours that are specific to a therapeutic modality (Fogarty, 2015). Most Treatment Fidelity scales are based on therapy manuals. As Gestalt therapy does not have a manual, the Treatment Fidelity scale project is currently being developed via a Delphi Study, which is a deeply consultative and collaborative communication method. International expert Gestalt therapists were asked to help with this project and over 60 responded with rich details in their comments. During the Delphi process, eight key concepts for GT and 24 therapist behaviours have been identified and the experts have reached a consensus on these (Fogarty, Bhar, Theiler, & O’Shea, 2016). Given the breadth of participation for the Delphi, the fidelity scale shows excellent face validity. The next step of the development process involves establishing reliability. This study is currently being conducted and substantiated in Australia. Once the scale is shown to be reliable and valid, it will be possible to use it in clinical trials, in research, and in training.

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Larger psychotherapy research field There is another aspect that provides us with some optimism regarding the establishment of a research tradition in our approach. Gestalt therapy is not alone in wanting to ground its practice and theory in scientific and academic ways. At the same time psychotherapy research in general has been advancing and the current developments and discoveries meet our epistemological roots in many ways. Qualitative research, which by its exploratory nature can be seen as the research equivalent to “raising awareness” in our psychotherapy practice, is now better appreciated and is gaining legitimacy in the world of psychotherapy research. It seems significant that in the last edition of Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (McLeod, 2013) a chapter about qualitative research has appeared for the first time. Furthermore, some well established and respected academic journals already accept qualitative studies as fully-fledged research contributions. Both qualitative and quantitative methods are accepted as types of evidence and as choices of what to use in a research project, the advantages of mixed methods are particularly valued. Some published studies point out differences between the quantitative and qualitative assessment of therapeutic change (e.g., Doran et al., 2015). Qualitative research methods are used for exploring therapeutic change (e.g., Elliott & Rodgers, 2008; Sandell, 1997) and thus complement the quantitative measurement of the effect of psychotherapy. Complex assessment of therapeutic change, which reflects the dialogical nature of psychotherapy, also pays considerable attention to the client´s perspective. The client’s voice is also valued in idiosyncratic methods, where items of quantitative measure are created by the clients themselves (e.g. Ashworth et al., 2005; Elliott, Mack, & Shapiro,1999; Paterson, 1996). The uniqueness of each client’s individual story and the specificity of each psychotherapeutic situation is best captured and explored in case studies. There are scientific journals which focus uniquely on case studies (e.g., Pragmatic Case Studies in Psychotherapy; Clinical Case Studies), or that dedicate a special section (Psychotherapy) or even a special issue to them (Counselling and Psychotherapy Research 2011/1; Person-Centered & Experiential Psychotherapies 2014/2). The common need for a systematic collection of case studies is becoming more and more explicit in the psychotherapy research field (e.g., Fishman, 1999; McLeod, 2010). We can therefore observe a new process of both sides moving towards each other. The Gestalt approach is moving towards a more formal grounding in academic, clinical and research contexts and the larger

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psychotherapy research field is becoming more open or even welcoming to research methodologies that are highly compatible with a Gestalt therapy episthemology.

The ground from which this book grew Chapters of this book in most cases originated from presentations at the Gestalt therapy research conference in Cape Cod in 2013 and the Gestalt therapy research seminar in Rome one year later. These two events became an invaluable stimulus for the Gestalt practitioner researchers’ community, and in order to familiarise readers with the broader context, a description of each follows. Cape Cod conference. Within the Association for the Advancement of Gestalt Therapy (AAGT), Philip Brownell began advocating for Gestaltbased research, and he assembled a group of prominent Gestalt therapists to create the Handbook for Theory, Research, and Practice in Gestalt Therapy (Brownell, 2008). The AAGT’s research committee was created with a concomitant fund to help support research in various ways. The momentum emerging from these circumstances led to the creation of the first international research conference, held at the Gestalt International Study Center (GISC) in Cape Cod and co-convened by Philip Brownell and Joseph Melnick. Philip Brownell had suggested the idea of systematically inviting “world class” researchers to the Conference, who would be present to encourage and stimulate novice Gestalt practitioner-researchers. He worked to contact and to obtain agreements with two such researchers. Joseph Melnick collaborated on the program and worked with staff at GISC to produce a stimulating and enriching professional event. Gestalt therapy researchers were encouraged to attend and to present their work. The theme “Towards a Research Tradition in Gestalt Therapy” was adopted, and people were encouraged to present in one of several categories: Research Completed or Underway, Research Methodology, or Philosophy of Science Supporting Research. What emerged from this meeting of researchers and practitioners was an international collaboration for a practice-based research using a single-case, timed series design, and that project is still ongoing. It includes an international panel of researchers from Chile, Russia, Germany, the Czech Republic, and the United States. Leslie Greenberg and Linda Finlay were to be the Mentors-inResidence for the first Conference, but, sadly, just days prior to the Conference, Leslie Greenberg’s wife was tragically killed in an accident;

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so, he could not attend. Finlay’s work in phenomenological research was warmly received. Because Leslie Greenberg could not be at the first Conference, he became a mentor for the second International Research Conference, “Towards A Research Tradition in Gestalt Therapy, Part Two,” which was held two years later, again at the GISC. Brownell and Melnick collaborated together again, and a second mentor, Scott Churchill, Editor of the journal The Humanistic Psychologist, was also present. Leslie Greenberg presented his work on emotion focused therapy and on the creation of a program of process-outcomes research. Scott Churchill presented on phenomenology and intersubjective process, largely based on his work with bonobo apes. Once again presenters came from all over the world. Progress on the international research project with a single case design and work on a Gestalt therapy fidelity scale was presented. Rome seminar. Considering the need for research in psychotherapy, the European Association for Gestalt Therapy (EAGT) decided to set up a Research committee in order to support the development of research in the European Gestalt therapy community. The EAGT Research Committee was founded in 2008 from the initiative of Peter Schulthess, who became the first chair of the Committee (Gianni Francesetti and Jan Roubal being the next chairs). Among other activities the Committee supported the translation of the book: Fritz Perls in Berlin 1893-1933: Expressionism, psychoanalysis, Judaism (Bocian, 2010) and the creation of a book: Gestalt Therapy in Clinical Practice. From Psychopathology to the Aesthetics of Contact (Francesetti, Gecele, & Roubal, 2013). Members of the EAGT Research Committee became aware that a need for an introduction to research methodology and practice had started to emerge in the Gestalt therapy community. The idea of organizing an educational seminar on research methods for Gestalt practitioners arose. Being aware that this first educational seminar in research was a novelty for the Gestalt therapy community, organizers discussed what the most appropriate method might be for participants and finally agreed on having ten invited lecturers who would present a mixture of theoretical practice and methodological perspectives that are significant for Gestalt therapy research. The seminar was convened by Gianni Francesetti, Jelena Zeleskov Djoric and Jan Roubal and it was held in Rome in May 2014. The first day program consisted of more general topics. The presenters talked about the possibilities of bridging Gestalt therapy theory and practice. To demonstrate this they presented models of research usable in Gestalt therapy with a particular emphasis on the presentation of the relational Gestalt therapy perspective and comparative naturalistic study. The next two days relied more on specific methodological approaches

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useful in Gestalt therapy research such as the use of CORE in Gestalt therapy research, grounded theory methods, single case studies, a qualitative method for management counseling as well as direct rating of the outcomes of psychotherapy. Even though organizers were expecting to receive a reasonable number of applications for this seminar, the final 76 participants from 25 countries exceeded their expectations. The growing shared need to explore and understand research amongst Gestalt practitioners was confirmed, opening a new door for this particular area in the everyday practice of Gestalt therapists. The feedback from participants reassured us that a research network had been created and that the EAGT Research Committee could serve as a supportive and coordinating centre for further research projects. The future. We hope to continue working with the essence and energy that came out of the Cape Cod and Rome research gatherings during the Third International Research Conference taking place in 2017. There will be a combination of educational workshops and presentations from world class researchers. Some of the presenters are from outside the field of Gestalt therapy and with their help we can continue to construct the bridge between Gestalt therapy and the larger psychotherapy community. The Conference will be held in Paris under a title “Exploring Practice-based Research in Gestalt Therapy”, with Vincent Beja, Jan Roubal, Gianni Francesetti and Mark Reck co-convening. Both the European Association for Gestalt Therapy (EAGT) and the Association for the Advancement of Gestalt Therapy (AAGT) will take part in its organisation.

What can you find in the book Maybe the best fitting metaphor for the characteristics of the book would be a mosaic. Each chapter, as a piece of the mosaic, depicts some aspect, some specific and limited way to respond to the need for research in our approach. The whole of the book gives the picture, which attempts to reflect the current state of research in Gestalt therapy with its spontaneity and enthusiasm, but also with the huge collection of practical experiences and richness of theoretically elaborated concepts. The book thus might offer a reduced scale picture of the state of research in Gestalt therapy in the larger field. And at the same time, the book itself is just one piece in the bigger picture of the movement towards the research tradition in our approach. Within the mosaic you can first find the theoretical ground in texts describing how research in Gestalt therapy is rooted in the historical, social and political context (chapters by Ken Evans and Margherita

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Spagnuolo Lobb) or in the development of a philosophy of science (chapters by Philip Brownell and Alan Meara). You can also find a personal reflection connected to introducing research into the Gestalt approach and illustrating the specific challenges met on the way (chapter by Joseph Melnick). The second, practical part of the book is dedicated to introducing research methods, and you can follow guideliness and examples of some specific research approaches well suited to Gestalt practitioners. Both a general research strategy which enables the use of our relational psychotherapy skills (chapter by Linda Finlay with Ken Evans) and a step by step introduction of specific research methodologies (the chapter by Jan Roubal with Tomas Rihacek, the chapter by Al Wong and his colleagues and the chapter by Rolf Sandell) are presented. A description of the process of using an established research instrument with the authors´ methodological guidelines offers reflections and suggestions for subsequent studies that can lead to subsequent research (chapter by Margherita Spagnuolo Lobb and chapter by Christine Stevens with Katy Wakelin). You can also find a detailed description of the process of creating your own original research instrument (chapter by Ida Babakhanyan with Todd Burley and chapter by Pablo Herrera Salinas). In the third part of the book you can find examples of completed research projects. The chapters can serve as an inspiration for you on how to conduct your own research project. Both qualitative and quantitative methods are used in exploring different aspects of psychotherapy and organisational consultant practice. Some researchers present projects using the Gestalt approach as an epistemological background and create their own, original methodological contribution (chapter by Laima Sapezinskiene with her colleagues, chapters by Liv Heidi Mjelve, Rob Farrands and Floriana Romano). Others introduce generally used research instruments into the Gestalt therapy context (chapter by Peter Schulthess with his colleagues and chapter by Jelena Zeleskov Djoric with her colleagues). Readers can benefit not only from familiarising themselves with successfully conducted research projects, but also from the experiences that the researchers gained when meeting obstacles, traps and impasses on the way. The mosaic of the book is colourful due to different research designs, but also due to contributions from different parts of the world and so from different Gestalt therapy traditions: there are 29 contributors from 14 countries: Australia, Canada, Chile, Czech Republic, France, Germany, Italy, Lithuania, Norway, Serbia, Sweden, Switzerland, United Kingdom and USA. Moreover, you can find inspiration from a larger psychotherapy

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research field (Rolf Sandell with his psychoanalytically based methodology, Linda Finlay contributing as a relational integrative psychotherapist, or a comparison of different psychotherapeutic treatments in the chapter by Peter Schulthess and his colleagues). The final touch to the whole picture is brought by Leslie Greenberg who has written the preface. One of the most influential psychotherapy researchers of our time reflects on the Gestalt therapy part of his psychotherapy background and offers his experiences as a support for establishing a research tradition in our approach.

Vision As Gestalt therapists, and moreover as trainers or people involved in organizations, we have the responsibility for having a vision for the future. Our vision is that Gestalt therapists enter more and more into dialogue with the wider community of psychotherapists. That they can raise their voice and listen to others in order to teach and learn from each other. That Gestalt therapy fully participates in the movements, developments and the growth of the psychotherapy community. That we can contribute, according to our tradition and our soul and enter into dialogue on a cultural, social and political level. We have the responsibility to transmit an open horizon to our colleagues and to our trainees, a horizon rich in connections and possibilities, in dialogical bridges and mutual learning. What kind of research can support this vision? Surely a research respectful of our epistemology, soul, interests, theory and practice. In the book by Perls, Hefferline and Goodman there is a chapter where the splits present in the actual culture are mentioned: body/mind, theory/practice, individual/social, conscious/unconscious, etc. They proposed to overcome these neurotic splits through the method they called Gestalt therapy. If we wrote our foundational book today, we should mention another split that our founders didn’t mention, the split between research and practice. The new trend emerging in psychotherapy research, the need to do research beginning as much as possible from the real clinical situation, means there is a need for researchers to be close to practice. And vice versa, there is also the need for practitioners to be involved in research. In summary, the aim is to bridge the gap between Gestalt therapy and other modalities, between theory and practice, between research and clinical work, to meet the needs of our field: the need not to be isolated but to share our understanding, to teach and learn from each other.

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Dedication This book is part of a big ongoing movement and it captures a particular period in the process of establishing a research tradition in our approach. However, it is important to stress that all this grew from a larger context. We want to acknowledge and thank all those Gestalt therapists involved in research who contributed to the groundwork which has made the rest possible. Namely we would like to honor here the substantial contributions of our two dear colleagues, who wrote their parts for this book, but unfortunately both deceased before they could celebrate with us its publication: Ken Evans and Todd Burley. We will miss them greatly in many ways, not least in the Gestalt practitioner-researchers’ community. We want to dedicate this book to both of them. Ken Evans was a visionary. As such, he recognized the need for research very early and he actively promoted qualitative research as an appropriate methodology for Gestalt therapists through international seminars and in the European Journal for Qualitative Research in Psychotherapy (which he founded and led). He realized the need to introduce the concept of research early on to Gestalt therapy trainees and started to integrate it into psychotherapy training programmes. Ken, together with Linda Finlay, edited a book Relational-centred Research for Psychotherapists: Exploring Meanings and Experience (Finlay, & Evans, 2009). To illustrate Ken´s contribution to the Gestalt therapy research movement and also his way of bridging practice and research we would like to quote Linda Finlay: Ken’s teaching and inspirational practice of relational psychotherapy helped me to more clearly articulate the relational approach I had been striving for in my research practice. In turn, my phenomenological research and writing experience gave voice to Ken’s intuitive though less formed research approach. As we witnessed each other’s work in both academic and therapy contexts, we saw the magic in the other’s practice. We appreciated the open, non-defensiveness of the other and the preparedness to set aside ego and shame processes, as we evolved our ideas. Our commitment to, and passion for, relational working (be it in therapy, training or research fields) grew. My view of Ken is that he was an extraordinary and inspiring psychotherapist with a special ability to be truly present in the here-andnow. He also could engage positively with multi-layered relational exploration. He had the courage to probe ambivalence and uncomfortable aspects – in himself and his clients – and he invited challenge from the Other in order to deepen understanding and to open to I-Thou contact. I think what stands out for me as his big contribution was his preparedness

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to be creative and go beyond traditional research boundaries in the service of relational explorations of lived experience.

Todd Burley was one of the rare and at the same time so much needed examples of connecting the community of Gestalt practitioners with the academic world. Through his teaching and writing Todd inspired people in both these fields. He trained Gestalt therapists in the USA as well as internationally. At the Department of Psychology at Loma Linda University he taught courses in Gestalt therapy, neuropsychological assessment, treatment and research in schizophrenia, cognitive psychology and cortical functions. Todd really believed in doing research that was meaningful and he encouraged his students to think outside the box. Todd Burley´s contribution is summarized by Bob Resnick: Todd eschewed that today's diagnostic systems and concomitant researchdriven outcome measures were overly focused on counting symptoms as opposed to conceptualizing the experience of the client. He was always interested in finding out how to understand something in process terms and had a longstanding interest in the inclusion of new research regarding the functioning of the brain in connection to psychotherapy. He was interested in the establishment of a generic psychotherapy that was not bound to a specific school or framework and he saw Gestalt therapy as the best integrative and integrating model for this task. Todd, among other things, was wickedly irreverent – about research, about religion, about people, about Gestalt therapy, about universities and more. His keen mind and sharp wit frequently had him thinking ‘out of the box.’ He was creative as well as methodical in his approach to the world although he was never known for either his memory or his follow through on topics of interest to others. He was a tireless seeker and traveler and was always interested in the differences in people, cultures and rituals. Todd valued the unusual, idiosyncratic and even exotic but always had the larger lens of integration.

Ida Babakhanyan adds her personal experience: When I presented to Todd why the established measure we used for my thesis didn't really capture the depressed state I saw clinically, he encouraged me to create a measure that would capture what I saw clinically if I cared about that work. That is consistent with how Todd approached research - if something doesn't work you don't give up on it, you find what works holding true to theory but also rigors science to validate the work.

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Introduction

Notes and acknowledgments A substantial part of this text was presented by Gianni Francesetti as his welcome speech at the EAGT Research Seminar in Rome, May 2nd-4th, 2014. The authors would like to thank colleagues who helped gather relevant information for the improvement of the text of the Introduction: Ida Babakhanyan, Linda Finlay, Madeleine Fogarthy, Alan Meara, Bob Resnick and Tomas Rihacek. Many thanks to all who volunteered in repeated proofreading of the chapters of the whole book: Rose Cha, Kate Esser, Jake Farr, Sarah Farrell, John Gillespie, Megan Gray, Ina Grigorova, Karen Hinchliffe, Hilary Holford, Rachael Kellett, Robin Leichtman, Gabriella Papp, Sarah Paul, Emmie Prosper, Judith Ridley, Lynne Rigaud, Amy Russell, Michelle de Savigny, Jacky Selwyn-Smith, Douglas Sharp and Tania Tuft. Many thanks to all colleagues who supported the creation of the whole book from the initial conference meetings to the final published volume. The shared supportive background of the Gestalt practitioners community was crucial in the creation of this book. Thanks to Dominika Zitnikova for her care in editing the book and organizing the bibliography. Finally, many thanks to Elisabeth Kerry-Reed for her invaluable help with getting the whole final manuscript ready for publishing and thanks to the European Association for Gestalt Therapy for the financial support of this work.

References Ashworth, M., Robinson, S. I., Godfrey, E., Parmentier, H., Shepherd, M., Christey, J., … Matthews, V. (2005). The experiences of therapists using a new client-centred psychometric instrument, PSYCHLOPS (Psychological Outcome Profiles). Counselling & Psychotherapy Research, 5(1), 37-42. Barber, P. (2006). Becoming a practitioner researcher, a Gestalt approach to holistic inquiry. London: Middlesex University Press. Bocian, B. (2010). Fritz Perls in Berlin 1893-1933: Expressionism, psychoanalysis, Judaism. Berlin: EHP - Verlag Andreas Kohlhage, Bergisch Gladbach. Brownell, P. (2008). Handbook for theory, research, and practice in Gestalt therapy. Newcastle: Cambridge Scholars Publishing. —. (2016) Contemporary Gestalt therapy. In D. Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice (2nd

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ed., pp. 249-250). Washington, DC: American Psychological Association Doran, J. M., Westerman, A. R., Kraus, J., Jock, W., Safran, J. D., & Muran, J. C. (2015, June). Do all roads lead to Rome? A critical analysis of agreement and divergence in qualitative and quantitative descriptors of change. Poster presented at the 46th International Annual Meeting of the Society for Psychotherapy Research, Philadelphia, PA. Elliott, R., Mack, C., & Shapiro, D. A. (1999). Simplified Personal Questionnaire procedure. Retrieved from http://www.experientialresearchers.org/instruments/elliott/pqprocedure.html Elliott, R., & Rodgers, B. (2008). Client Change Interview. Retrieved from http://www.drbrianrodgers.com/research/client-change-interview Finlay, L., & Evans, K. (2009). Relational-centred Research for Psychotherapists: Exploring Meanings and Experience. WileyBlackwell. Fishman, D. B. (1999). The case for pragmatic psychology. New York, NY: New York University Press. Fogarty, M. (2015). Developing a Fidelity Scale for Gestalt Therapy. Gestalt Journal of Australia and New Zealand, 11(2), 39-54. Fogarty, M., Bhar, S., Theiler, S., & O’Shea, L., (2016) What do Gestalt therapists do in the clinic? The Expert Consensus. British Gestalt Journal, 25(1), 2-41. Francesetti, G., Gecele, M., & Roubal, J. (2013). Gestalt therapy in clinical practice. From psychopathology to the aesthetics of contact. Milano: FrancoAngeli. McLeod, J. (2010). Case study research in counseling and psychotherapy. London: Sage. McLeod, J. (2013). Qualitative research: Methods and contributions. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 49–84). Hoboken, NJ: John Wiley & Sons. Paterson, C. (1996). Measuring outcomes in primary care: A patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ, 312, 1016-1020. Sandell, R. (1997). Rating the outcomes of psychotherapy or psychoanalysis using the CHange After Psychotherapy scales (CHAP): Manual and commentary. Stockholm: Stockholm County Council Institute of Psychotherapy and Karolinska Institute. Strümpfel, U. (2006). Therapie der Gefühle. Forschungsbefunde zur Gestalttherapie. Bergisch Gladbach; EHP.

PART I: THEORETICAL GROUND

CHAPTER ONE WARRANT, RESEARCH, AND THE PRACTICE OF GESTALT THERAPY PHILIP BROWNELL

Introduction The field of Gestalt therapy has experienced a sea change with regard to the issue of the relevance of research for Gestalt therapy. In a recent article and related commentaries (Brownell, 2014a, 2014b; Burley, 2014; O’Shea, 2014; McConville, 2014) several Gestalt writers agreed the field of Gestalt therapy needed to “get serious” about research, and Ken Evans (2013) called for more research on the subject in his chapter in the landmark volume edited by Francesetti, Gecele, and Roubal (2013). In taking research more seriously, then, Gestalt therapists need to identify with a philosophy of science that works best for them, embrace an array of research methodologies, and attend to the publication of their research in both Gestalt-oriented, peer-reviewed journals, and those in the wider field of psychotherapy outcomes studies. The professional world in which we live has clearly become pragmatic and utilitarian with regard to psychotherapy. It has become based on evidence. The evidence-based movement in psychology began in medical practice, and it has spread to virtually every sector of the public square. People simply demand that providers of all sorts do something that works and that can be shown to work. Thus, there must be evidence, and that evidence must be credible. At one point this might have been cast as an intrusion of managed care, but it has long since become a matter of public policy, best practice, and resulting treatment guidelines that also impact the licensing of providers and the provision of continuing education. Thus, the conversation that Gestalt therapists need to have with one another about issues related to research is not an idle and academic consideration. We need to get serious about research, but we cannot do that if we are

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laboring under outdated views of science and how research is actually carried out. I realize that gut reactions are common when someone makes an assertion, but we as Gestalt therapists really do need to get serious about evidence-based practice and the research that supports it, and when I say that, I mean we need to come up to speed, to be more informed, nuanced, and current with regards to our philosophy of science and our understanding of the processes of research, including how these relate to evidence-based practice. Research is not the bogey man. We are not stuck somewhere in a polarity between positivism and social construction with some forms of research being inherently Gestalt friendly and others not. The fact is that there are various kinds of research that each are best suited for differing kinds of purposes, and all of them are appropriate to the support of Gestalt therapy. People need science to keep the philosophers’ feet on the ground, and people need philosophy to help number crunchers get to the significance of their equations. In one version of the scientific method, for instance, it is a three-legged stool (Machado, 2007). One leg consists of systematic observation. A second leg is composed of mathematical analysis, and the third leg resides in the critical thinking of what the numbers may mean, i.e. science and philosophy. In terms of philosophy, although there may be many kinds of philosophy relevant to psychology, such as ethics, I will focus on three elements of a contemporary philosophy of science: naturalism, critical realism, and post-positivism. In terms of science, an adequate philosophy helps people consider the multitude of methods that comprise acceptable evidence for an evidence-based practice. These things will be examined subsequently.

A current philosophy of science An adequate philosophy of science, one that provides appropriate and sufficient support for the pursuit of research within a Gestalt-therapy ethos, must address the issue of naturalism, the shift from positivism to post-positivism, and the need for a critically realist worldview.

Natural vs. anti-natural attitudes Naturalism is the philosophy of the naturalist perspective, and it stands behind the human science of psychology. K. A. Aho (2012), in the Journal of Theoretical and Philosophical Psychology, asserted that a human being is a “lived-body,” – a dialogical way of being that is already engaged and embedded in a web of socio-historical meanings. That is, people are born

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Chapter One embodied into a culture, thrown into it as the philosopher Martin Heidegger has said. Aho claimed that the job of the human sciences is not to explain existence but to understand how we interpret ourselves, how we make meaning out of our experience of being in this world. A background of meanings is always already in place informing the development and direction of a worldview. The background that informs the discipline of psychology is naturalism, but by contrast the background that informs the discipline of theology is anti-naturalism, and perhaps for some a more specific version of non- or anti-naturalism known as supernaturalism. (Brownell, 20131)

One can be a naturalist or one can be an anti-naturalist, and many people espousing a worldview consistent with phenomenology are of the latter variety. That is because naturalism functions within a natural attitude, and philosophical phenomenologists attempt to escape it by adopting a phenomenological attitude and conducting phenomenological reductions2 (Sokolowski, 2000; Moran, 2000). One of the reasons this philosophical method is unsatisfactory for psychotherapists and has to be adapted (Giorgi & Giorgi, 2003; Giorgi, 2009; Bloom, 2009) is that it thematizes the observed client, who becomes a construction of the therapist’s constituting ego. This thematizing, further, is not a simple theorizing or interpreting; it is the reduction of something complex to something manageable within the symbolic nature of language, “… reducing the texture of lived experience to the stilled life of conceptual thought” (Smith, 2002, p.69)3. Emmanuel Levinas considered such thematizing to be a violence toward the transcendent Other (Critchley, 2002; Levinas, 1999). Because he proposed such a transcendent Other, and because such an Other is necessary to Gestalt’s theory of dialogue (see below), the consequences 1

This section borrows highly from my chapter in Thomas Plante’s three-volume work on abnormal psychology through the ages. 2 “The turn to the phenomenological attitude is called the phenomenological reduction, a term that signifies the ‘leading away’ from the natural targets of our concern, ‘back’ to what seems to be a more restricted viewpoint…this suspension, this neutralization of our doxic modalities, is also called the epochƝ …The epochƝ in phenomenology is simply the neutralizing of natural intentions that must occur when we contemplate those intentions.” (Sokolowski, 2000, p. 49) 3 “Thematizing” is a complex construct; in addition to what is said above, thematizing refers to such things as how evoked imagery in our experience is given form as mental imagery, involving quasi-pictorial representations (Martin, 2004) and how the pre-verbal “feel” of a given space ignites context sensitivity in a given, situated subject (Lewandowski, 2000).

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for Gestalt therapists are two-fold: (1) there is an actual other that is present and having effect in the life of the therapist, and (2) this experience of encountering the Other can only be had in a natural attitude (the Other must be accepted “as is,” that is, without a reduction). It is the difference between one form of Husserlian phenomenology, attempting to bracket the natural attitude, and an understanding of Heideggerian phenomenology, attempting to develop a phenomenology of the natural attitude (Smith, 2002). We deal with the tangibles in what presents itself – the givenness of a given moment. This is also what Francesseti refers to as the “obvious” when speaking of that which emerges in the here and now of a phenomenal field (Francesseti, 2015). Although philosophy undergirds much of the theory of Gestalt therapy, the practice of Gestalt therapy is not a philosophical project. It is practical, pragmatic. It is, in a sense, extraordinarily ordinary. The natural attitude is basic to Gestalt process in that contact (especially informed by alterity) is conducted in the natural attitude. This is evident in dialogue during inclusion, in which the therapist allows the Other to be present in whatever way the Other offers him or herself and for the therapist in whatever way the Other is given (Marion, 2002). It is evident in the belief that what is given is actually there. It is evident in the natural flow of pre-theoretical experience in which the therapist is dialogically present to the client. This meeting, this contacting, forms the evolving experience of self for each of them, giving rise to their emergent and tenuous states of being.4 Thus, being is ontologically natural, and an anti-naturalist attitude is dissonant to Gestalt therapy (this is another reason the phenomenological method must be adapted in our unified theory). Someone might say there is a difference between naturalism and the natural attitude. “One is a belief system, the other a perspectival stance” (Dan Bloom, personal communication, November 17, 2012). Granted that naturalism, as a worldview, and the natural attitude, as a perspective, are not identical; however, they are significantly related. Attitude in phenomenology organizes perception according to interest, and in the natural attitude interest can take many avenues (Luft, 1998), but still remain affected by perceptual faith (Merleau-Ponty, 1968; Brownell, 2011), trusting one’s contacting, or as Merleau-Ponty (1968) put it, “the certitude I have of being connected up with the world by my look…” (p. 28). Taking something as given is to function in the natural attitude, and so 4

“Tenuous” because states of being balance on a fine edge at the boundary of contacting. Being itself is one thing and states of being is another. I am not saying that experience precedes being.

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even though one might have a therapist’s interest in the client, that can be entirely pursued in a therapeutic-natural attitude that takes the client as given. This does not mean we believe everything the client says, but it does mean that we absorb the client’s presence. In a similar fashion naturalism in contemporary research involves phenomena of interest that can be observed and measured, and the philosophy of science involved is more Galilean than Aristotelian, more critical realist5 than social constructionist. How so? A great deal of research accepts things as given and attempts to understand their relationships with other things – how they work within their respective contexts rather than what they are in and of themselves. This was Lewin’s approach to research (Lewin, 1999), and it is one consistent with Gestalt therapy’s emphasis on field dynamics. Lewin accepted things as given, as he encountered them, rather than questioning their existence as isolated facts, and he investigated the causal influences among them. In his work on Aristotle and Galileo he contrasted the Aristotelian approach that investigates objects in and of themselves with the Galilean approach that “includes a penetrating investigation of precisely the situation factors” (Lewin, 1999, p. 56). More to the point concerning research, naturalism takes two subcategories. Ontological naturalism concerns reality – 6the proposition that nothing exists outside that which can be examined empirically in the physical world. Methodological naturalism concerns the way to investigate that physical world – a commitment to certain methods for limited purposes, i.e. the scientific method (Papineau, 2007). By contrast, in discussions of research methodology anti-naturalism is everything that goes beyond the physical world and is usually pointed at confronting naive realism and ontological naturalism. Thus, for instance, phenomenology, which is a philosophy of subjective experience, is of the non-naturalistic perspective7 (Gallagher & Zahavi, 2008). Classic, Husserlian phenomenology is a system designed to escape the natural attitude and one elevated into an all-encompassing (and anti-naturalistic) theoretical outlook (Moran, 2000)

5

See on critical realism below, especially on the work of Margaret Archer, who addresses emergent field dynamics from within a critical realist perspective. 6 See below for critical realism as opposed to naive realism 7 Why? Because one cannot put the subjective experience of another person on a scale and weigh it; it cannot be seen; it cannot be experienced by another. While the person having a subjective experience can be observed, the person’s subjective experience itself cannot.

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that shares significant worldview and metaphysical standing with supernaturalism.

Post-positivism in psychology As positivism fell apart, researchers became aware of the limitations of our knowledge and of our thinking about knowledge. Positivists held that the researcher and the researched person were independent of each other, but that gave way to the realization that “the theories, hypotheses, background knowledge and values of the researcher can influence what is observed” (Robson, 2002, p. 27). As the certainty of positivism crumbled, the concept of truth as a universal norm wore out, and with that developed the suspicion of ontological realism (Groff, 2004). A relativistic social constructivism surfaced as a contender for the new paradigm, but it was not alone. Post-positivism also emerged. According to Creswell (2009) the post-positivist worldview as it relates to science consists of positions with respect to knowledge, research, influence, goals and values: Table 2-1: Post-positive worldview Knowledge Research Influence Goals

Values

Conjectural and anti-foundational; absolute truth can never be found. Evidence found in research is imperfect and fallible. The process of making claims and then refining or abandoning them for other claims more strongly warranted. Data, evidence, and rational considerations shape knowledge To develop relevant statements that explain situations, describe causal relationships, or advance the relationship among variables in order to pose hypotheses Being objective and accounting for bias in methods and conclusions; standards for validity and reliability.

A related term for post-positivism is post-foundationalism. Once “a system of thought that is committed to realistic description becomes aware that its own most basic rules are precisely that and not foundations sunk into the structure of reality itself,” then that is a post-foundational system (La Montagne, 2012, p. 7). It is also very much post-positivist. It is somewhat common to split out positivism from post-positivism and contrast them as being about objective facts, naturalism, and quantitative methods on the one hand (positivism) and social constructivism, phenomenology, and qualitative methods on the other (post-positivism). This was the approach of Noor (2008), and it is a

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simplistic reduction. Obviously, anything “post–“ comes after, but in what way does post-positivism succeed positivism? Is it a radical departure and a total repudiation, or is it an adjustment? Most post-positivists accept critical realism (see below) and operate within a naturalistic worldview, even in the more qualitative, phenomenological kinds of research projects, and that anchors post-positivism more squarely as an adjustment instead of a radical departure.

A critically realistic perspective One prominent form of post-positivism is critical realism. One of the nicest descriptions of critical realism was provided by the New Testament scholar, N.T. Wright (1992), when he said, “I propose a form of critical realism. This is a way of describing the process of ‘knowing’ that acknowledges the reality of the thing known, as something other than the knower (hence ‘realism’), while fully acknowledging that the only access we have to this reality lies along the spiralling path of appropriate dialogue or conversation between the knower and the thing known (hence ‘critical’).” (p. 35)

Thus, we know some things about the world in which we live, and we continually refine our knowledge of that world. Our knowledge of the world is not an exhaustive knowledge; it is an investigative knowledge. Further, one can escape the representationalism common in some forms of phenomenology by embracing the direct contact that is resident in other forms of phenomenology.8 When I bump my head on the bedpost, I am situated in direct contact with the bedpost, and I am assessing my experience, its implications, and its significance for me as I reflect on my “knowledge” of the bedpost. I may take a second, long look at the thing upon which I bumped my head. I may reach out and touch it. I may deal with my wife laughing. I might even address the bedpost, saying, “You blankety blank bedpost!” I don’t need the phenomenological method to figure out that it IS the bedpost or that I have bumped my head on it. Jean-Luc Marion (2002) claims there is a kind of "saturated phenomenon" that overwhelms our ways of knowing in direct contact and has an effect on us as a kind of revelation – it is given. However, Jean-Louis Chrétien (2004) says that we cannot know the call (of a phenomenon that is given) 8

To list and categorize which phenomenologists fall into which categories is beyond the scope of this article.

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but through the response of the "contacted,” the experience of receiving the call. These are two ways of thinking about contact that each require a form of realism. They come in the wake of Husserl, Heidegger, and Merleau-Ponty. Contact is essential for Gestalt therapy; yet, contact is not possible without “contacter” and “contacted,” and so the fact of contact yields the realization that there is something rather than nothing, and we can learn about it through contact. Thus, critical realism. In one of the more salient examples of the application of critical realism (because this relates to field theory) the issue of the relationship between individual agents and social structures has been explicated by Margaret Archer (1995). Referring to her work, Wikgren (2005) noted that in the critical realist philosophy, the very possibility of social theory is based on the existence of real social structures and systems that are emergent entities which operate independently of our conception of them, conditioning – but never determining – intentional agential activity, being nonetheless dependent on that human activity to endure or change. (p. 12)

That is a picture of the field at work in which environment and organism are dynamically one whole–social structure and individual agents. That is also the picture of emergent entities and supervenient relationships one sees in the dynamic between brain and mind. The brain engaged in the world, including the relational aspects of its various parts working as they do, gives rise to the emergent mind, and in Gestalt vernacular to the subjective experience we know as “self.”

Putting it all together Gestalt therapy is a phenomenological approach, but its phenomenological stance is attenuated by its other chief theoretical tenets: its emphasis on contact, relationship, field dynamics, and movement through time by means of an existential and experimental way of living. Critical realism is consistent with this form of contemporary Gestalt therapy and also undergirds a contemporary approach to research. The deployment of empirical research methods is increasingly underpinned by a meta-theory embracing epistemological and ontological elements, and this meta-theory refrains from committing one to the view that absolute knowledge of the social world is possible. Critical realism is the most appropriate metatheory to underpin the use of empirical research methods (Scott, 2005). This is so whether one is given to qualitative or quantitative methods, and the split between those methods is a distraction.

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A naturalistic, critically realist, and post-positive philosophy of science is a counter to the vestiges of an antiquated positivism that sees a strict correlation between what is observed and an independent, separate observer, with foundational assumptions about the nature of reality or what is possible in the processes of discovery. It is also a counter to the social constructivist approach, which “becomes little or nothing more than the (inter)subjective accounts, interpretations and viewpoints of those studied: a socially constructed world of sorts, with its own empiricist overtones to boot via the commitment to qualitative research methods… filtered through a biographical lens and/or a narrative reference point” (Williams, 2003, p. 47). In a less polemical statement, and in a particularly nice summary of all this, Trochim (2006) asserted, Positivists were also realists. The difference is that the post-positivist critical realist recognizes that all observation is fallible and has error and that all theory is revisable. In other words, the critical realist is critical of our ability to know reality with certainty. Where the positivist believed that the goal of science was to uncover the truth, the post-positivist critical realist believes that the goal of science is to hold steadfastly to the goal of getting it right about reality, even though we can never achieve that goal! Because all measurement is fallible, the post-positivist emphasizes the importance of multiple measures and observations, each of which may possess different types of error, and the need to use triangulation across these multiple errorful sources to try to get a better lead on what's happening in reality. The post-positivist also believes that all observations are theory-laden and that scientists (and everyone else, for that matter) are inherently biased by their cultural experiences, world views, and so on. (n.p.)

Troachim’s assertion about the wisdom in multiple methods is important in the effort to establish a research tradition for Gestalt therapy. Gestalt therapists will do well to strengthen the discipline by embracing what he has said. However, it goes even beyond what he has said. Not only are multiple methods necessary because all measurement is fallible, but because not all methods accomplish the same thing. A person needs to understand what these various methods can do and what they can’t do. It doesn’t work very well to apply frosting to a cake by pounding it with a hammer.

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An informed understanding of evidence-based practice All this exploration of philosophies relevant to science is ground in the consideration of research and the issue of evidence-based practice. When Gestalt therapists express their skepticism about whether even the most sophisticated research paradigms can adequately support a dialogical endeavor that revolves primarily around one’s values and personal meanings (Yontef & Jacobs, 2014), they are pointing to their bias, and it is a bias seemingly out of touch with a contemporary philosophy of science. Neither scientism nor positivism are necessary to the processes of research that are essentially naturalistic, critically realistic, and post-positivist. Further, it is not managed care that is the driving force behind the evidence-based movement; it is the need to be ethical that is to be competent, to do no harm, and to utilize what actually works. Yes, there are fiscal considerations, but ethical practice is the real driver in the evidence-based movement (which, as I have said, leads to public policy, treatment guidelines, and regulation in the form of licensing considerations), and part of that is the desire to be efficient, but that is not always measured in monetary increments. Gary Yontef and Lynne Jacobs (2014), likely also speaking for others as well, believe that the question of an evidence-based practice at all is misplaced. They do not trust the processes of research that would produce such evidence, and they do not believe that “evidence” is even an appropriate consideration for something as unique as the meeting of one person and another. The concern is that nomothetic data might be privileged over the individual values, capacities, preferences and experiences of the particular patient-therapist pair. That is a problem at two levels: (1) a concern for the application of research but a mistaking of the processes of research for the application of research and (2) an apparent failure to understand that idiographic data is also available and a significant outcome in research. These point to good reasons why Gestalt therapists need to learn about research; namely, so they will know how to develop it, evaluate it, and understand what can and cannot be done with its results. Edwin Nevis (2008) wrote for the back cover of the Handbook for Theory, Research, and Practice in Gestalt Therapy and said, “I recommend this book to anyone who is serious about practicing his or her craft better by supporting it with a broader base, one that demonstrates that merging existential phenomenology with phenomenological behaviorism can produce verifiable, replicable results for what is essentially an ideographic pursuit.” The point is not to sell the book but to sell the

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acceptability of research as something worthy of the Gestalt approach and a wise investment of the resources of Gestalt therapists. The American Psychological Association (APA) adopted a working definition of evidence-based practice when they asserted that evidencebased practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (APA Presidential Task Force, 2006, p. 273). Falzon, Davidson, and Bruns (2010) identified five steps in developing an evidence-based practice: (1) Formulate a clear question about patient or research issue; (2) search the literature to find the best available evidence; (3) critically appraise the evidence for its validity, accuracy, and usefulness; (4) apply useful findings, integrating them with clinical expertise and patient’s characteristics, culture, and preferences; and (5) evaluate the outcomes and, if needed, initiate a refined search. (p. 551)

Please note that this is a procedure for the application of research. It is not a search to prove one’s a priori bias one way or the other. As I will show subsequently “evidence” can take many acceptable forms. What is required is that a person becomes more knowledgeable with regard to what is actually going on with research so that a critical analysis can be practical and so that useful findings can be distinguished from unwarranted conclusions. Further, in utilizing research to generate an evidence-based practice, one integrates the results and their implications with clinical expertise and the client’s “characteristics, culture, and preferences” – all field dynamics. This seems compatible to the practice of Gestalt therapy. Various kinds of support qualify as “best available research” for such an evidence-based practice. The APA opened up multiple and relative streams of support, including diverse research designs, as constituting such "evidence." They include clinical observation, qualitative research, systematic case study, single-case experimental designs to examine causal factors in outcome, process-outcome studies to examine mechanisms of change, effectiveness studies in natural settings, random controlled treatments and efficacy studies for drawing causal inferences in groups, and meta-analyses for observing patterns across multiple studies with respect to effect sizes. Carlson, Ross & Stark (2012) contrasted single-case research design with clinical case studies by saying, Single-case design may be viewed as the downward extension of group experimental methodology to the single unit or small N level. In contrast, the clinical case study may be defined as a detailed analysis of individual,

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couples or family therapy that includes verbatim clinical case material and is instructive regarding the treatment, the problem, or population. (p. 49)

With regard to any particular treatment intervention, the APA task force identified two considerations: does the treatment work, which is a question of its efficacy (and which is most related to internal validity), and does it generalize or transport to the local setting where it is to be used, which is a question of its effectiveness (and which is most related to external validity) (Brownell, 2008). Gestalt therapists have already offered many of these kinds of evidence.9 They have provided subjective reports based on their clinical observations and discussions while participating in various online discussion groups and professional conferences. They have described case studies. They have conducted qualitative research. They have provided studies involving random, controlled treatments. Gestalt therapists have provided effectiveness studies in natural settings. They have also provided meta-studies. The variety of different patients, diagnoses, and settings of these studies taken as a whole is evidence for the effectiveness of Gestalt therapy even with highly impaired patients. In developments that hold even more promise for the future, Gestalt therapists have expressed growing interest for utilizing single-case research designs (single-case, timed series studies), and they are beginning to conduct international conferences dedicated to research. Borckhardt, Nash, Murphy et al. (2008) pointed out that the “(…) practitionergenerated case-based time-series design with baseline measurement fully qualifies as a true experiment and that it ought to stand alongside the more common group designs (e.g., the randomized controlled trial, or RCT) as a viable approach to expanding our knowledge about whether, how, and for whom psychotherapy works” (p. 77). Division 12’s Task Force on Promotion and Dissemination of Psychological Procedures recognized such time-series designs as important and fair tests of both efficacy and/or effectiveness. Ray and Schottelkorb (2010) described how such singlecase research designs are acceptable as means of evaluating the relative merit of treatments. Thus, the single-case research design can do a great deal for Gestalt therapists. It is a design individual Gestalt therapists can 9

I will not cite the actual references to these studies for two reasons. First, it would take up too much space to cite and explain each one. Second, I am obligated to provide this information for the forthcoming 2nd edition of Humanistic Psychotherapies: Handbook of Research and Practice, edited by D. Cain, to be published by the American Psychological Association.

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utilize at the level of the clinic to track the outcomes of their own work with individuals, couples, and families. Because such designs are a powerful way of evaluating the effectiveness of the work of any given therapist, the Centro de psicoterapia Gestalt de Santiago, Santiago, Chile, will require each of their trainees (about thirty each year) to conduct a single case, experimental study as part of their training (Pablo Herrera Salinas, personal communication, May 29, 2012). These developments and other relevant research issues were explored during The Research Conference in 2013, “The Challenge of Establishing a Research Tradition for Gestalt Therapy,” which was co-hosted by the Gestalt International Study Center and the Association for the Advancement of Gestalt Therapy, an international community.

Conclusion One person believes the other is serious when that person’s actions match his or her rhetoric or when non-verbal discourse is congruent with verbal discourse. Thus, for Gestalt people to pay lip service to research without supporting it, engaging in it, becoming knowledgeable about it, or to shrug it off in public while admitting that, well, yes, we have to get serious about research, is not actually being serious. We must GET serious, but how do we, as a field, do that? Try these suggestions (some of which are being instituted as I write10): x Associations of Gestalt practitioners (both clinical and organizational) create research committees commissioned to find ways to promote and support research on the organizational level, either through funding, training, and/or the organizing of specific research projects. x Individual Gestalt training institutes or programs add training on research so that budding Gestalt practitioners pick up on the positive attitude toward research and also get some needed training/orientation with the result that they can evaluate and assimilate research literature that contributes to better Gestalt practice. x Gestalt practitioners participate in actual research projects as the 10

Since the first writing of this paper the global movement for research in Gestalt therapy has picked up momentum. In all fairness, I believe Gestalt people are getting to be quite serious about research.

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appropriate opportunities arise (and perhaps they also join various online Gestalt research communities to learn more about such opportunities). x Gestalt practitioner-researchers form solid, practice-based research networks that generate credible research projects that in turn are made known through publishing in peer-reviewed journals both inside and outside of the Gestalt “conclave.” x Gestalt practitioner researchers participate in research conferences both inside and outside of the field of Gestalt therapy in order to cross-pollinate, infuse Gestalt with increasing expertise and competence, and share the growing Gestalt research tradition with the larger field of clinical psychology and psychotherapy.

References Aho, K. A. (2012). Assessing the role of virtue ethics in psychology: A commentary on the work of Blaine Fowers, Frank Richardson, and Brent Slife. Journal of Theoretical and Philosophical Psychology, 32(1), 43-49. American Psychological Association, Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 611, 271-285. Archer, M. (1995). Realist social theory: The morphogenetic approach. Cambridge: Cambridge University Press. Bloom, D. (2009). The phenomenological method of Gestalt therapy: Revisiting Husserl to discover the “essence" of Gestalt therapy. Gestalt Review, 13(2), 277-295. Borckardt, J., Nash, M., Murphy, M., Moore, M., Shaw, D., & O’Neil, P. (2008). Clinical practice as natural laboratory for psychotherapy research: A guide to case-based time-series analysis. American Psychologist, 63(2), 77-95. Brownell, P. (2008). Handbook for theory, research, and practice in Gestalt therapy. Newcastle: Cambridge Scholars Publishing. —. (2011). Intentional spirituality. In D. Bloom & P. Brownell (Eds.), Continuity and change: Gestalt therapy now (pp. 236-260). Newcastle: Cambridge Scholars Publishing. —. (2013). A supernatural perspective on psychopathology. In T. Plante (Ed.), Abnormal psychology through the ages, Volume one history and conceptualizations (pp. 139-162). Santa Barbara, CA: Preager/ABCCLIO.

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—. (2014a). C’mon now, let’s get serious about research. Gestalt Review, 18(1), 6-22. —. (2014b). Response to McConville, Burley, and O’Shea. Gestalt Review, 18(1), 48-53. Burley, T. (2012). A phenomenologically based theory of personality. Gestalt Review, 16(1), 7-27. —. (2014). Commentary II: Can we get back to being serious about the processes of experience, awareness, and the action of Gestalt formation resolution? Gestalt Review, 18(1), 32-35. Carlson, C., Ross, S., & Stark, K. (2012). Bridging systematic research and practice: Evidence-based case study methods in couple and family psychology. Couple and Family Psychology: Research and Practice, 1(1), 48–60. Chrétien, J-L. (2004). The call and the response. New York, NY: Fordham University Press. Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). London: Sage. Critchley, S. (2002). Introduction. In S. Critchley & R. Bernasconi (Eds.), The Cambridge companion to Levinas (pp. 1-33). Cambridge: Cambridge University Press. Evans, K. (2013). Research and Gestalt therapy. In G. Francesetti, M. Gecele & J. Roubal (Eds.), Gestalt therapy in clinical practice: From psychopathology to the aesthetics of contact (pp. 149-158). Siracuse: Istituto di Gestalt HCC Italy Publ. Co.. Falzon, L., Davidson, K., & Bruns, D. (2010). Evidence searching for evidence-based psychology practice. Professional Psychology: Research and Practice, 41(6), 550-557. Francesseti, G. (2015). From individual symptoms to psychopathological fields. Towards a field perspective on clinical human suffering. British Gestalt Journal, 24(1), 5-19. Gallaher, S., & Zahavi, D. (2008). The phenomenological mind: An introduction to philosophy of mind and cognitive science. New York, NY: Routledge. Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified Husserlian approach. Pittsburgh, PA: Duquesne University Press. Giorgi, A., & Giorgi, B. (2003). The descriptive phenomenological psychological method. In P. Camic, J. Rhodes & L. Yardley (Eds.), Qualitative research in psychology: Expanding perspectives in methodology and design (pp. 243-274). Washington, DC: American Psychological Association.

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Groff, R. (2004). Critical realism, post-positivism and the possibility of knowledge. New York, NY: Routledge. La Montagne, P. (2012). Barth and rationality: Critical realism in theology. Eugene, OR: Cascade Books. Levinas, E. (1999). Alterity & transcendence. New York, NY: Columbia University Press. Lewandowski, J. D. (2000). Thematizing embeddedness: Reflexive sociology as interpretation. Philosophy of the Social Sciences, 30(1), 49-66. Lewin, K. (1999). The conflict between Aristotelian and Galilean modes of thought in contemporary psychology. In M. Gold (Ed.), The complete social scientist: A Kurt Lewin reader (pp. 37-66). Washington, DC: American Psychological Association. Luft. S. (1998). Husserl’s phenomenological discovery of the natural attitude. Continental Philosophy Review, 31, 153–170. Machado, A. (2007). Toward a richer view of the scientific method. American Psychologist, 62(7), 671-681. Marion, J-L. (2002). Being given: Toward a phenomenology of givenness. Stanford, CA: Stanford University Press. Martin, B. (2004). Using the imagination: Consumer evoking and thematizing of the fantastic imaginary. Journal of Consumer Research, 31, 136-149. McConville, M. (2014). Commentary I: Gestalt therapy, research, and phenomenology. Gestalt Review, 18(1), 23-31. Merleau-Ponty, M. (1968). The visible and the invisible. Evanston, IL: Northwestern University Press. Moran, D. (2000). Introduction to phenomenology. New York, NY: Routledge. O’Shea, L. (2014). Commentary III: Cultivating a community of practitioner/researchers. Gestalt Review, 18(1), 36-47. Noor, K. B. M. (2008). Case study: A strategic research methodology. American journal of applied sciences, 5(11), 1602-1604. Papineau, D. (2007). Naturalism. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy. Retrieved from http://plato.stanford.edu/entries/naturalism. Ray, D., & Schottelkorb, A. (2010). Single-case design: A primer for play therapists. International Journal of Play Therapy, 19(1), 39-53. Robson, C. (2002). Real world research (2nd ed.). Oxford: Blackwell Publishing. Scott, D. (2005). Critical realism and empirical research methods in education. Journal of Philosophy of Education, 39(4), 633-46.

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Smith, J. K. A. (2002). Speech and theology: Language and the logic of incarnation. London: Routledge. Sokolowski, R. (2000). Introduction to phenomenology. New York, NY: Cambridge University Press. Trochim, M. K. (2006). Research methods knowledge base. Retrieved from http://www.socialresearchmethods.net/kb/positvsm.php Wikgren, M. (2005). Critical realism as a philosophy and social theory in information science? Journal of Documentation, 61(1), 11-22. Williams, S. (2003). Beyond meaning, discourse and the empirical world: Critical realist reflections on health. Social Theory & Health, 1, 42–71. Wright, N. T. (1992). The New Testament and the people of God. Minneapolis, MN: Fortress Press. Yontef, G., & Jacobs, L. (2014). Gestalt therapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (pp. 299-338). Independence, KY: Brooks/Cole–Cengage Learning.

CHAPTER TWO RESEARCH IN GESTALT THERAPY: A WAY OF DEVELOPING OUR MODEL MARGHERITA SPAGNUOLO LOBB

Psychotherapy is a constant search. It´s ability to challenge the truth continuously changes the patient's life. —Spagnuolo Lobb, Lipari, 2010, p. 32

Introduction Decades ago, research was considered by humanistic approaches to be a difficult matter, even in contradiction to their aims. More recently research projects are growing and there is a shared enthusiasm for research among psychotherapists of all methods. The research mentality is possible among Gestalt therapists, if we overcome the original (narcissistic) attitude to fight against rules and reown the original tradition of phenomenological research used by Gestalt theory circa 1920. Nowadays, fighting amongst institutions is meaningless. We do not need to develop our ego and let it flourish in its beauty, we rather need to feel rooted in primary relationships and in society (Spagnuolo Lobb, 2013a). In this time and in this society, research can help us to feel rooted in what we do, to monitor, with humility and responsibility for our social task, what is most appropriate and effective. As a matter of fact, today – in a horizontal society - we need to be recognized by our siblings more than to fight against our fathers. Particularly, it seems that finally research in psychotherapy can be considered a way to study this particular kind of human relationship, albeit not according to natural sciences (therefore seeing human behaviour and relations as an object), but rather keeping the freshness that is a feature of the psychotherapeutic contact. Moreover, today research can give psychotherapists a recognition of the importance

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of their work, against the actual tendency to reduce the treatment of human sufferings to mere medical or behavioural change. Unlike the time when humanistic approaches were founded, research today is not considered in opposition to the complexity and spontaneity of the psychotherapists’ work, but rather as a possible ally in the recognition of its importance. The development of phenomenological research, in particular, has helped Gestalt therapists to consider research as an interesting tool, both to check the efficacy of their work and to understand better what they do. These two needs (to check the validity of their work and to understand what changes and how) are solved by two different traditional methods of research in psychotherapy: 1) outcome research that measures the results after psychotherapy, for instance the differences between before and after psychotherapy with standardized instruments; 2) process research that studies various aspects of the psychotherapy process, which can be measured even while treatment is ongoing, independently from the results.

Outcome research With this research we try to measure with standardized instruments, the effect of psychotherapy treatment, after it is finished, usually by comparing the before and after condition and perception of the client. An example of a tool for outcome research is the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM, Mellor-Clark & Barkham, 2006; Palmieri et al., 2009), which is applied in many psychotherapy services all over Europe, in particular it has been applied by Gestalt psychotherapists by Christine Stevens and colleagues (2011). FIAP (The Italian Federation of Associations of Psychotherapy) recommends that it be applied by all methods in Italy, and SIPG (Italian Association for Gestalt Therapy) supports and teaches Italian Gestalt psychotherapists to use it.

Process research This kind of research measures, both during the treatment and independently from the result, certain aspects related to the therapeutic process: it answers questions like “What does it change?”, “What are the main conditions for change to happen?”, “What are the relational (verbal and non verbal) aspects that facilitate change?” An example of process research is the measurement of “therapeutic alliance” in various phases of therapy, compared with other variables of the same process, like sex or age of client and therapist, number of sessions, length of treatment, type and

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seriousness of diagnosis, etc. (Colli & Lingiardi, 2009). Other examples of this kind of research are the Fivaz-Depeursinge’s Lousanne Trialog Play (a research situation to study various relational aspects of interactions in primary triangle) (Fivaz-Depeursinge & Corboz-Warnery, 1999), or the Stern’s Boston Change Process Study Group research on moments of meeting in psychotherapy, phenomenological research conducted in an intervision setting (Stern, 2004; Stern et al., 1998a, 1998b, 2003).

The development of psychotherapy research The very first trials of psychotherapy research can be considered those of Abraham in Berlin around 1920, by Glover in London around 1930, and most of all by Carl Rogers, in the US in the 1940s, the first who used the tape recorder to study psychotherapy sessions (see Migone, 1994). We can however consider the history of psychotherapy research since the 1950s. In the first phase (from the 1950s to the 1970s), the interest was directed towards the outcome of psychotherapy and the main requirement was the social legitimacy. The question was: “Does psychotherapy work?” The debate was motivated especially by the provocation of Eysenk (1952) who had stated that there was no evidence of the effectiveness of psychotherapy, since changes after psychotherapy were not different from changes due to "spontaneous remission". The question of the placebo effect is still alive, when for instance a research demonstrates that 10% to 18% percent of clients already show a meaningful improvement when they are put onto a waiting list for psychotherapy (Migone, 1996). Frank (1961) stressed that the real therapeutic factors are the aspecific ones, those which are not strictly related to what is crucial for that specific method. He claimed that if all therapies work whilst remaining different, obviously the therapeutic agent must reside in the factors which are common to all. He identified four fundamental "nonspecific" elements shared by all psychotherapies, which are: the relationship, the environment, the conceptual framework and prescriptions of a set of procedures (see Parloff, 1985, pp. 25-28). “It’s obvious that if the ‘nonspecific’ factors were the true therapeutic factors, they would automatically become ‘specific’, while those factors that many forms of therapy consider specific (i.e., "technological" intervention, such as, the interpretation for psychoanalysis, deconditioning for behavioral therapy, modification of pathogenic beliefs for cognitive therapy, etc.) would automatically become ‘nonspecific’ factors, a sort of ‘rationalization’ of psychotherapy itself” (Migone, 1996).

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Following these kinds of research, Luborsky, Singer and Luborsky (1975) officially proclaimed the “Dodo verdict” (from Alice in Wonderland): “All methods have won, and everybody will receive a prize”. This made clear that outcome research is not sufficient to understand how psychotherapy works, process research is also necessary. It was in fact realized that if one method might initially appear to be more effective than another, under a more accurate test this difference disappeared (Smith, Glass & Miller, 1980). In the second phase, from the 1960s to the 1980s, process research dominated the scene. In 1970 in Chicago there was the first conference of the newborn Society for Psychotherapy Research (SPR). The journal Psychotherapy Research was founded only 20 years after, in 1990. The Handbook of Psychotherapy and Behavior Change, with its four editions from 1971 to 1994 (Bergin & Garfield, 1994), a sort of bible of research on psychotherapy, became the reference point to demonstrate that psychotherapy is on average more effective than placebo; in fact it’s impossible to define a placebo in the realm of human relations. What was clear to researchers in these years was that there had to be a correspondence between the process that is important for a particular method and the researched process in the client. Some main psychotherapy methods published their “manuals” among which were that of Wolpe (1969) for behaviour therapy and that by Beck et al. (1979) for a cognitive approach to depression. These manuals include a practical description of the principles of that technique, clinical examples of the described principles, and a series of rating scales to measure the clinical outcome of those principles. The feature that allowed a change in the methodology of the research concerns in particular the use of rating scales that measure the degree to which a sample of treatment is within the principles of the technique. The third phase began around the 1970s, it is characterized by an intensification of the studies on the process. Today many prejudices about the usefulness of the research have vanished and many researchers cross the barriers of their schools to find new challenging universal ways to see change in psychotherapy (Migone, 1994).

Process and outcome research Outcome research was more prevalent in psychotherapy research when the question was “Does psychotherapy work?”, Now that the question has become “How and for whom does it work?”, we see a growing interest in process research, which is considered more useful to understand what

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really happens in psychotherapy. Today interest has shifted from the study of the result to the study of the relationship between process and outcome. Therefore the question became: "What has to happen in the course of psychotherapy that makes it reasonable to expect a positive result?"

Why outcome research today? Nevertheless, today outcome research is still necessary, especially to demonstrate the usefulness of psychotherapy treatment to insurers. This is especially true in the case of Gestalt therapy, which in many countries is not included in the procedures of accreditation. At the same time, it gives Gestalt psychotherapists a simple feedback of their work.

The fascination of process research If outcome research is useful for giving feedback on a psychotherapist’s work, process research is more interesting for the development of one’s approach for many reasons. First of all, it helps in finding a good equilibrium between being free and at the same time rooted into our epistemology, it helps to choose what to look at, and at the same time allows the psychotherapist to be creative enough to see what is not usually seen. An example of process research in our field is the Gestalt Therapy International Network (GTin) which gathered from 2001 till 2003: a group of psychotherapists (Jean Marie Robine - coordinator, Gary Yontef, Michael Vincent Miller, Peter Philippson, Philip Lichtenberg, Miriam Sas de Guiter, Lilian Frazao and myself) attempted to answer an important question: What makes change possible in Gestalt therapy? Besides theoretical exchange, we experimented in co-leading small groups and individual work. Reflecting on differences and similarities among colleagues who had never worked together was an inspiring learning experience which remained for years in our theory and practice. It is a pity that we did not continue that kind of research, which only produced one book (Robine, 2001).

Researching in Gestalt therapy: To maintain our roots and move towards our future Our roots in Gestalt theory help us to locate ourselves in the contemporary trend of phenomenological research. As a matter of fact, we need to use a coherent research method.

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What can be a coherent outcome research method for us? The COREOM can be adequate, if we focus on the differences in the experience (not the behaviour and not inner conflicts) of the client before and after therapy. The CHAP, by Rolf Sandell (1987), is both an outcome and process research method. This can be in line with Gestalt therapy if we search for the perceptive categories of the client after therapy (not for inner conflicts). If we use it to research how post therapy perception is structured, not only in the client but also in the psychotherapist, it can be very interesting for us. A trial to adjust the CHAP interview to Gestalt therapy is in process in my Institute. A further purpose of research is to validate a clinical model. This is what I have done in my contribution to organizational consulting (Spagnuolo Lobb, 2012a, 2012b). The text analysis, used as part of the model (Romano, 2012), is coherent with Gestalt therapy, since it gives information on what is figure for the client (the manager of the organization in our case), and also from what experiential ground the figure is formed. The more universal the research method that we use the more our result will be reliable. The research situation is the independent variable, the specific principles that we use to describe the situation are connected to the specific method. A famous example is the already mentioned Boston Change Process Study Group by Stern and colleagues, who used phenomenological language to study intersubjective processes between client and psychotherapist. Using the theory of complexity to read the accounts that psychotherapists give of atypical sessions with their clients in a situation of intervision. The wandering around, the emergence of intersubjective properties, and the now moments are the new concepts that Stern uses to describe what makes change possible. Another example is the Lousanne Trialogue Play by Elisabeth Fivaz-Depeursinge (1999). Triadic interactions in the given research situation are seen according to systemic theory, but it is possible to read them with different languages and epistemologies. In my Institute, we have created a research situation to observe contact making and withdrawal among members of young families (with children from 5 to 7 years old). The first purpose of the research is to observe contact modes in the family, considered as a phenomenological field. The second purpose of the research is to find an observable family Gestalt measure, developed in line with the Gestalt therapy epistemology, composed of three domains: functioning of the self, basic contactmovements, experience of conflict. The third purpose is to prove the measure in a research situation: 20 minutes of filmed family interplay with

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a specific task. The fourth purpose is to rate the films with raters. The fifth purpose is to correlate the rates with the development of psychotherapy or of other life situations like social tolerance of children at school, or hospitalization of a family member or other traumas. The research aims to: 1. validate the observable Gestalt measure and 2. correlate contact modes of family members with social attitudes (tolerance in children for instance) or psychotherapy outcomes (efficacy and timing of change). These are examples that are in line with Gestalt therapy theory and cover all the three fields: outcome research, process research and validation of a practical model.

Research as rootedness Today we are in a time when to fight against institutions and to see research as a means of power and control has no meaning any more: more than the need to develop our autonomy, we experience the need to be rooted in environment and in relationships (Spagnuolo Lobb, 2013a). In this paper I have demonstrated that all kinds of research are coherent with a Gestalt approach: outcome research, process research, and support of a clinical model. Research helps Gestalt psychotherapists root themselves in what they do, and to monitor, with humility and responsibility for their social task, whether their work is appropriate and the most efficient. Research also gives a solid language to dialogue with other approaches, which today represents a key aspect. “What we need in our liquid society is to re-own the sure ground, to feel our body and what we feel when our feet are on the ground, to stay with the experience of our senses, not to stand as a figure in front of another figure (child against father, student against teacher, etc.), but to feel that we can rely on the ground where we stand.” (Spagnuolo Lobb, 2013b). Research will not deprive Gestalt therapists of their innate creativity. Research will instead support their curiosity, which - as Michael Vincent Miller (2003) and Erving Polster (1987) might say – is the soul of therapeutic love.

We all are and have to be curious, in order to highlight the shining beauty that our boring and bored client has hidden. Research is curiosity. Research supports therapeutic love.

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References Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press. Bergin, A. E., & Garfield S. L. (Eds.). (1994). Handbook of psychotherapy and behavior change: An Empirical Analysis (4th ed.). New York: Wiley. Colli, A., & Lingiardi, V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolution in psychotherapy. Psychotherapy Research, 19(6), 718-734. Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324. Fivaz-Depeursinge, E., & Corboz-Warnery, A. (1999). The primary triangle. New York: Basic Books. Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. New York: Schocken Books. Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: Is it true that everyone has won and all must have prizes? Archives of General Psychiatry, 32, 995-1008. Mellor-Clark, J., & Barkham, M. (2006). The CORE system: Developing and delivering practice-based evidence through quality evaluation. In C. Feltham & I. Horton (Eds.), Handbook of counselling and psychotherapy (2nd ed., pp. 207-224). London: Sage Publications. Migone, P. (1994). Una breve storia del movimento di ricerca in psicoterapia. Il Ruolo Terapeutico. Milano: Franco Angeli, 33-36. Migone, P. (1996). La ricerca in psicoterapia: Storia, principali gruppi di lavoro, stato attuale degli studi sul risultato e sul processo. Rivista sperimentale di freniatria, CXX(2), 182-238. Miller, V. M. (2003). The aesthetics of commitment: What Gestalt Therapists can learn from Cèzanne and Miles Davis. In M. Spagnuolo Lobb & N. Amendt-Lyon (Eds.), Creative license. The art of Gestalt therapy (pp. 153-161). New York: Spring. Palmieri, G., Evans, C., Hansen, V., Brancaleoni, G., Ferrari, S., Porcelli, P., ... & Rigatelli, M. (2009). Validation of the Italian version of the clinical outcomes in routine evaluation outcome measure (CORE̺ OM). Clinical psychology & psychotherapy, 16(5), 444-449. Parloff, M. B. (1985). Psychotherapy outcome research. In R. Michele & J. O. Cavenar Jr. (Eds.), Psychiatry (Vol. 1, chap. 11). Philadelphia: Lippincott.

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Polster, E. (1987). Every person’s life is worth a novel. New York: W.W. Norton & Co. Robine, J. M. (Ed.). (2001). Contact and relationship in a field perspective. Bordeaux: L'Exprimerie. Romano, F. (2012). Il benessere organizzativo e la vitalità del gruppo di lavoro: Un progetto di ricerca. Sandell, R. (1987). Assessing the effects of psychotherapy: III. Reliability and validity of “change after psychotherapy”. Psychotherapy and Psychosomatics, 47(1), 44-52. Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore, MD: John Hopkins University Press. Spagnuolo Lobb, M. (2012a). Il now-for-next nella psicoterapia di gruppo. La magia dello stare insieme. Un modello di intervento Gestaltico nei gruppi. Quaderni di Gestalt, XXV(1), 57-70. Spagnuolo Lobb, M. (2012b). Stress e benessere organizzativo. Un modello Gestaltico di consulenza aziendale. Quaderni di Gestalt, XXV(1), 87-104. —. (2013a). From the need for aggression to the need for rootedness: A Gestalt postmodern clinical and social perspective on conflict. British Gestalt Journal, 22(2), 32-39. —. (2013b). Isomorfismo: Un ponte concettuale tra psicoterapia della Gestalt, psicologia della Gestalt e neuroscienze. In P. A. Cavaleri (Ed.), Psicoterapia della Gestalt e Neuroscienze. Dall'isomorfismo alla simulazione incarnata. Milano: Franco Angeli Spagnuolo Lobb, M., & Lipari, D. (2010). Ricerca e fascino in psicoterapia: Addestrare a vedere la bellezza nascosta del paziente. Idee in psicoterapia, 3(2), 31-38. Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York: W.W. Norton. Stern, D. N., Bruschweiler-Stern, N., Harrison, A., Lyons-Ruth, K., Morgan, A., Nahum, J., Sander, L., & Tronick, E. (1998a). Noninterpretive mechanisms in psychoanalytic therapy. The “something more” than interpretation. International Journal of PsychoAnalysis,79, 903-921. Stern, D. N., Bruschweiler-Stern, N., Harrison, A., Lyons-Ruth, K., Morgan, A., Nahum, J., Sander, L., & Tronick, E. (1998b). The process of therapeutic change involving implicit knowledge: Some implications of developmental observations for adult psychotherapy. Infant Mental Health Journal, 3, 300-308. Stern, D., Bruschweiler-Stern, N., Harrison, A., Lyons-Ruth, K., Morgan, A., Nahum, J., Sander, L., & Tronick, E. (2003). On the other side of

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the moon. The import of implicit knowledge for Gestalt therapy. In M. Spagnuolo Lobb & N. Amendt-Lyon (Eds.), Creative license: The art of Gestalt therapy (pp. 21-35). Vienna and New York: Spinger. Stevens, C., Stringfellow, J., Wakelin, K., & Waring (2011). The UK Gestalt psychotherapy CORE Research Project: The findings. The British Gestalt Journal, 20(2), 22-27. Wolpe, J. (1969). The practice of behavior therapy. New York: Pergamon.

CHAPTER THREE CRITICAL REALISM AS AN ONTOLOGY FOR GESTALT THERAPY RESEARCH ALAN MEARA

Everything is in flux. Only after we have been stunned by the infinite diversity of processes constituting the universe can we understand the importance of the organizing principle that creates order from chaos; namely, the figure-background formation. —Perls, 1948/2012, p. 49

Introduction Recently, at the 2010 AAGT Conference “Continuity and Change,” Frank Staemmler stated: Since it is a truism that the sciences never come to a standstill, it follows from their [PHG, (1951, p. viii)] statement that if Gestalt therapy wants to remain a “consistent and practical psychotherapy,” it needs to take notice of and integrate “whatever valuable substance the sciences of our time have to offer.” In other words, we must transform ourselves again and again, if we want to remain true to ourselves and stick to our principles. (Staemmler, 2011, p.100)

My starting position in this chapter is that complexity theory constitutes a valuable substance of the science of our times. Complexity theory, which includes self-organization and chaos theory, is also concerned with the themes of continuity and change and the possibility of transformation. The above quote from Perls demonstrates that he, as one of the founders, had already recognised some of the themes that link Gestalt theory with complexity theory: flux, diversity of processes (my italics) and organizing principles. Some of these concepts have found their

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way into the unsatisfactory mire (see Staemmler, 2006) of what is called “field theory”. In approaching research however, engaging with complexity theory raises philosophical implications due to the inherent nature of complex systems: non-linearity; multiple interactive parts/processes; attractor dynamics and system evolution in particular (Burlingname, Fuhriman, & Barnum, 1995). Traditional research positions may not suffice. Whether the implications of complexity theory support postmodernism or postpositivism is the subject of some debate, and a way to transcend an “either/or” debate and perhaps move to “both/and” is potentially offered by critical realism. At first glance, there is strong challenge to constructivism, “complexity theorists aim to make sense of a world that exists objectively, beyond our language games” (Morcol, 2001, p. 105). More overtly: “We start with the understanding that complexity is a real, non-constructed property of the world” (Gerrits & Verweij, 2013, p. 168). Assumptions about the nature of reality, and thus ontology, require examination. My intent is to present an argument that the critical realist view of ontology and epistemology deserves consideration as a research approach for Gestalt therapy and secondly to stimulate interest in exploring potential research applications that incorporate complexity theory. I will explore the relationships between critical realism, complexity theory, as well as phenomenology as a foundational influence on Gestalt therapy, with some examples of research activities. Given the increasing interconnection between these fields, presenting a traditional linear discourse has its challenges, so the full picture will be an emergent process. At times I will refer to a discontinued doctoral research project. The setting for the research was a Gestalt oriented personal development group, with myself as facilitator and thus a participant-researcher. The methodology was an iterative case study approach to theory building consistent with critical realism (Eisenhardt, 1989). The method utilised qualitative and quantitative analyses, but where the quantitative analysis was a non-linear technique, called time series embedding, which graphically displayed patterns of coded language allowing the identification of shifts in patterns (attractors) over time. A key feature of the conception of the group was that of nested systems. The intrapsychic level was differentiated into subsystems such as thoughts, feelings and body sensations and tracked through language. The same tracking was applied to interpersonal, subgroup, group as a whole and interactions with the context.

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Such a model is consistent with an emergentist ontology and is supported by Burlingname et al. (1995) who list similar multiple levels, each potentially being connected and influencing each other, claiming that it is impossible to analyse a single part in isolation when seeking to describe the embeddedness that is present1. The intention was to match pattern shifts to events in a real time description of group interactions and facilitator action, with a descriptive rather than predictive focus, leading to potential identification of what tended to promote or inhibit revolutionary change. The proposed outcome was a process based theory for the facilitation of groups grounded in Gestalt and complexity theory, and within a critical realist framework2.

Ontology The fundamental question of ontology is “What is the nature of reality?” Representatives of the three strands of thought that braid my research have answers with a high degree of resonance, perhaps a weak form of consilience. In brief at this point, critical realism presents a stratified ontology of three domains (real, actual, and empirical) each with emergent properties. The domain most representative of ontology is the real domain which is populated by variably interacting causal mechanisms that do not necessarily generate “constant conjunctions of events” (Bhaskar, 1989). Complexity theory also views the nature of reality as a dynamic, recursive process, which contains chaotic and non-chaotic characteristics, and may exhibit self-similarity at different system levels. General processes are determinable, but specific outcomes are unpredictable (Gregerson & Sailer, 1993). And, in one of the few explicit ontological statements within Gestalt literature, the nature of reality is seen as an ongoing, constantly changing process, where all things exist in relation to other things and are thus engaged in process. Again, consequences are not necessarily explainable by causality (Korb, Gorrell, & Van de Riet, 1980). At the most general level, ontologies may be considered as subjectivist or objectivist, as can epistemologies, and thus combinations may be constructed that represent various research positions. Positivism for example is represented by objectivist ontology and epistemology, and postmodernism by both subjectivist ontology and epistemology. The latter position is criticised by Johnson and Duberley (2000) as relegating science 1 2

See Meara (1999) for a description of the setting and method. See Meara (2005) for an outline of the model.

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to a self-referential exercise with no common ground for judgement between theories. Bhaskar also criticises postmodernism as containing an “epistemic fallacy”, which collapses epistemology and ontology into one another, the separation of which is central to Bhaskar’s position. Critical realism accepts a relativist epistemology, but not a relativist ontology. In accepting a relativist epistemology, that knowledge (not reality) is socially constructed, the means for judging theory come from an appeal to the causal mechanisms located in external reality, and the efficacy of human actions in achieving outcomes (Johnson & Duberley, 2000). While phenomenology could be seen as a postmodern enterprise, perhaps this view can be reconsidered. There is a strong constructivist element in recent Gestalt writings, particularly those of Gordon Wheeler and Mark McConville, who explicitly denies a reality beyond what is cocreated: “Fields cannot be spoken of properly as existing in themselves, in nature, apart from a co-constitutive human subjectivity, and it is this philosophical tenet that justifies Gestalt therapy’s reverence for firstperson experience” (McConville, 2001, p. 201). I would argue that my experience of gravity does not create gravity. Yet, the constructivist position is not firm, and Burkitt (2003) reviews how Shotter, Gergen and Harré address the issue of those aspects outside discourse as “an already partially structured dynamic environment” (Shotter, cited in Burkitt, 2003, p. 332) in what seems to be an uneasy recognition that not all reality is socially constructed, yet without a way to reconcile this recognition. A further challenge is offered by Arthur Roberts (1999) who argues that the field of field theory is not socially constructed and existed prior to our discussion about it. In terms that resonate with complexity theory and critical realism, and also echo Kurt Lewin, he claims that “The field is lawful, nuanced, precise, dynamic and intricate. The laws to which it conforms are its own laws. We do not construct them” (Roberts, 1999, p. 35).

Phenomenology and ontology Within the phenomenological movement itself, Husserl set aside the nature of reality, and in employing eidetic, transcendental and phenomenological reductions, his phenomenology is “an analysis of the meaning-contents of intentional experiences” (Smith & McIntyre, 1982, p. 104). On the other hand, Heidegger’s Dasein is thrown into a world that pre-exists, and is therefore arguably real. Heidegger is undecided on the nature of such a world, and in a debate on that topic Dreyfus and Spinosa (1999, p. 52) argue that he was a “robust” realist since he describes phenomena that

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enable him to distinguish between the everyday world and the universe. By robust, they mean that there exists a reality accessible to science independent of our experience of it, in other words the critical realist position. In fact, in describing Heidegger’s insistence that “entities are independently of the experience by which they are disclosed, the acquaintance in which they are discovered, and the grasping in which their nature is ascertained” (as cited in Dreyfus & Spinosa, 1999, p. 54) they reveal a statement that is very close to Bhaskar’s stratified ontology. Merleau-Ponty is of special significance for ontology, first with his focus on the importance of embodiment where he “identifies the experiencing self with the bodily organism” (Abram, 1996, p. 45). Here he supported a reality separate to our experience: “our embodiment brings to our perceptual experience an a priori structure whereby it presents itself to us in consciousness as experience of a world of things in space and time whose nature is independent of us” (1996, p. 9). Merleau-Ponty also anticipates complexity theory and makes several references to selforganization, in one example saying that the field of action and perception, the brain and the functioning of the organism are “nothing outside the process which organizes itself” (Merleau-Ponty, 1983, p. 207). Both the Gestalt psychologists and PHG describe equilibrium models of change (organismic self regulation, for example) which restore an organism to balance, however Merleau-Ponty is wary of these, emphasising the fragility of equilibria, and the ambiguity of perception. Flynn (2009) notes that in the Structure of Behaviour, Merleau-Ponty (influenced by Hegel) describes three emergent layers, or orders, of Gestalten (patterns or structures) of phenomena. The simplest is the structure found in the physical world such as how oil spots form in water; more complex are vital structures that describe animal behaviour without insight, such as a bird attempting to fly through a window; and the most complex being the human order. In this latter order, he states that a delay between biological stimulus and response constitutes “work”, an internal processing and choice which is a direct parallel with the concept of organismic processing of stimuli before responding, as proposed in PHG. Again, Merleau-Ponty anticipates critical realism and complexity theory which both take emergent open systems as the basis for ontology, the latter emphasising the need for far from equilibrium conditions for fundamental change to occur. However, in his last work, The Visible and the Invisible (1968), unfinished, Merleau-Ponty left glimpses of a quest to move beyond The Phenomenology of Perception and address ontology. What remains are a set of working notes for example: “Necessity of a return to ontology – The

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ontological questioning and its ramifications: the subject-object question; the question of inter-subjectivity; the question of Nature” (Merleau-Ponty, 1968, p.165), and: “Results of Ph.P. – necessity of bringing them to ontological explication” (Merleau-Ponty, 1968, p.183). While Merleau-Ponty’s key idea of the perceived-body or embodied consciousness has been “a major source of the somatic turn in social science theory, it is important to recall that the central principle which underwrites his concepts of the lived-body”, “intercorporeity, and ‘flesh’ is the self of movement” (Varela, 2003, p. 125). He proposed that our body and the world are two aspects of a single reality: “flesh” (chair, in French). According to Charles Varela (2003), flesh refers to “the primordial reality of causal powers in nature” (p. 128), a direct connection to critical realism. In the Gestalt literature, and recognising the potential importance of the concepts of reciprocity and intercorporeity for practice, Staemmler (2009) reports the creation of a new word in German – “einleibung” translated approximately as embodypathy. For MerleauPonty, the field that he speaks of is an intercorporeal space before it becomes an intersubjective one (Burkitt, 2003). In relating these difficult terms to ontology in general, Ian Burkitt (2003) takes Merleau-Ponty’s conception of humans as situated in a “wider field of Being” to radically extend constructionism (and also Heidegger’s being-in-the-world): field of Being is not centred on humans: it includes us, but the human world is only a dimension or a moment of the field of Being, not its origin. This insight reconnects us to our primal ties with the world, which forms a brute Being or wild ontology. (Merleau-Ponty, as cited in Burkitt, 2003, p. 327)

The seeds of this later ontology may be found in Merleau-Ponty’s essay on Cézanne: He wanted to depict matter as it takes on form, the birth of order through spontaneous organization. … He wanted to put intelligence, ideas, sciences, perspective and tradition back in touch with the world of nature which they were intended to comprehend. He wished, as he said, to confront the sciences with the nature “from which they came” (1964, pp. 13-14).

To illustrate intercorporeality, Merleau-Ponty (1964) quotes Cézanne: “The landscape thinks itself in me and I am its consciousness” (p. 17). In his art, Cézanne was striving to capture the world as we see it before we make sense of it, something that is central to the phenomenological

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philosophy tradition; “the notion of pre-reflective self-consciousness; a form of primitive self-awareness that is believed to belong inherently to any conscious experience” (Hanna & Thompson, 2003, p. 134). They go on to say that such states are access consciousness in principle, in that they are the kind of states that can become available to reflective awareness and verbal report. The inclusion of body related data in my research project, expressed through verbal and nonverbal language, allowed such access. From a different perspective, that of cognitive neuroscience, Legrand (2007) outlines experiential and empirical methods for exploring and defining pre-reflective consciousness, that she claims has been missed in that field´s exploration of neural correlates of the self. In a broader context, there have been calls to naturalise phenomenology, since “the phenomena it studies are part of nature and are therefore also open to empirical investigation” and “that scientific investigation and phenomenology should mutually inform each other” (Gallagher & Zahavi, 2008, p. 32). The parallel development of neurophenomenology, has an explicit research programme, addressing epistemological issues with the fallibility of first person reporting, delineated by Francisco Varela (1996). The general approach, at a methodological level, is (i) to obtain richer firstperson data through disciplined phenomenological explorations of experience, and (ii) to use these original first-person data to uncover new third-person data about the physiological processes crucial for consciousness. (Lutz & Thomson, 2003, p. 32)

Furthermore, “neurophenomenology endorses the strategy, now shared by many researchers, to use the framework of complex dynamical systems theory.” (Lutz & Thomson, 2003, p.40) In raising the issue of physiological processes, a further avenue for research in potential partnership with neuroscience is opened that explores out of awareness dynamics in psychotherapy. In a PhD project for which I was a co-supervisor, therapists and clients undertaking brief therapy were monitored through various measures including EEG, heart rate and skin conductance, while also reporting through various questionnaires including the Working Alliance Inventory, in order to identify the physiological correlates of empathy from a relational perspective (See Stratford, Lal, & Meara, 2012). The findings of neurophenomenology and neuroscience may go beyond offering confirmation of what Gestalt therapists do, and provide the opportunity for the integration of valuable new ideas and approaches to Gestalt theory and practice. Critical realism methodologies would allow the extension of empirical studies to attempt the identification of the

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background processes (generative mechanisms) that interact to allow the observable events to potentially occur.

Critical realism Originally, the philosophical basis for Bhaskar’s ontology of science was termed Transcendental Realism, later followed by Critical Naturalism as an approach to the possibility of a social science. In time, the generic term Critical Realism became generally adopted (Bhaskar, 1989; Harvey, 2002). The core of Bhaskar’s objectivist ontology is a stratification into three domains: the real, where interacting causal or generative mechanisms reside, independently of our knowledge of them; the actual, where events occur whether we observe them or not; and the empirical, where events are measured or experienced. This is not the critical realism referred to by Staemmler (2006, p.70) citing Mehrgardt (2005, p. 35) as informing the Gestalt psychologists, particularly their idea of isomorphism. While Mehrgardt (2005) outlines a case for Gestalt therapy’s epistemology to be dialectic constructivism, in which he states “one cannot pursue epistemology without ontology” (p. 40), he seems to imply an ontology that is incompatible with constructivism. Bhaskar’s critical realism is firmly placed in examining the mechanisms within social structures such as the family, the state and language in relational terms; “Social structures…advance an understanding of the social world as essentially consisting in or depending upon relations,” and “(…) where social phenomena are the product of a plurality of structures, realism helps to guide empirically controlled investigations into the structures generating social phenomena” (Bhaskar, 1989, p. 3). Another key aspect of Bhaskar’s ontology is that of emergence and he goes so far as to say: “It is only if social phenomena are genuinely emergent that realist explanations in the human sciences are justified” (1986, p. 103). A useful summary of an emergentist ontology is provided by Dave Elder-Vass, saying that it: (…) identifies a number of structural elements that we would expect to find in any object of scientific enquiry: entities, made up of parts (which are themselves entities), organised by particular relations between the parts, and possessing emergent properties in virtue of these relations. In order to explain these entities, relations and properties, we need to identify the mechanisms by which the parts and relations lead to the properties, the morphogenetic causes that bring this set of parts into this set of relations in the first place and the morphostatic causes that keep them so. And once we are equipped with these elements, we can go on to explain events, and

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perhaps event regularities or partial regularities, by showing how the emergent properties or causal powers of the entities concerned interact to co-determine actual events. (Elder-Vass, 2007, p. 231)

The value of a layered, emergent ontology is that the analyses are capable of relating the interdependent levels of human engagement with society (O’Mahoney, 2011). Morphosatic and morphogenetic causes should not be understood as implying linear causality, but as tendencies that resonate with the continuity and change theme noted at the beginning of the chapter. Such terms may be related to Lewin’s forces for change and sameness, inhibitions and drivers of contact, and the dynamics of self organisation and complex systems. In the literature on critical realism there are three broad streams, one that clarifies versions of realism, one as a critique of other philosophies of science, and one as a more conciliatory position that seeks to build bridges. Some examples follow, to illustrate the diversity of applications and potential convergence in research thinking and application. In developing an argument for an autonomous psychiatric nursing profession not founded on medical psychiatry, Littlejohn (2003) states that the underlying tension “(…) cannot be resolved by way of the underpinning philosophies of these positions, namely empiricism and idealism. Instead, critical realism positioned between these philosophies offers a methodology through which to seek a new paradigm” (p. 450). Connelly (2007) presents an argument for critical realism as a context based relationship focused method rather than empiricist based RCTs for evaluating complex public health interventions. O’Mahoney (2011) outlines possibilities for critical realism for the study of the self, identity and agency, incorporating notions of discourse, arguing that “in the social sciences, critical realism has established a persuasive and credible foothold between the correlational approaches of logical positivism and the ‘collapsed ontology’ of anti-realism” (p. 122). (Clarke, 2003) offers critical realism as a bridge between Archer’s agency and personal relations psychoanalytic theories. In examining agency and structure theory from an organisational studies perspective, Fleetwood (2005) notes that the postmodern turn away from naïve realism introduced an ambiguous, socially constructed ontology and suggests critical realism as an alternative ontology that overcomes the postmodern criticisms of such theory. A further development arising in the critical realist literature is the inclusion of embodiment. In seeking to provide a solution to constructionism’s ambivalence to subjectivity and absence of the body, Cromby (2004) introduces his concept of embodied subjectivity, and

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argues for a critical realist form of social constructionism. Cromby draws on the work of Harré (2002), “who lays the foundation for a future ‘cognitive science’ by deploying three grammars (in Wittgenstein’s sense of that term), as systems and clusters of rules ordering human activity” (p. 801). Using the background of a study on depression, he draws from sources in neuroscience to provide examples for Harré’s framework of three “grammars” of causality and influence: person; organism and molecules. Shotter’s rhetorical-responsive constructionism is placed in the person category, Damasio’s somatic marker hypothesis and Gazzinaga’s left-brain based “interpreter” in the organism category, and neurotransmitters in the molecule category. He argues that an integration of these as embodied subjectivity “makes constructionism more coherent, credible, and critical” (Cromby, 2004, p. 797). In referring to the movement known as “embodied cognition” initiated by Francisco Varela and others, Garbarini & Adenzato (2004) describe how the concept of affordances, introduced by J.J. Gibson in 1947, acts as an ontology for the relationship between physical objects in the environment and animal behaviours. Gibson was inspired by Koffka’s “demand character of an object” to propose that the environment offers affordances such as possibilities for nutrition, tool manipulation and emotional responses. The concept has been extended to human/environment interactions (Garbarini & Adenzato, 2004; Chemero, 2003; Letiche & Lissack, 2009). In particular, Chemero (2003) argues that affordances are relationships in the animal/environment system that require a realist ontology, as affordances exist whether perceived or not. He also sharpens the definition of affordances as relations between the abilities of organisms and features of the environment. Others link affordances to emergence and complexity theory (Letiche & Lissack, 2009), and to mirror and canonical neuron systems (Garbarini & Adenzato, 2004; Sahin & Erdogan, 2009). Not surprisingly, there are references of support for embodied cognition from the body oriented phenomenology of Merleau-Ponty, particularly in the work of Lakoff and Johnson (1999) who note the dual acceptance of the lived body and the biological body implied in the term. In summary, critical realism is emerging as a higher order application of research philosophy across the social sciences, including psychotherapy. In particular, some of the core elements of critical realism; emergence (holism), embodiment and relational processes are fundamental to Gestalt therapy, and so consideration of this philosophy is deserved.

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Complexity theory Complexity theory is an umbrella term that includes chaos theory, selforganised criticality, autopoiesis, self-organisation, dissipative structures, and complex adaptive systems, all of which are based on nonlinear processes in open systems, in both the natural and social worlds. I will focus on chaos theory and self-organisation, as being most relevant aspects of complexity theory for research projects. Critical realism has begun to recognise the implications of complexity theory in several ways. Harvey (2002) describes the formation of complex realism, the use of complexity theory to read and interpret Bhaskar’s original model. Bhaskar had always considered his project to be based on open systems which are a given for the emergence of non-linear dynamics: …historically embedded cultural and social processes of reproduction inherently possess a sensitive dependence upon initial conditions. Hence, … well-tested strategies or traditional techniques can produce radically different outcomes over time which introduces future uncertainty and contingency into … Bhaskar’s model. (Harvey, 2002, pp. 168-169)

In terms of relating complexity theory to other philosophies, it is clear that postmodernism and complexity science are incompatible, “anchored in different ontologies and epistemologies” (Morcol, 2001, p. 104). The relationship to postpositivsm is not so clear, given the diversity of approaches in both areas. Some complexity theorists, an exemplar being Prigogine and Stengers (1984), allow for an indeterminacy characteristic of reality that aligns with a postpositivist view that knowledge is contextual, and that some generalisations are still possible. Predictability, however, is not. Therefore a nonlinear dynamics approach will not produce results that can be assessed by typical postpositivist statistical analyses. Briefly, chaos theory emerged from the study of mathematical models of nonlinear dynamical equations, where the relationships between parameters are not simply additive, and where parameter values at a certain time are influenced by prior values (Gleick, 1987). The various analytic methods of chaos theory based modelling were soon used to explore the dynamics of a wide range of social and biological systems, where seemingly complex processes were shown to have an underlying order that could be described mathematically (Krippner, 1994). For example, Badalamenti and Langs (1992) used language as a measure for undertaking used phase space analysis, and found attractors in trajectories of patient and therapist entropies, supporting the idea that interactions in

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groups may exhibit attractor dynamics revealed by language. More generally, chaotic dynamics have been demonstrated in many human biological and psychological systems (including mood disorders), and Orsucci (2006) provides an overview while proposing the value of Husserlian phenomenology and embodied cognition in extending the contribution of complexity theory to clinical neurocognitive science. My research interest was to explore group dynamics, in part using a technique called time series embedding (Sterman, 1998), which allows system behaviour to be visualised through the use of a phase space, a graphic display of the pattern of states (attractors) visited by a system over time. A state is defined at a point in time determined by the values of the parameters chosen for a study, in this case a typology of language utterances. The parameters form the axes of the graph, and the determination of a state at a point in time involves the value of parameters at the previous point. So, rather than producing a time series, the system is in essence folded back on itself through iteration to reveal a moving present. A noticeable shift in attractor patterns may be called revolutionary change, as opposed to evolutionary, where any minor disturbances may affect the system to a small degree and a semi-stable state is returned to. A qualitative analysis can then be used to categorise factors present at times of pattern shifting and examine any “left over” data for possible new categories. The intention was to explore whether certain activities are associated with pattern shifts, that is, what facilitates change. When exploring group dynamics, “the shape of the phase space mapping of a group’s variables over time may describe the emerging variables that reveal the group’s or members’ movement from disorganisation to organisation or movement from organisation to disorganisation” (Rivera, Wilbur, Frank-Saraceni, Roberts-Wilbur, Phan, & Garrett, 2005, p.117). A related concept, self-organisation, is more interested in the movement from disorder to order. Self-organisation is a way to describe a system that may have chaotic and non-chaotic dynamics or patterns, but takes a broader view, seeking to describe the various factors that may influence an open system. The term self-organisation itself refers to the capability of an open system to “acquire some degree of stability, as well as the ability to flexibly reconstruct, when destabilized by new internal or external information, without specification from external cues” (Rivera et al., 2005, p. 118, italics added). With some background in Gestalt, and seeking to extend Kurt Lewin’s models of change, Smith and Gemmill (1991) hypothesised the key elements of self-organisation in small groups as: non-equilibrium conditions; symmetry breaking (linked to unfreezing and

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amplification of disorder through questioning assumptions); experimenting; alignment to deep structure and self-reference (linked to system history); and resonance, reparation and orchestrated movement. They noted that experimenting behaviour creates variety and improves the possibility of adapting to a more complex environment. Smith and Comer (1994) utilised an instrument, a self-reporting Coaction Diagnosis Scale (CDS) to show that task effectiveness was enhanced when groups exhibit characteristics of self-organisation. This type of research, however, does not examine the dynamics of real time interaction. In the domain of research into psychotherapy process Burlingname, Fuhriman and Barnum (1995) identified two broad categories. One is process as phenomenon: investigating an aspect of therapist/client behaviour through static samples of a variable, or repeated static samples to plot shifts over a period of time. The other is process as interaction: detailing the reciprocal transactions between participants by measuring a variable moment by moment. The latter was the approach I favoured as enabling a more dynamic examination of self-organising behaviour and potential identification of change points.

Research implications Having described the interrelationships in the fields of interest I submit that there is sufficient support for applying critical realism to research in Gestalt therapy, while recognising the caveats associated with the types of outcomes expected. However, a recent survey showed that critical realism in the social sciences has largely addressed macro-level analyses of social factors such as class, or theoretical approaches positioning the critical realist ontology against other positions. Only 2% of studies were published in psychology or psychiatry journals, meaning there is little in the way of establishing a tradition of critical realist analyses of the self and associated methodologies (O’Mahoney, 2011). Bhaskar himself had developed an emergent model of self, with ascending layers moving from neurological matter to mind to consciousness to selfhood to personal identity to social agency and so had provided a view that “self could be presented as a complex, multi-layered and embedded being” (O’Mahoney, 2011, p. 125), allowing a movement beyond the narrow definition of reflexive agency favoured by most realist macro studies. Such a model resonates with the Gestalt informed nested system model of a group that I employed in my research. In brief, the methodology adopted Eisenhardt’s (1989) model of building theory from case research method, but with the sequential and

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iterative processes of analytic induction, all within a transcendental realist epistemology. This was particularly suitable for the study with its emphasis on understanding the dynamics within a single setting, although multiple cases are utilised. The methodology was translated into a design for this particular research, each of the six group meetings represented a case in itself. It was planned to conduct cross case analysis after meeting four, when sufficient data had been amassed, and a longitudinal analysis after completion of the sessions. This approach is supported by Werstlein and Borders (1997) who recommend single subject (one group) research designs and case studies such as those used by Fuhriman and Burlingname (1994), which involve multiple process variables which may provide the clearest means to describe the group, and specify changes in the behaviours or actions of the group over time. The same principles could apply to researching families, couples and individuals. They also suggest that a discovery oriented research procedure may be most appropriate in the investigation of complex, nonlinear group variables; because, “discovery oriented research is viewed as a necessary first step in the systematic inquiry of phenomenon, with the goals of describing what is actually happening and then generating hypotheses for future study” (Werstlein & Borders, 1997, p, 122). Furthermore, a critical realist use of case studies sheds light on specific conditions under which generative mechanisms act, and these explanatory idiographic studies are “epistemologically valid because they are concerned with the clarification of structures and their associated generative mechanisms, which have been contingently capable of producing the observed phenomena” (Tsoukas, 1989, p. 556, but see Trimarchi, 1998 for a detailed discussion of critical realism applied to case studies). I offer the project as an example of what might be possible in applying critical realism coupled with complexity theory, which supplies a form of quantitative evidence, supported by phenomenologically-based qualitative evidence. The inclusion of nonlinear dynamics appears to me to be an important consideration for future research directions in Gestalt therapy, given the fundamental assumptions about the nature of the conditions within which Gestalt practice is conducted. Efficacy studies will always be probabilistic, and moves to develop a manualised standardised approach may further increase the linearity of assumptions, as well as limiting the identification of the perturbations or fluctuations that allow selforganisation to occur. The claims that modality specific skills and techniques are unimportant have been challenged (Asay & Lambert, 1999), and an open system process oriented approach could allow the

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identification of aspects of the Gestalt approach that could flesh out and add to the common factors debate. In particular, I would urge the incorporation of body related data, the use of language to go deeper than categorising statements, and real time assessment of the quality of relating processes. My wish in summarising the ongoing trend to convergence in phenomenology, critical realism, complexity theory and neuroscience, is that others will be motivated to embark on a voyage of discovery and create research applications that add to our understanding and valuing of what Gestalt offers. A primary element of human being is “perceptual faith” in the field, which is not a certainty or knowledge about the world, but more of a naïve belief that “there is a world, there is something… there is cohesion, there is meaning” (Merleau-Ponty, 1968, p.88). We are then left with the feeling that there is something left to be said; that something of the world has escaped our attempts at articulation and that there is a need to speak or write to continue the dialogue. (Burkitt, 2003, p. 331).

References Abram, D. (1996). The spell of the sensuous. New York, NY:Vintage. Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 33-56). Washington, DC: American Psychological Association. Badalamanti, A. F., & Langs, R. J. (1992). The progression of entropy of a five dimensional psychotherapeutic system. Systems Research, 9(3), 328. Bhaskar, R. (1989). Reclaiming reality. London: Verso. Burkitt, I. (2003). Psychology in the field of being. Theory & Psychology, 13(3), 319-338. Burlingname, G. M., Fuhriman, A., & Barnum, K. R. (1995). Group therapy as a nonlinear dynamical system: Analysis of therapeutic communication for chaotic patterns. In F. D. Abraham & A. R. Gilgen (Eds.), Chaos theory in psychology (pp. 87-105). Westport CT: Praeger. Chemero, A. (2003). An outline of a theory of affordances. Ecological Psychology, 15(2), 181–195.

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Harvey, D. L. (2002). Agency and community: A critical realist paradigm. Journal for the Theory of Social Behaviour, 32(2), 163-193. Johnson, P., & Duberley, J. (2000). Understanding management research – An introduction to epistemology.London: Sage. Korb, M., Gorrell, J., & Van De Riet, V. (1980). Gestalt therapy practice and theory (1st ed.). Pergamon: New York Krippner, S. (1994). Humanistic psychology and chaos theory: The third revolution and the third force. Journal of Humanistic Psychology, 34(3), 48-61. Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York: Basic Books Legrand, D. (2007). Pre-reflective self-as-subject from experiential and empirical perspectives. Consciousness and Cognition, 16, 583-599. Letiche, H., & Lissack, M. (2009). Making Room for Affordances. E:CO, 11(3), 61-72. Littlejohn, C. (2003). Critical realism and psychiatric nursing: A philosophical inquiry background. Journal of Advanced Nursing, 43(5), 449–456. Lutz, A., & Thompson, E. (2003). Neurophenomenology: Integrating subjective experience and brain dynamics in the neuroscience of consciousness. Journal of Consciousness Studies, 10(9–10), 31–52. Meara, A. (2005). Facilitating change in open systems. Gestalt Journal of Australia and New Zealand, 2(1), 7-30. —. (1999). The butterfly effect in therapy: Not every flap of a butterfly’s wing… Gestalt Review, 3(3), 205-225. Merleau-Ponty, M. (1968) The Visible and the Invisible, followed by Working Notes (A. Lingis, Trans.). Evanston, IL: Northwestern University Press. —. (1964). Cézanne’s doubt. In sense and non-sense (Studies in phenomenology and existential philosophy) (pp. 9-25). Evanston, IL: Northwestern University Press. (Original work published 1948.) —. (1983). The structure of behavior (A.L. Fisher, Trans.). Pittsburg, PA: Duquesne University Press. (Original work published 1942) McConville, M. (2001). Let the straw man speak: Husserl’s phenomenology in context. Gestalt Review, 5(3), 195-204. Mehrgardt, M. (2005). Dialectic constructivism: An epistemological critique of Gestalt Therapy. International Gestalt Journal, 28(2), 3165. Morcol, G. (2001). What is complexity science? Postmodernist or postpositivist? Emergence, 3(1), 104-119.

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O’Mahoney, J. (2011). Critical realism and the self. Journal of Critical Realism, 10(1), 122-129. Orsucci, F. F. (2006). The paradigm of complexity in clinical neurocognitive science. Neuroscientist, 12, 390-397. Perls, F. S. (2012). From planned psychotherapy to Gestalt therapy: Essays and lectures - 1945 to 1965 Frederick Salomon Perls. Highland, NY: Gestalt Journal Press. (Original work published 1948) Prigogine, I., & Stengers, I. (1984). Order out of chaos. Man’s new dialogue with nature. London: Flamingo. Rivera, E. T., Wilbur M., Frank-Saraceni, J., Roberts-Wilbur, J., Phan, L. T., & Garrett, M. T. (2005). Group chaos theory: A metaphor and model for group work. The Journal for Specialists in Group Work, 30(2), 111-134. Roberts, A. (1999). The field talks back: An essay on constructivism and experience. British Gestalt Journal, 8(1), 35-46. Sahin, E., & Erdogan, S. T. (2009, September). Towards linking affordances with mirror/canonical neurons. 24th International Symposium on Computer and Information Sciences, Guzelyurt, 397– 404. Smith, C., & Comer, D. (1994). Self-Organisation in small groups: A study of group effectiveness within non-equilibrium conditions. Human Relations, 47(5), 553-581. Smith, C., & Gemmill, G. (1991). Changes in the small group: A dissipative structure perspective. Human Relations, 44(7), 697-716. Smith, D. W., & McIntyre, R. (1982). Husserl and intentionality: A study of mind, meaning and language. Dordrecht and Boston: D. Reidel Publishing Co. Staemmler, F-M. (2006). A Babylonian confusion? On the uses and meanings of the term ‘field’. British Gestalt Journal, 15(2), 64-83. —. (2009). On Macaque monkeys, players, and clairvoyants: Some ideas for a Gestalt therapeutic concept of empathy. In D. Ullman & G. Wheeler (Eds.), Co-creating the field: Intention and practice in the age of complexity (pp. 73-101). NY: Routledge, Taylor & Francis. —. (2011). Continuity and change. In D. Bloom & P. Brownell (Eds.), Continuity and change: Gestalt therapy now (pp. 100-108). UK: Cambridge Scholars Publishing. Stratford, T., Lal, S., & Meara, A. (2012). Neuroanalysis of therapeutic alliance in the symptomatically anxious – The physiological connection revealed between therapist and client. American Journal of Psychotherapy, 66(1), 1-21.

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CHAPTER FOUR RESEARCH FROM A RELATIONAL GESTALT THERAPY PERSPECTIVE KEN EVANS

What Does it Matter if We Gain the World but Lose Our Soul? —Mathew 16:26, adapted

Engaging brain In this chapter I address the need for integrity and congruence between the philosophies and values underpinning Gestalt and the research methods used when engaging in research from a Gestalt perspective. This includes methods and approaches adopted from mainstream research as well as those created by Gestalt practitioner-researchers. In the late 1980s I was Chair of an organising committee for a national Gestalt conference located in Nottingham, England. In the spirit of Gestalt, the organising committee was committed to encouraging workshops that would critique Gestalt theory and practice and evolve its growth and development. During the final plenary session, a senior member of the Gestalt community (now deceased) stood up and, vigorously waving a copy of Gestalt Therapy: Excitement and Growth in the Human Personality, berated the entire conference community, except for a handful of idealising disciples. He insisted that none of our ideas were contained in this book! To my mind he resembled a fundamentalist preacher holding high the bible and exhorting us to step back from heretical thinking and return to the 'true' path. Ironically, the conference location was a theological college. Frank and Frank suggest that belief in one's modality is central to an understanding and application of any psychotherapeutic approach, both on

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the part of the therapist and the client (Frank & Frank, 1991). However, along with Downing, I think it potentially dangerous when beliefs are held as if they were absolute truths (Downing, 2000). Over the past sixty years, Gestalt has evolved some core values, but Gestalt is not a religion. Gestalt therapy continually needs to critically explore theory and clinical practice and this can only be effective if we are cognizant of the values underpinning theory and the epistemología (theories of knowledge) that in turn underpin these values. Only with such critique of our philosophy, values, and theory can we adequately inform and further evolve Gestalt in all areas of application and avoid the excesses of passion without reason, blind dogma. Psychotherapists, however, rarely appear to reflect on or question the philosophical assumptions underlying their theories, models and approaches (Mace, 1999) and, according to Spinelli, psychotherapists in general impress as philosophically naive. Certainly it is naive to assume that, as Gestalt researchers and therapists, we can suspend our values, which are always implicit and sometimes explicit in our behaviour and attitudes in the research interview or during the therapy session. The Gestalt research-practitioner is a reflexive-practitioner. The capacity for reflexivity is arguably the key component of research and practice, in all areas of Gestalt application. Reflexivity requires that we think about self, other(s) and the process “between” self and other(s) with the twin goals of awareness and contact, the latter more especially in clinical practice. For a modality that honours its origin and growth in the radical movements of the 1960’s practitioner engagement in research with a critical reflexive mind set might be assumed to be a characteristic feature of contemporary Gestalt. But is it? In recent years, motivated in large part by political necessity, there has been a welcome growth of interest in research in the Gestalt community culminating in a successful research conference in Rome in May 2014, organised by the Research Committee of the European Association for Gestalt Therapy. Speakers came from several European nations and the USA and contributed to an exciting and stimulating weekend. If the Gestalt research community which emerged from the Rome conference is to grow, flourish and foster long lasting results, the urgency to engage in research must go deeper than a pragmatic response to the contemporary demand for evidence-based practice. For the Rome conference to have a fruitful legacy, we need to find ways to inspire the Gestalt practitioner to engage in research. Currently, Gestalt research is almost exclusively confined to those relatively few Gestalt training programmes that require a research dissertation as a key component of practitioner evaluation. Over

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and above this welcome development, we need to evolve research methodologies that inspire graduates to continue research after qualification and motivate experienced practitioners in the field to tap into their rich and varied experiences of clinical practice. History always tells a story. Over the past forty years or so, an increasing distance has emerged between clinical practice in the field and specialist researchers who are largely university-based (McLeod, 2002). Few psychotherapists (including Gestalt therapists) appear to read research and this seems partly because much contemporary research is excessively technical and difficult to follow (Cohen, Sargent, & Sechrest, 1986). Also, there are few sources of funding available outside universities, and, within universities, there is an incessant demand on staff to produce publishable research to ensure the university rating scale is maintained or improved, linked as it is to government and other sources of funding. In my experience, university teaching staff can sometimes expend a lot of perspiration, but considerably less inspiration, in the drive to meet university deadlines. Gestalt therapists are usually unimpressed with statistics and research methods that objectify clients, or fail to describe in depth the experiences of clients, or give little regard to the cultural, socio-political, ecological and spiritual dimension of human experience, or fail to address the cocreated and relational dimension of Gestalt therapy. In addition much contemporary outcome-based research generates suspicion about bias toward certain modalities. For the Gestalt practitioner to be inspired to engage in research, we need approaches that demystify research, challenge the manualisation of therapy and the objectification of the client, and are relevant to clinical practice. Above all, Gestalt research needs to speak to the heart as well as the mind, and therefore needs to be rooted and grounded in Gestalt philosophy and values. It is impossible to adequately critique Gestalt theory or the values conveyed in the clinical and research application of Gestalt if we are not clear about our philosophical roots and rely on an implicit only understanding of our value base. What then is the ground from which the figure of Gestalt-oriented research (and clinical practice) emerges? What are the philosophical bases of Gestalt and what are the values they generate and which we convey to clients and research participants, directly or indirectly? To understand the contemporary philosophical influences on Gestalt therapy and research, it is first important to understand the wider field, including the historical context out of which our current philosophical

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ideas have emerged, if we are to build a suite of genuinely Gestalt-oriented research methodologies.

Locating Gestalt The way we human beings look at ourselves and the world that gives meaning to our lives, and shapes an entire cultural age, has come to be known as a paradigm (world view). A paradigm shift or change requires new theories and new assumptions that are contrary to and incompatible with prevailing theories, and that bring about major changes in what is deemed worthy of consideration for inquiry and inclusion in the field of study (Kuhn, 1962). So let's begin by reminding ourselves of where Gestalt has come from. The ground out of which contemporary society has emerged comes from three major paradigms, or epochs, which continue to influence our world view today. In the history of Western philosophy, it is possible to distinguish these three distinct world views: the Classical, the Modern (or Age of Enlightenment), and the Postmodern.

The Classical paradigm The classical age culminated in Greece (429-347 BC) with the Platonic notion that all reality was based on Ideals and Forms, which transcended human reason. Truth was considered universal because it was grounded in universal forms, such as beauty, goodness, justice, and so on. Such forms were metaphysical, and human knowledge was contingent on the existence of these forms. Within the Jewish and Christian traditions, this was manifest in the notion of God as creator, and everything, including human beings, was contingent upon God. Faith was a form of knowledge, revealed knowledge. Truth was universal because it was grounded in an eternal and external creator: God is, therefore I am.

Modern paradigm (the Enlightenment) In the 17th and 18th centuries, the Modern Age, or Age of Enlightenment, moved knowledge beyond superstition and religious dogma and instead put its trust in the power of reason. Observation, calculation, checking results, deducing conclusions, testing ideas, developing theories were all made possible by new technology such as the telescope and the prism. In the West, people began to move out of the prison of dogma and fear of

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divine punishment. These experimental methods moved perception and understanding away from a basis in blind faith to one in observed fact. A process of de-centering the universe began. This was a paradigm shift of immense proportions, from a theocentric to a ratio-centric way of thinking. The universe was rational and could be understood by reason. Truth was held as universal because human beings were rational. Descartes (15961650) epitomised this shift from dogma to reason with his famous statement: I think, therefore I am.1 In the light of the above, it is possible to identify the first of two broad contemporary research orientations. First, Positivist research. Positivists are optimistic about the possibility of gaining 'true' knowledge about an independently existing ‘real’ world. Based on the modernist paradigm, they believe there is a relatively straightforward relationship between the world of objects/events and our perceptions and understanding of it. The goal of research is objective knowledge achieved by the researcher as an impartial observer who stands outside the phenomenon or process under investigation. They further believe that it is possible that findings/outcomes/understandings can be achieved by researchers working independently of one another, such that the findings of one researcher can be replicated or verified by another. The positivist range of research methodologies is firmly rooted in the “Modern” age, which is centuries old and somewhat of an “antique” in comparison with the contemporary philosophical ideas of the so-called postmodern age.

Postmodern age There is speculation as to when the postmodern age began, but it certainly accelerated rapidly after the end of the Great War of 1914–1918, a war that witnessed 50,000 men die on the Somme in single day. This was closely followed by the Second World War with its sophisticated war machines, gas chambers and atomic weapons. Subsequently, nuclear weapons and various weapons of mass destruction have been cultivated, alongside chemical weapons and, more recently, means of cyber-attack. 1

Please note that in the classical and modernist paradigm the notion that “truth” can be found or discovered is central to both paradigms, it is only the means by which this “truth” is discovered or revealed that differs profoundly.

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Science has given us the wonders and hell of technology. As a result, we appear to have lost faith in emancipation and progress through knowledge, reason, and scientific research alone (Kvale, 1992). The idea of the postmodern expresses a widespread loss of faith in big ideals and theories (Tanesini, 1999). Lyotard describes the postmodern as “incredulity toward metanarratives” (Lyotard, 1996). In this postmodern age, personal understanding and subjectivity give meaning while objectivity is viewed with skepticism. According to Rosen, “knowledge and meaning are constructed and reconstructed over time and within the social matrix. They do not constitute universal and immutable essences or objective truths existing for all times and cultures” (Rosen, 1996, p. 20). Consequently, the essential reality of nature is no longer separate and complete in a way that allows it to be examined objectively and from the outside. This is a problem that much of positivist quantitative research appears not to have addressed, instead clinging ever more tightly to an illusion of objectivity. Contemporary psychology and medicine are firmly embedded in a modernist paradigm that first emerged some 500 years ago, and yet it dominates the field and has swept over Europe like a tsunami in recent years, monopolising government funding and diminishing, wittingly and unwittingly, other ways of approaching research, particularly outcome research. The consequent impact of a blind-faith scientific value base has yet to be estimated, but we live in a fantasy world if we continue to naively pursue an approach to research (e.g., random controlled trials) that is outdated and relevant perhaps only to the measurement of efficacy of the products of the pharmaceutical industry and rarely applicable to the complex and thankfully unpredictable nature of human beings. The second of the two broad approaches to research today is Interpretivist research. Interpretivist researchers emerging out of the postmodern paradigm deny the possibility of capturing “truth”, which they regard as relative. There is not one “reality”, as the positivists argue, but many; what is true for you may not be true for me – it all depends on our perspective. Different realities result from “construction and negotiation deeply embedded in culture” (Bruner, 1990, pp.24-25). Interpretivist epistemology states that people’s perceptions and experiences are socially, culturally, historically and linguistically produced. Interpretivist researchers argue that it is impossible to be objective as the researcher’s identity and standpoint shape the research process and findings in a fundamental way. In my opinion, Gestalt therapy is firmly rooted in the interpretivist perspective. We see ourselves as part of the world we are studying rather than external to it. In our view, any understanding we gain from research

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informs us simultaneously about the subject of study and about our own preoccupations, expectations and cultural traditions. The postmodern interpretivist paradigm, based on a relativist ontology (multiple realities), a subjectivist epistemology (therapist and client cocreate meaning), and a naturalistic (in the natural world) set of methodologies (Denzin & Lincoln, 2000) underpins most qualitative research – in particular Gestalt phenomenological relational-centred research. Twenty-first Century postmodernism is the ground out of which the figure of Gestalt research and therapy emerges and it challenges the very foundations of what modernist science knows and how it knows what it thinks it knows. From a 21st century post-modern perspective, there is no single, universal, privileged, accurate, truthful, and secure way of understanding anything, especially people! Postmodernism “demystifies the great narrative of modernism” writes Gergen (Gergen, 1992, p. 28). It encourages inquiry and questioning of all phenomena, and is supportive of the notion of the Gestaltist as a reflexive practitioner-researcher engaged in an ongoing process of inquiry and self-questioning.

Philosophical foundations of Gestalt In seeking to establish some of the core values of Gestalt research, I think it has been crucial to have first located Gestalt within the postmodern paradigm, thus enabling us to proceed to identify the key epistemological perspectives that in turn inform and help shape Gestalt theory and practice, namely phenomenology, field theory and holism. All three are widely held to be the major influences on Gestalt fundamentals and all three are interrelated.

Phenomenology From the phenomenological perspective, human behaviour is seen as influenced primarily by personal experience rather than by an external objective reality (Cohen & Manion, 1994). The phenomenological method of inquiry honours the importance of subjective experience as a valid source of knowledge. Emphasis is placed on direct experience and engagement. "The most significant understandings that I have come to have come through my direct perceptions, observations, and intuitions” (Moustakis, 1994, p. 41).

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Field Theory Phenomenology is in turn compatible with field theory. “Field theory, according to Lewin (1952), is a way of looking at the ‘total situation,’ which has been described as the organised, interconnected, interdependent, interactive nature of human phenomena” (Parlett, 1991). In this context, what the field produces is viewed as having intrinsic meaning and value in itself. An experience is intimately connected with the current field conditions and cannot be understood in isolation. This underpins the importance of sensitivity to the context of the research in a participant’s life.

Holism In focusing on the totality of experience at any given moment, field theory is compatible with holism. Holism maintains that the whole is greater than the sum of the parts. From the holistic perspective, nothing is deliberately ignored. Observation of the happenings in the external world is made in parallel with observation of one’s inner subjective world. Holistic observation is therefore not simply “looking” but rather looking mindfully and in depth. The holistic process offers active involved observation in all of one’s being, including cognition, sensation, and emotion. One attempts to bring the whole of oneself to what is figural in the whole of one’s engagement with the world.

Critique In the spirit of postmodernism, and to ensure it does not itself drift into blind dogma, critique is essential. Arguably the most serious critique of postmodernism is its attitude to the notion of “truth”. While absolute truth is neither as absolute nor as true as the modernist paradigm would have us believe, the opposite polarity—that truth is indistinguishable from opinion— can mean that “nothing is real, nothing is true and nothing is important” (Holland, 2000, p. 3). According to Holland, modern skepticism as expressed, for example, in the writings of Jacques Derrida, does not attempt to cultivate a new philosophy of life but rather to critique the theories and prejudices of others. But if we take everything apart, then on what authority do you judge anything? “Postmodern philosophy at its worst, presumes no authority at all except to claim with authority that there are no authorities” (Holland, 2000, p. 365). I have considerable sympathy with Holland when he concludes that, “neither the simplicity of

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grand narratives (modernism) or skepticism (postmodernism) deal with the complexities, inconsistencies and paradoxes of real life” (Holland, 2000, p. 360). How can we avoid our assumptions becoming reified in dogma (religious dogma or scientific dogma) and at the same time avoid the ultimate impotence of unyielding skepticism (Downing, 2000)? For a more detailed discussion of this dilemma, I refer you to my article “Living in The Twenty First Century: A Gestalt Therapists search for a new paradigm” (Evans, 2007), obtainable as a free download via the Gestalt Review.

A Post postmodern paradigm for the twenty first century The epistemological bases of Gestalt psychotherapy already outlined above include the nonlinear multi-causality of field theory, the illumination of subjective personal experience of phenomenology, and the simultaneous exploration of both inner experience and outer engagement with the environment which is fundamental to holism. The dialogical perspective developed by the existential philosopher Martin Buber is compatible with all these epistemologies, and adds a further dimension crucial to Gestalt research and therapy: the inter-human dimension. Buber criticised the overemphasis of individual existence at the expense of human inter-existence (Buber, 1923/1996). Consequently, Gestalt affirms the paradoxical nature of the inter-human dimension and the challenge to develop our capacity for “presence”- to be with self and other with openness, a willingness to be vulnerable, and the courage to sit with ambiguity, uncertainty, and “not knowing” (Gilbert & Evans, 2000). It also involves a radical extension of Buber’s I–Thou, myself and the single other person, to embrace the multiple others, all fields of Gestalt application and even the wider world community (Buber, 1923/1996). The radical extension of I-Thou dialogue to the wider field, including the research field, exemplifies the postmodern spirit of open enquiry, rather than the postmodern skepticism that in extremis takes anti-rationalism to absurdity, or the blind scientific dogma that reduces the human to an object of study. You are, therefore I am, therefore We can be Buber’s emphasis on the I-Thou of relationship leads naturally to a belief in the co-creation or co-construction of all relationships. The research relationship, like the therapeutic relationship, is an interactional event in which both parties participate. Regarding the presence of the

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therapist, but equally applicable to the Gestalt researcher, in my opinion, Staemmler writes, “Any attempt to negate subjectivity would mean to negate one’s own subjective humane-ness and thereby to withhold exactly the human counterpart from the client who s/he urgently needs for her or his personal growth” (Staemmler, 1997, p. 45). Thus research need not be a one-sided relationship in which one party “does” to the other while the other is a passive recipient but rather a constantly evolving co-constructed relational process to which researcher and research participant (and client and therapist) alike contribute. The Gestalt perspective on relationship is exemplified in the literature of several contemporary Gestalt writers, including, among many others, Chidiac, Denham-Vaughan, Evans, Hycner, Jacobs, Staemmler, Wheway, and Yontef (Chidiac & Denham-Vaughan, 2007; Evans, 2007; Hycner & Jacobs, 1995; Spagnuolo Lobb, 2013; Staemmler, 1997; Wheway, 1997; Yontef, 1993). All these publications approximate, more or less, to Intersubjectivity Theory which emphasises “reciprocal mutual influence” (Storolow & Atwood, 1992, p. 18). They have, in turn, significant areas of commonality with contemporary Relational Psychoanalysis, which “views the patient-analyst relationship as continually established and reestablished through ongoing mutual influence in which both patient and analyst systematically affect, and are affected by, each other” (Aron, 1999, p. 248). All three approaches to psychotherapy: Dialogical Gestalt, Intersubjectivity Theory and Relational Psychoanalysis stress the mutuality of the therapeutic process. For a comprehensive survey of the similarities and differences regarding the co-created nature of the therapeutic relationship from the perspective of several contemporary psychotherapy modalities, see Relational Integrative Psychotherapy (Finlay, upcoming publication 2015 from Wiley publishers). It is characteristic of a “new” paradigm that its central ideas emerge outside a single group or school or movement, engaging a wider participation across diverse cultures. You are, therefore I am, therefore we can be is emerging not simply across relationally oriented psychotherapies but throughout the world as we evolve the notion of the global village (Evans, 2007).

Gestalt values I would like to share with the reader some suggested Gestalt values consistent with the post postmodern paradigm and the philosophies underpinning Gestalt. They are a slightly modified version of an original initiative of Linda Finlay (Finlay & Evans, 2009).

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The list of core values below is not to be read as if they were a “rule book” about how relational oriented researchers should behave. They only suggest an orientation of the attitude or spirit we aspire toward in our research engagement. These values are not abstract, reified concepts but rather reflect the I-Thou attitude which we hope to enact in practice, in research, in therapy and in relation to others in general, families and social networks (Lichenberg, 2007).

Values related to the researcher Self-awareness As Gestalt researchers, we accept the need to identify and acknowledge our own lived body humanness, including our emotions, cognitive processes, behaviour, values, frailties and strengths. To continuously grow a depth of understanding arising out of our personal development of where we have come from - our relational and social/cultural background. It is ourselves as a whole that we bring to the relational encounter. In every human voice, there are echoes of the mother’s tongue, echoes of significant teachers, respected elders, close friends; and there are accents, too, which bind the voice to the history of a region, a culture, and generations of ancestors. (Levin, 1985, p.174, as cited in Finlay & Evans, 2009)

Integrity We aim to be authentic and transparent and reasonably direct in our research encounters. We do not necessarily seek to be unconditionally accepting or neutral in our responses. Instead we are prepared to challenge and disagree. For example, where our values confront racist or oppressive remarks, we might challenge the other while maintaining an I-Thou attitude (Lichtenberg, 1996). Reflexivity Going beyond awareness of conscious processes, we may explore reflexively how our unconscious process may be impacting upon the researcher – participant relationship. This will challenge us to decide and assess both what to respond to and what to hold for further reflection with our academic and or process supervisor. Reflexivity helps us reveal moral dilemmas, monitor the research process and identify any ethical issues.

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Inclusion and presence The Gestalt researcher is responsible for building a bridge to the research participant(s) using awareness, skills, experience and knowledge (Evans & Gilbert, 2005). Our goal is to comprehend meaning from within the other(s) own subjective frame of reference. We approach the other with curiosity, empathy and compassion, encouraging them to share their thinking, feelings, ideas, fantasies, hopes and fears. At the same time, we ensure a degree of separateness for there to be sufficient distance to be able to critically reflect on the process “between”.

Values related to the research participant(s) Acceptance The subjective experience of the other is their truth and this is the starting point of any exploration. Here we recognise clearly the postmodern attitude to the nature of “truth” as subjective and relative. The participants experience and comments are accepted and assumed to reflect their perceptions of their life world. We accept that what is given is their reality as they understand it. Part of this acceptance is also acceptance of the participants’ socio-cultural background, taking seriously our respect for difference and diversity. Agency Gestalt researchers strive to honour the participant's choices and capacity for agency. We understand that the participant's creative adjustment comes from their significant relational experiences. At the same time, we believe we are all “response-able” and thus are able to make choices and, to a significant degree, determine our own behaviour.

Values relating to the research relationship Mutuality Relational-centred research invites reciprocal dialogue and participation during the data collection stage, and sometimes even during the data analysis and writing-up stages. It will almost certainly involve some mutual self-disclosure as an essential component of “mutual creative meaning–making” (Shaw, 2003). Relational-centred research recognises that two people cannot be in relationship without impacting on each other, consciously and unconsciously. “A genuine conversation gives me access to thoughts that I did not know myself capable of” (Merleau-Ponty, 1968, p.13).

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Transparency and openness We sit inside (and simultaneously outside) the research engagement open to the process and “whatever layered meanings might emerge in the intersubjective space between researcher and co-researcher” (Finlay & Evans, 2009, p.39). This takes courage!

Conclusion I have argued that the philosophy, theory and values of the Gestalt approach need to be congruent, explicit and consistent, so that they can be accessible to critique and guide the continuing development and application of Gestalt across a range of applications. I have further argued that the philosophical bases of contemporary relational-oriented Gestalt emerge from the postmodern paradigm. They are interrelated and mutually supportive and are the foundations for the values that inspire us and in turn underpin the theory and methods of Gestalt research that guide us. Finally, I have suggested that the emergence of a post postmodern paradigm: the inter-human paradigm You Are, therefore I Am, therefore We can Be, suggests a growing consciousness of interconnection and interdependence which has the potential to form the basis of a new and radically human set of Gestalt approaches to research. Gestalt approaches which are not only congruent with the philosophy and values of Gestalt therapy but hopefully capable of inspiring many and diverse research applications within the Gestalt community and across the range of Gestalt applications, including psychotherapy, coaching, consultancy, education, human rights and ecology.

References Aron, L. (1999). The patient’s experience of the analyst’s subjectivity. In S. A. Mitchell & L. Aron (Eds.), Relational Psychoanalysis (p. 248). Hillsdale, NJ: The Analytic Press. Buber, M. (1996). I and Thou (J. Kaufmann, Trans.). New York: Touchstones. (Original work published 1923) Bruner, J. (1990). Acts of meaning. England: Cambridge University Press. Chidiac, M. A., & Denham-Vaughan, S. (2007). The process of presence. British Gestalt Journal, 16(1), 9-19. Cohen, L., & Manion, L. (1994). Research methods in education (4th ed.). London: Routledge.

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Cohen, L. H., Sargent, M. M, & Sechrest, L. B, (1986). Use of psychotherapy research by professional psychologists. American Psychologist, 41, 198-206. Denzin, N. K., & Lincoln, Y. S. (2000). Introduction: The discipline and practice of qualitative research. In G. W. Ryan, H. R. Bernard, N. Denzin, & Y. Lincoln (Eds.), Handbook of qualitative research (2nd ed., pp. 1–28). Thousand Oaks, CA: Sage. Downing, J. N. (2000). Between conviction and uncertainty. Philosophical guidelines for the practicing psychotherapist. New York State: University of New York Press. Evans, K. (2007). Living in the 21st century: A Gestalt therapists search for a meaningful paradigm. Gestalt Review, 11(3), 190. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Finlay, L. (2015 upcoming). Relational integrative psychotherapy: Processes and theory in practice. Wiley Publishers. Finlay, L., & Evans, K. (2009). (Eds.). Relational-centred research for psychotherapists. Malden, MA: J. Wiley & sons. Gergen, K. J. (1992). Toward a postmodern psychology. In S. Kvale (Ed.), Psychology and postmodernism: Inquiries in social construction (pp. 17-30). London: Sage. Gilbert, M., & Evans, K. (2000). Psychotherapy supervision: An integrative relational approach. Buckingham: Open University Press. Holland, L. A. (2000). Philosophy for counselling and psychotherapy. London: Macmillan Press. Hycner, R., & Jacobs, L. (1995). The healing relationship in Gestalt therapy. New York: Gestalt Journal Press. Kuhn, T. S. (1962). The structure of scientific revolutions. Chicago, IL: University of Chicago Press. Kvale, S. (1992). Psychology and modernism. London: Sage. Lewin, K. (1952). Field theory in social science. London: Tavistock. Lichtenberg, P. (1996). Community and confluence: Undoing the clinch of oppression. Cleveland: Gestalt Institute of Cleveland Book Series/The Analytic Press. Lichtenberg, P. (2007). Enriched awareness and fuller citizenship. Gestalt review, 11(3), 170. Lyotard, J. F. (1996). The postmodern condition: A report on knowledge. Manchester: Manchester University Press.

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Mace, C. (1999). Introduction: Philosophy and psychotherapy. In C. Mace (Ed.), Heart and soul: The therapeutic face of philosophy (pp. 269278). London: Routledge. McLeod, J. (2002). Research in person-centred, experiential and humanistic counselling and psychotherapy: Meeting new challenges. Counselling & Psychotherapy Research, 2(4), 259-262. Merleau-Ponty, M. (1968). Le visible et l´invisible. Evanston, IL: Northwestern University press. Moustakis, C. (1994). Phenomenological research methods. London: Sage, 41. Parlett, M. (1991). Reflections on field theory. British Gestalt Journal, 1(2), 69-81. Rosen, H. (1996). Meaning-making narratives: Foundations for constructivists and social constructivist psychotherapies. In H. Rosen & K. T. Kuehlwein (Eds.), Constructing realities: Meaning making perspectives for psychotherapists: Inquiries in social construction (p. 20). London: Sage. Shaw, R. (2003). The embodied psychotherapist: The therapist’s body story. New York: Bruner-Routledge. Spagnuolo Lobb, M. (2013). The now for next in psychotherapy: Gestalt therapy recounted in post modern society. Siracuse: Istituto di Gestalt HCC Italy Publ. Co.. Staemmler, F. M. (1997). Cultural uncertainty: An attitude for Gestalt. British Gestalt Journal, 6(1), 40-48. Storolow, R. D., & Atwood, G. E. (1992). Contexts of being. Hillsdale, NJ: The Analytic Press. Tanesini, A. (1999). An introduction to feminist epistemologies. Oxford: Blackwell. Wheway, J. (1997). Dialogue and intersubjectivity in the therapeutic relationship. British Gestalt Journal, 6(1), 16-28. Yontef, G. (1993). Awareness, dialogue and process. New York: Gestalt Journal Press.

CHAPTER FIVE LOOKING BACK: REFLECTIONS ON RESEARCH JOSEPH MELNICK

Introduction When I co-founded Gestalt Review with Edwin Nevis nearly twenty years ago, one of our primary foci was to encourage more research by Gestaltoriented professionals. In order to do so we published four issues per year, and we used a blind peer review process to make our journal more attractive to academics for whom tenure and pay are dependent on publishing in journals with this format. We also had a section of each issue dedicated to research (overseen by Professors Ansel Woldt of Kent State University and Iris Fodor of New York University). Despite our best efforts, we were unable to generate enough submissions to keep this section alive. A few years later, we tried a different approach. We created our first research conference at the Gestalt International Study Center in Massachusetts, USA. Although the turnout was adequate and the research presentations interesting nothing much came of this effort. Our next research conference was in 2013 and it was well attended by dedicated Gestalt researchers and the presentations were first class. It was this conference which helped create the energy for future ones (two have already been scheduled) and many of the papers in this book. It appears that Gestalt practitioners lack of interest in research has done an “about face”. The reasons for the historical lack of interest in research by Gestalt practitioners are well known. The first is the scarcity of Gestalt-oriented professors in traditional academic institutions. Our organizational life from the start has been conducted in institutes (Melnick, 2013). Thus, we were never under the “publish or perish” pressure of many therapeutic traditions. Secondly, our phenomenological values and approach have led

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us to reject, or at least be deeply suspicious of quantitative research. There were many reasons for this. For example, as a result of academic pressure for professors to publish one or two research studies per year, ”patients” were often gleaned from introductory psychology students needing to participate in a study in order to complete course requirements, and “therapists” from the ranks of first year clinical psychology graduate students. In addition, “treatment” was defined as anything that could be conducted within an academic year. No wonder we were suspicious of research. Finally, many Gestalt practitioners practiced outside traditional definitions of psychotherapy. Since licensure and advanced degrees were of less interest to Gestaltists until recently and many did not have the incentive to complete research-based Master’s theses or Ph.D. dissertations. Much has changed and psychotherapy has become mainstream. The profession has also become deeply regulated. The evidence-based movement that demands treatment be based on research results has taken control of the therapeutic profession. Spurred by the insurance industry, which seeks to deconstruct complex psychological phenomena into simplistic constructs, psychotherapy seems to be more concerned with cost containment than with change and development. One result is that insurance companies are controlling more and more who gets to see whom. This restriction on psychotherapy which originally began in the United States has been spreading throughout the world and psychotherapists are now being pushed towards licensure. Insurance companies and governments will not pay for unlicensed psychotherapists, and in some countries one has to be trained in a specific “school”, most often psychoanalytic or cognitive behavioral, they are seen as legitimate and insurance reimbursable. Potential patients, if forced to choose between a therapist for whom a third party will pay 50-100% of treatment versus one for whom a third party pays nothing, will most often take the first choice. This cultural shift, while troublesome, has helped to mobilize Gestalt practitioners to seek licensure. With licensure comes the commitment of acquiring advanced degrees and for many, of doing a research project. More and more institutes in Europe are demanding a master’s degree as part of their therapist certification process. Of equal importance, the definition of what is acceptable research has broadened. The age of qualitative research is upon us, thus allowing Gestalt therapists to conduct research in a way that is much more in line with our values and way of viewing the world. Furthermore, quantitative research has become more sophisticated, resulting in much more believable results. Advances in neurological

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research have resulted in findings that tend to support the basic Gestalt belief that growth and change emerge through awareness and relationship (Lehrer, 2008). An example of how this change has impacted the Gestalt world is the recently edited book Gestalt Therapy around the World (O’Leary, 2013). Each chapter has a section on research. This focus would have been unheard of just a few years ago. I am very pleased by the proliferation of Gestalt-based research, the support our approach is receiving from neurological exploration, and the acknowledgement from thought-based approaches that emotions, awareness, and relationship matter deeply. However, there is one other area that I believe has been neglected and might add support to the Gestalt method as a research supported approach to psychotherapy. This involves a looking back and reinterpretation of past research through a Gestalt lens. I would like to do this in the remainder of this chapter using two of my own research projects as examples. But first, I would like to provide a little background.

A little about me While I was in graduate school in the late 1960s and early 1970s, we had begun to move away from Freud, and humanism was emerging. The focus was less about what was going on inside the person’s head, and more about what was going on within the person/environment field. The primary proponent of the behavioristic approach was B.F. Skinner who focused on reinforcement schedules and contingencies. This led to behavior therapy and ultimately, cognitive behavior therapy, which for many is still the gold standard for evidence-based support. As a young graduate student I fell in love with this approach and did my first research project working with children with developmental disabilities using “skinner boxes” (Melnick, 1972). When my major professor died unexpectedly, I decided to transfer universities to study with well-known behavior therapy researchers (cf. Kanfer & Phillips, 1970). (As an aside, it was about this time that I became acquainted with Gestalt therapy theory by a supervisor who was studying at the Gestalt Institute of Cleveland.) Upon completion of my Ph.D., I was hired to teach in the Psychology Department of the University of Kentucky, primarily in the area of behavior modification. My dissertation involved using that modality to help shy males feel more comfortable with females (Melnick, 1973). I will say more about this later. By this time my identity as a Gestalt practitioner and theorist was forming. The research I was conducting did not have the power for change

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that I experienced in my own psychotherapy or my research with groups, despite this being more in line with Gestalt principles (cf. Bednar, Melnick, & Kaul, 1974; Crews & Melnick, 1976). Eventually I left the academic environment, and for many years, the world of research. This self-imposed exile changed during the mid-1980s when Donna DeMuth, a friend and colleague, approached me about her concerns about nuclear war. It should be noted that during this time, the threat of nuclear war was high and a majority of people believed that it would happen in their lifetime (Fiske, Pratto, & Pavelchak, 1983). Eventually we decided to conduct research on the impact that fear of a nuclear holocaust would have on families. We ended up conducting a very complex qualitative study that spanned nearly six years (DeMuth & Melnick, 1998). Looking back over my doctoral dissertation and research on the impact of nuclear war on families, I find that the word “Gestalt" does not appear. While participating in the research conference that stimulated this book, I began recollecting my research past, and I realized that both pieces of research were supportive of a Gestalt perspective. I also came to believe that looking at past research through a Gestalt lens might provide supportive evidence for the therapeutic efficacy of the Gestalt approach. Therefore I would like to apply this method to my own research, for the remainder of this chapter. I hope it will stimulate you, the reader, to do the same.

Research project one As a doctoral student I wanted to do research that went beyond the “one session” studies so prevalent during this time period. My intention was to work with people who had real problems. In those days assertiveness training was a popular focus of therapy and research so I decided to work with shy college age males, who were awkward and unassertive around women. I developed a complex and, in hindsight, overly ambitious design that involved teaching males to be more competent in talking to women (See Appendix). To summarize briefly, the primary treatment groups differed in the following ways. One group observed competent male/female contact. Another group practiced interacting with a female surrogate for four sessions (simulated dating interaction). The final two groups first practiced and then watched themselves afterwards on videotape, with one of the groups also receiving coaching. The results were complex and discussing them in full goes beyond the intent of this article. However, I have summarized the results below.

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In general, groups that practiced having conversations with women and received feedback by watching their interactions via on video-tape: did better on most post study measures than the ones who just observed others, and the ones who just practiced. I concluded that practice with feedback leads to increased self-monitoring (awareness) and, thus, to better positive change. In hindsight, the results support our Gestalt theory of change being paradoxical in nature (Beisser, 2004). As we become aware of what we are doing we experience choice, then change naturally occurs. Our results also support the notion that for change to “stick”, it must live in the body, in the cells, and in the muscles. One does not change by reading or thinking or even discussing (as my control groups did), but by doing. The results also support our notion of “experimenting” which involves both a doing and feedback (Melnick, 1980). This concept of feedback has been articulated by Zinker (1978) in his concept of “grading” that helps create a behavior that can stretch the individual to increase his or her learning, while not making it too easy or too hard. During the years following this study, I slowly drifted away from research and became more interested in theory development. My interest also moved away from individuals to larger systems such as couples, groups, organizations, communities and social change in addition to psychotherapy. In fact, I believed that my inclination toward research had been extinguished. My interest in research returned when a group of us began meeting around our concerns of how a potential nuclear holocaust might impact families. We created a research design and began engaging families for the study. The reaction of my colleagues was very interesting; some wanted to know if we had psychiatric backup; others implied that suicide was a potential outcome of having this conversation, and still there were others who agreed to be interviewed would forget and miss the meeting. Most people, rather than exploring if talking about it would help, believed that talking about it would hurt. In fact, this view was supported by much of the analytically oriented literature of the time that suggested that repression and suppression were healthy responses to nuclear threat (cf. Lifton, 1967). I would like to note here how different this is to the Gestalt notion of dealing with trauma with awareness and support.

Our design Ultimately, twenty-one families including 35 adults and 38 children were interviewed, with a requirement that at least one child in each family be

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between the ages of 10 and 14. The small size of the sample reflects the difficulty we faced in recruiting families who were willing to be interviewed. All prospective parents were given a description of the study and of the procedures in advance of the interview. Our major tool was a structured family interview designed to provide safety for family members as they explored their feelings about nuclear war. The format was relatively clear. Using a funnel design, the interview moved from concrete personal questions to questions about the world in general, and eventually questions about a potential nuclear war. We started by first attempting to develop a trusting climate by making verbal contact with each individual family member. After filling out a series of questions, each family member was handed an 8” x 11” piece of paper with a large circle on it and given access to a wide range of drawing materials. Using a mandala format (a way to present factual information while demonstrating the interconnectedness of all things), each member was asked to draw their concerns about the world. We then directed them to talk about themselves regarding a series of topics ranging from current events to nuclear issues. The last instruction in this series was extremely powerful and provocative: “Talk to each other about what you would do if you were to learn that a nuclear bomb would be dropped in your city in a few hours.” Finally they were given a large (17” x 24”) piece of paper and asked as a family to draw a mandala picture of their hopes for the world. At the end of the session they were invited to comment. Then thanked and debriefed. Three weeks later they were asked to fill out a post-interview questionnaire. In addition to the videotapes, we used a series of pre-and postquestionnaires. There were also scales for rating levels of family interactions while drawing together.

Findings from follow up Review of the videotapes and process notes revealed that on the whole, families were able to remain focused and involved during the interview. We were surprised about the willingness of the families to talk about the issues. They talked, cried, and expressed anger and sorrow. They created wonderful drawings which reflected their worries and their hopes. More importantly they engaged powerfully and creatively with each other. The most important result was that talking about it did not hurt. Parents and children alike reported the experience to be positive with no adverse reactions. We found this to be true at the end of the interview, from the response to post-interview questionnaires, and during follow up phone calls with parents one year later. Not one family member reported the

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discussion as being too upsetting, nor did parents report children showing behavior signs of anxiety or depression afterwards. Concern and worry was carried by “every member of the family”. We had originally thought that families might have a “designated worrier,” someone who would carry the concern for the family. This was not the case. Each family member carried worry, although this varied from family to family. Our rich sources of data (questionnaires, process notes, and drawings) allowed us a more in-depth evaluation of individual levels of concern. For example, we found that many family members who expressed a low degree of concern on questionnaires had drawings that were rated high on anxiety measures. Some expressed anxiety verbally, some non-verbally and some in their drawings, but each worried. Each family was able to find its own unique coping style. Each seemed to grapple with the threat of nuclear war in different ways. Rhythms were developed in which families moved from thought to affect; despair to hope; reality to fantasy; laughter to tears and back to laughter again. Each family seemed to have an internal, homeostatic mechanism which allowed it to deal with this issue in a creative, respectful manner. What support for our uniqueness of human experience and the Gestalt concept of creative adjustment! Our families reported increased closeness and cohesiveness as a result of the interview process. Also, the parents reported that they had learned more about each family member, particularly their children. Our Gestalt notions of the power of contact, of raising awareness, of the creation of support for an emerging figure are just a few that this study illuminated. Looking back, I am pleased that we are generating research that looks at the efficacy of the Gestalt approach. But my own refocusing on and revisiting my past research prompts me to wonder how much more is out there that might support our approach.

References Bednar, R. L., Melnick, J., & Kaul, T. J. (1974). Risk, responsibility and structure: Ingredients for a conceptual framework for initiating group psychotherapy. Journal of Consulting Psychology, 21, 31-37. Beisser, A. (2004). The paradoxical theory of change. International Gestalt Journal, 27, 103-107. Crews, C. Y., & Melnick, J. (1976). The use of initial and delayed structure in facilitating group development. Journal of Counseling Psychology, 23, 91-98.

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DeMuth, D., & Melnick, J. (1998). What happens when they talk about it? Family reactions to a structured interview about nuclear war. Peace and Conflict, Journal of Peace Psychology, 4(1), 23-34. Fiske, S. T., Pratto, R., & Pavelchak, M. A. (1983). Citizens’ images of nuclear war: Content and consequences. Journal of Social Issues, 39(1), 41. Gough, H. G., & Heilbrun, A. B., Jr. (1965). The Adjective Check List manual. Palo Alto, CA: Consulting Psychologists Press. Kanfer, F. H., & Phillips, J. S. (1970). Learning foundations of behavior therapy. New York: Wiley. Lehrer, J. (2008). Proust was a neuroscientist. New York: Mariner Books. Lifton, R. J. (1967). Death in life: Survivors of Hiroshima. New York: Simon & Schuster. Mahl, G. F. (1956). Disturbances and silences in patients’ speech in psychotherapy. Journal of Abnormal and Social Psychology, 53, 1-15. Melnick, J. (1972). The effects of summated stimuli with retarded children. Journal of Experimental Child Psychology, 14, 277-286. —. (1973). A comparison of replication techniques in the modification of minimal dating behavior. Journal of Abnormal Psychology, 81(1), 5159. —. (1980). The use of therapist-imposed structure in Gestalt therapy. The Gestalt Journal, 3, 4-20. —. (2013). Gestalt Therapy in the United States of America. In E. Oleary (Ed.), Gestalt therapy around the world (pp. 289-303). West Sussex, UK: John Wiley & Sons, Ltd. O’Leary, E. (Ed.). (2013). Gestalt therapy around the world. West Sussex, UK: John Wiley & Sons, Ltd. Rehm, L., & Marston, A. R. (1968). Reduction of social anxiety through modification of self-reinforcement: An instigation therapy technique. Journal of Consulting and Clinical Psychology, 32, 565-574. Zinker, J. (1978). Creative process in Gestalt therapy. New York: Vintage.

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Appendix Method The following account summarizes the method employed. A complete description of instructions, questionnaires, rating categories, role-playing tasks, and other details is available in Melnick (1971). Subjects Fifty-nine male undergraduates were recruited from introductory psychology classes at the University of Cincinnati. The Ss had a mean age of 19.4 yr. (range 17-23 yr.). On the basis of their responses to a screening questionnaire, Ss were accepted for the study if: (a) they were dating less than twice a week; (b) dating sufficiently they felt uncomfortable in social situations with members of the opposite sex; and (c) they expressed an interest in changing in order to date successfully. Of 78 male students who expressed an interest in the study, 60 were accepted. Three Ss dropped out of the experiment, 2 during the first week and 1 during the fourth week. The first 2 were replaced. Design and Procedure The 59 Ss were randomly assigned to two control and four experimental conditions. All groups contained 10 Ss except for group SO, which contained 9. A 2 x 6 factorial design was employed in the study. Separate analyses were performed on each of the dependent measures. Three measures (Factor 1) obtained at the pre-treatment and post-treatment phases of the experiment (Factor 2) were the main dependent variables. The six different experimental conditions represented the treatment factors. Additional analyses were performed on the self-report measures. A further description of the design is shown in Table 5-1. Dependent Variables Simulated Dating Interaction (SDI) All Ss participated, pre- and post-treatment, in a 4-min., audiotaped SDI. It began with S being asked to wait alone in a room with an attractive female confederate until another room was vacant. At the completion of the experiment, all Ss were told that their interactions had been tape recorded, that the female Ss were, in fact, confederates, and why deception had been used.

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Situation Test (ST) Before and after treatment, all Ss were given the ST. It consisted of two equated forms, each containing 10 social situations. The ST was adopted from a test developed by Rehm and Marston (1968) which employed audiotaped situations. In the present study, the situations were videotaped. The items were presented by a male voice describing a situation involving a girl (e.g., You are on a date and have just come out of a theater after seeing a movie. You ask your date what she would like to do since it is early and she replies…). A female then appeared on the videotape monitor and read a line of dialogue to which S was asked to respond aloud (e.g., Oh, I don’t know, it’s up to you). The Ss were told that their responses would be audiotaped and were asked to respond as if they were in a real-life situation. Adjective Checklist (ACL) Portions of the Gough Adjective Checklist (Gough & Heilbrun, 1965) were administered before and after treatment to all Ss. Three male graduate students in clinical psychology indicated whether they thought each adjective would be indicative of a positive or negative self-concept if used by a male college student to describe himself. Of the adjectives which had attained perfect rater agreement, 100 positive and 100 negative adjectives were chosen. The pre-administration of the SDI, ST, and ACL occurred 1 wk. prior to the beginning of treatment. The postadministration occurred 1 wk. following the conclusion of treatment. Other measures In addition to the screening questionnaire, a session questionnaire was filled out after each treatment session, a take-home questionnaire was filled out once a week by Ss in the NT group, and a post-treatment questionnaire was completed by all Ss at the end of the study. The session questionnaire included items inquiring about S’s feelings of self-confidence in situations involving females, feelings about himself, level of anxiety when interacting with girls, amount of effort expended to meet girls, and responses to the just-completed session. The take-home questionnaire was similar to the session questionnaire, but it excluded questionnaire items which were concerned with the treatment sessions. The post-treatment questionnaire, in addition to the questions listed on the session questionnaire, inquired about Ss perception of the procedure, number of dates S had during the study, predictions as to amount of interactions he will have with girls in the future, changes in ability to evaluate his performance, reasonableness of treatment approach, and degree of confidence that the experiment was what it claimed to be.

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The ST was also used as a measure of anxiety. Response latencies and speech disturbance ratios (cf. Mahl, 1956) were computed for S’s responses to the last nine items to both pre- and post-administrations of the ST (Melnick, 1973, pp. 52-53). Table 5-1: Replication techniques in modifying dating behavior (design and procedure) PrePostTime in Allotment of therapy Group test test therapy time No-treatment control (NT)

Yes

Yes

None

Therapy control (THER)

Yes

Yes

Four 40 min. sessions

The S discusses feelings With female therapist.

Yes

Four 40 min. sessions

The S observes video recording of male and female engaged in date-like behavior.

Four 40 min. sessions

5 min. of videotape observation (same as Group VIC), 5 min. of live guided participation, and 30min. of nonmonitored participation.

Yes

Four 40 min. sessions

Same as Group PM except S spends last 14 min. viewing videotape of justcompleted behavior.

Yes

Four 40 min. sessions

Same as Group SO except S receives 10 systematic reinforcements during self-observation.

Vicarious conditioning (VIC)

Participant modeling (PM)

Participant modeling and selfobservation (SO) Participant modeling, selfobservation and reinforcement (REIN)

Yes

Yes

Yes

Yes

Yes

None

PART II: INTRODUCING METHODS

CHAPTER SIX AN ADVENTURE IN GROUNDED THEORY METHOD: DISCOVERING A PATTERN IN THE FLOW OF A THERAPY PROCESS JAN ROUBAL, TOMÁŠ ěIHÁýEK

Introduction This chapter describes the process of a particular research project (Roubal & ěiháþek, 2014) from beginning to end. We will present the grounded theory method (GTM). The entire research process will be divided schematically into a sequence of steps; we will demonstrate practical examples of the researchers’ work and provide a theoretical explanation for the method used. Practical research steps are described from the position of the first author (JR). The second author (Tě) participated in the research as a methodological consultant and auditor. His main contribution to the text of this chapter is a theoretical description of the GTM.

Step 1: Research question The research topic emerged during my clinical work. After finishing my medical and psychiatric studies and completing Gestalt therapy training, I worked in the psychotherapy section of a psychiatric hospital. The main part of my work as a psychotherapist was group and individual therapy with depressive clients. I was happy working with these clients, as it was challenging to meet people immersed in severe emotional states. It was rewarding for me to see (some) of them climb out of the depressive state and start to perceive the colours in life. However I must say that it wasn’t easy for me, and I was very tired after sessions. To maintain my interest and enthusiasm, it helped me to think theoretically about psychotherapeutic work with depressive clients. I worked on how to use Gestalt therapy for the treatment of depression (Roubal, 2007). I realize

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that thanks to my writing of theoretical articles, I started to spend more time alone at work with the computer than directly with depressive clients. Gradually, after about four years of work with these clients, I began to see that this work burdens me more than I thought. I saw symptoms of burnout in myself. This forced me to make important changes in my professional and personal life and it also brought me to a troubling question: How is it possible that I had experienced burnout when I followed the rules of mental hygiene, separating work and personal life, having other interests, good relationship with friends, etc.? What makes contact with depressive clients so burdensome? In conversations with my colleagues, I learned that my experience is not rare. I decided to explore it further. The first, essential step was to define the area of interest and then to formulate research questions. I wanted to make use of my experience with depressive clients. In addition, I wanted to focus on Gestalt’s foreground: co-creation of the relational field. In cases of depression, the therapist is not outside of the depression that he diagnoses in a client. Instead he helps to shape a depressive organization of the relational field in the here and now situation with the client. Client and therapist are “depressing” together (Francesetti & Roubal, 2013). Various interpersonal theories of depression (Roubal & ěiháþek, 2014) partly summarize thoughts of psychotherapists on this topic, nevertheless the research examining the dynamics of co-creating the depressive situation is scarce and gives little detail. So I decided to closely examine what happens in the therapeutic relationship with the depressive client and consider the therapist’s contribution. A preliminary research question was: “How do therapists experience their work with depressive clients?” Research question in grounded theory method Formulating a research question is the initial step in every research study. In GTM, and in qualitative research in general, the aim of a research question is to identify the phenomenon to be studied (Strauss & Corbin, 1998). However, a research question does more than that. It establishes a perspective from which the phenomenon will be approached and it determines what kind of information will become important and what will be left aside. Consider, for example, the difference between the following two research questions: (a) How do therapists experience their work with depressive clients? (b) How do therapists work with depressive clients? In other words, the way a researcher asks questions shapes his or her way of perceiving the world and thinking about phenomena.

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A research question can be derived from literature or from a researcher’s own personal or professional experience (Strauss & Corbin, 1998). A researcher may even enter the area of interest with no predefined problem or question and may deliberately postpone the formulation of the research question only after having done several preliminary interviews or observations (Glaser, 1992). Whichever way researchers choose to arrive at a question, they should be prepared to modify it flexibly in interaction with their data. Typically, a research question is formulated rather broadly at the beginning of the study and becomes more focused as the research process evolves.

Step 2: Research methodology I followed my decision of WHAT to study by deciding HOW to do the research. What would be the appropriate method of collecting/co-creating of data and the data analysis? The topic of the therapist’s experience in direct contact with a currently depressed client is theoretically and academically little researched (Roubal & ěiháþek, 2014). To explore a little-known area, the best choice is qualitative research, which aims to uncover the nature of one’s experience and to gather detailed information on the researched phenomenon. When choosing a particular qualitative approach, the phenomenological analysis would be at hand (e.g., Smith, Flowers, & Larkin, 2009), which is designed to explore the lived experience. My interest, however, was not only to map different experiences of the psychotherapists working with depressive clients, but also to understand the laws of the microprocesses that take place in such sessions. That’s why I preferred the grounded theory method, which allows the researcher to register procedural aspects of studied phenomena and to create a theoretical construct based on data through which it is possible to understand and describe the process in detail. When to choose grounded theory method Though GTM shares many virtues and shortcomings with other approaches in qualitative research, it also has distinctive features. GTM researchers often focus on a psychological or social process and want to describe its regularities, as well as its variability. The final outcome of GTM is usually a compact and parsimonious model of “how things work” in a particular area, often organized around a central concept (Glaser & Strauss, 1967; Strauss & Corbin, 1998). In this sense, a grounded theory is “more” than a

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simple classification of phenomena or a description of a set of themes. Rather, it is a conceptual framework useful in explaining or predicting a certain phenomenon. To sum up, if a researcher intends to create a theoretical model of a (preferably processual) phenomenon, then GTM is a method of choice. Nowadays, there are several influential variants of GTM, particularly Glaser’s version (Glaser, 1978, 1992), Strauss and Corbin’s approach (Strauss, 1987; Strauss & Corbin, 1998) and Charmaz’s constructivist formulation of GTM (Charmaz, 2006, 2009). Among other adaptations of the method, Rennie’s approach is particularly suitable for research in the field of psychotherapy (Rennie, 1998, 2000; Rennie & Fergus, 2006; Rennie, Phillips, & Quartaro, 1988). These variations of the method differ in many aspects; describing these differences is, however, beyond the scope of this chapter.

Step 3: Researcher’s self-reflection First, I needed to chart what it is that I myself already knew about the studied phenomena. What were my own experiences with the topic of the psychotherapeutic relationship in the psychotherapy of depression, what was my personal attitude towards this, and with what preconceptions was I entering the research? This pre-understanding of mine would inevitably affect data creation as well as data analysis. I used the two-chair technique, which in addition to its therapeutic use is also suitable for the researcher’s self-reflection (Finlay & Evans, 2009). I changed seats between the two chairs as I interviewed myself about my experiences in conducting therapy with depressive clients, about my preconceptions of the studied topic and about my own approach to the phenomenon of depression. In one chair I asked a question from the researcher’s position and in the second chair I answered from the position of therapist and theorist. This interview served as a pilot and was not included in the analysis. However, it was recorded, transcribed and used for the following purposes: (1) Awareness of the pre-understanding of the topic that the researcher brings to the study; (2) Awareness of emotional and relational personal aspects of the researcher, which can affect conducting interviews; (3) Specification of the research topic and clarifying of the research question; (4) Identifying substantial questions (and putting aside irrelevant ones) to conduct further interviews and to form their specific wording in order to gather more data; (5) Validation of the research findings by the auditor in the final stage of research (see The

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Research Phase 6). My pre-understanding included my personal experience, my own concept of depression associated with personal values and history, and also my own conceptual understanding of the theory of change in psychotherapy, psychopathology and diagnostics. Researcher’s involvement and reflexivity Researchers’ experience, knowledge, and values inevitably enter into the research process. The more researchers are personally involved in their research topics, the more they are prone to let their values “sneak” into data creation and analysis, shaping them according to their own fore-understanding. To “control” this influence at least to some degree, researchers need to develop reflexivity – a stance of sustained critical self-reflection towards their social background, assumptions, positioning, values, etc. (Finlay & Evans, 2009). Reflexivity can be applied on different levels, including strategic, contextual-discursive, embodied, relational, and ethical reflexivity (Finlay, 2012). However, total elimination of a researcher’s personal contribution to the research is neither possible nor desirable. It is exactly the researcher, who – through his or her knowledge, theoretical sensitivity (e.g., Glaser, 1978; Strauss & Corbin, 1998) and personal insights – conceptualizes the raw material of data into the fabricated tissue of a theory. Personal involvement is important in qualitative research also for another reason: the research process is often very time consuming and exhausting and the researcher needs to have a strong interest in the topic under study to persist in the seemingly endless process and resist temptations to conclude the research on a premature and superficial level.

Step 4: Conducting interviews and formulating a provisional central concept I interviewed therapists whom I knew worked with depressive clients. I chose those who had completed psychotherapy training and had a minimum of five years’ experience of psychotherapeutic practice. First I introduced the research topic to each of them and had them sign the informed consent and after that I conducted semi-structured interviews. I first helped participants to recall the experience of a depressive client´s presence: “Try and recall a session in which one of your clients is going through depression.” Then I developed the main question in an

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interview: “What did you experience in that moment?” I let the interview naturally unfold and I helped the therapist to a more detailed understanding by asking sub-questions as in: “Did your experience change somehow over the course of a session? What did you do? What did you find helpful? What happened next?” and also by using their own metaphors to describe the situation with a depressive client. I analyzed the transcribed interviews using open coding process (partly using Atlas.ti software), from which these main themes emerged: “feeling threatened by the client’s depression” and “a desire to protect ourselves from the client’s depression”. Areas where I don’t have enough information and where more research is needed also emerged. Accordingly, I focused the following interviews more, asked more in-depth questions and gathered richer data that described the process of the therapy sessions in more detail. Data creation Semi-structured interview is the most common method of data creation in GTM, though other common methods (observation or products of participants’ activity, such as diaries or blogs) can be used as well. If the data is not already in the form of text, verbatim transcription is made to prepare the data for analysis. It is characteristic for GTM that data creation is not separated from analysis. Rather, these two activities are tightly interwoven in the course of the research process: initial interviews are immediately analyzed and concepts emerging from the analysis inform further data creation, i.e., they help researchers narrow the focus of their study, ask more focused questions (to further elaborate these emerging concepts) and extend their sample by selecting participants who can provide them with rich information needed to develop the concepts. This way the research process continues until the point of theoretical saturation (see below). Thirty therapists participated in this study (17 females and 13 males). Their age varied between 26 and 67 (m = 40.1, SD = 10.3) and they had between half a year and 37 years of experience of working with depressed clients (m = 10.3, SD = 8.9). The sample represented a variety of theoretical orientations: psychodynamic/psychoanalytic (16), humanistic/experiential (15; eleven of which were Gestalt therapists), systemic/family systems (3), cognitive-behavioral (2) and integrative (2). Twenty-three of the therapists were trained in one approach, six in two approaches, and one in three approaches. Individual interviews were conducted with eight of these

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therapists. The remaining twenty-two (14 and 8) therapists participated in two focus groups (see the following step 5). Sample creation In GTM the representativeness of concepts is important because the research is focused on events and cases that characterize and define studied phenomena the most. The aim of GTM is not to generalize to the wider population, but to specify studied phenomena and its conditions, actions or interactions. Theoretical statements that result from this method are therefore valid only in the studied conditions (Strauss & Corbin, 1990). In the early research phase, the open coding phase, the sample is chosen in order to identify the greatest number of categories with their dimensions and characteristics. thus selecting those who offer the greatest opportunity for gathering data essential to the studied phenomenon. In the later stages of research, the choice of participants is more selective and is conducted so as to help fill in the “white spots” of the emerging theory (Charmaz, 2006; Strauss & Corbin, 1998). Gradually I analyzed all seven individual interviews using the open coding method. I compared the new codes with those I gathered in previous data by detecting their differences and similarities. I grouped the codes into categories, I named their properties and explored relations between them, and thus the theory originated. The first step in analysis: Open coding The analytic process begins with close and repeated reading of the data. A researcher searches for any part of the text related to the research question. These parts (which may be of word-length or may encompass several paragraphs) are captured by an apposite code and gradually elaborated into concepts (categories), which then become “building blocks” of the emerging theory. These concepts should express the essence of the phenomena under study in an abstract and comprehensible way, being firmly grounded in the data at the same time. Code, and later concept, names may be taken directly from the data (“in vivo” codes), may be designed by a researcher or may be “borrowed” from existing scientific concepts. Each of the three ways has its advantages and its drawbacks (Strauss & Corbin, 1998).

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The name of this phase – open coding – comes from an open and non-evaluative stance of the researcher who should not make premature judgements about what is and is not important and should rather consider multiple possibilities of how the data can be conceptualized. Let’s see what the whole process looked like in practice. Here we can see a part of a transcribed interview with a therapist, Fanny, and can examine how data originated in the research interview: Researcher: “(...) Try to say how you experienced that (...) during the therapy session with her.” Therapist: “I perceived it as difficult from the beginning. I had a question, whether the therapy has a chance to succeed. (...) [I felt] a big burden, boundedness, helplessness.” R: “Hm, hm. These are your feelings, right? Did you feel it somehow in your body?” T: “Yes. Certainly, such immobilization. Maybe numbness.” R: “Yes, yes.” T: “At the same time a little bit of... With this case I sometimes thought: "this story is really very difficult". And I had such a life-saving tendency; that I would like to help her somehow. The tendency to tell her that there is still something else in life.” R: “Did you try it? (...)” T: “I tried to explore with her if there was any other value in life, if there was something she could be happy about. Something that she could do and get satisfaction from. Something she could still value. I tried this approach but I absolutely didn't do well. (...) It didn't work. Not at all. (...) I tried to find some value. But there wasn't any. Or none that was strong enough. (...)” R: “Yes, yes. And what happened, when you tried it this way?” T: “It was like (...) in a garden... one is looking forward [to get the fruits] and then it rains and the strawberries rot anyway. Such [a feeling]: "nothing matters and nothing works out".” R: “Yes, yes. And how did that affect you in that moment?” T: “Well, maybe [I felt] something like helplessness. Maybe some anger in that moment.” R: “Hm. What did you do with these feelings?” T: “I think that mostly I just held them [or] I simply did not recognize them. Mostly it was a signal for me (...) that I was pushing somewhere, where it was closed. I realized this and I stopped going that way. I just stopped.” V: “And what did you do?” (...) T: “Well, it was more like (...) I stopped activating her and more like I joined her. (...) Well, but this mostly ended in such a resignation. But I

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Now let’s take a look at an example of open coding. First, researcher divided the text into meaning units. For example we can choose this part of the text: “It was like (...) in a garden... one is looking forward [to get the fruits] and then it rains and the strawberries rot anyway. Such [a feeling]: "nothing matters and nothing works out".”

A code “Frustration” was assigned to this unit and the researcher developed a conceptual content of the code, wrote his own comment: “The therapist is polarized against the client. She tries to supply the client with optimism, she searches for positive resources, looks for a motivation (in the context of the previous text). The intended effect, however, does not occur and the therapist feels frustrated. The experience that follows (“Nothing matters and nothing works“) is similar to the client´s symptoms – the symptoms of depression. The therapist is sharing the experience of the client.” Subsequently the researcher grouped codes with similar content into one category. For example the above code “Frustration” was merged with: x Meaning unit: “I simply feel a kind of angriness. I am really angry at them. (...) The immobility, the inertness [makes me angry]. [It is] as if you call into a black hole” (Kyle). x Code: “Angriness and frustration because of the impossibility of changing anything” x Comment: “The therapist did not succeed in her efforts to change the client´s symptoms. She is angry because her client does not fulfil her expectations.”

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By merging with other semantically similar codes, a category was created and the higher concept of “Frustration” was elaborated. Comments on individual codes have been used to describe properties of a given category. Figure 7-1: Elaboration of the concept “Frustration”

Anger and frustration because of the impossibility of changing anything

Frustration

Frustration Main categories describing the experience of therapists emerged: “Distancing from the client’s experience” and “Copying of the client’s experience”. The theory started to emerge, crystallizing around the “central concept”: the therapists tended to describe their own in-session experiences in relation to their client’s depressive experience as either similar or contrasting. Therapists used the metaphor of “Experiential distance” which started to serve us as a central concept. Central concept Glaser and Strauss (1967), the originators of GTM, emphasized the role of a central concept in a grounded theory. A central concept is an overarching concept with high explanatory power and close interconnections with many other concepts. It “holds” the whole theory together, making it compact and comprehensible, and it often takes the form of a more general psychological/social process (Glaser, 1978). The presence of a central concept is an aspect that distinguishes GTM from other qualitative methods, which may present their results, for instance, in the form of a set of themes (thematic analysis) or turning points in a narration (narrative analysis). At this stage of research, the research question was specified and narrowed down. The ongoing analysis enabled further narrowing of the topic on the experience and coping with the experience only in the context of psychotherapeutic sessions. Long-term experience, even in-between sessions was not included in the analysis.

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Specifying and narrowing the question GTM is usually chosen to study areas that have not been systematically explored previously. This means that researchers may even not know what kind of questions they should ask in the first place. Only after the research process has started can the researchers begin to orient themselves in the field, they start to understand “what it is all about” and they are in a better position to decide how to aim their study to achieve useful results. We can say that the research question develops together with the researchers’ understanding of the phenomena they study and sometimes it achieves its final form only at the end of the study.

Step 5: Conducting focus groups and refining categories I continued to collect data to elaborate and clarify the categories from previous analysis. I conducted two focus groups (14 and 8 therapists) centered on therapists’ experiences in psychotherapy with depressive clients and I aimed to understand how similar or different the therapists’ experience in psychotherapy was to the experiences of depressive clients. Once again, I analyzed transcripts of focus group interviews using the open coding method. Data from focus groups enriched the already created categories, adding fine details, creating a better way of defining the characteristics of every category. Focus group A focus group interview is an interview with a small group of people (typically 6 to 10) on a specific topic. Unlike individual interviews, focus groups enable participants to hear and react to each other, providing an opportunity to explore the differences and to map the variability in the participants’ experience. However, it does not allow a researcher to explore an individual’s experience in detail and it limits the number of questions that can be asked (Patton, 2002). The central concept of “Experiential distance” was further developed into “Experiential oscillation.” Therapists described how they were experientially “getting closer” to a client’s depressive experience and “moving away” from it. One therapist from the focus group expressed it aptly: “During the therapy session I felt (...) as if I was going towards her [the client] for a while and then going aside. (...) I kind of oscillate in it”.

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Figure 7-2: The central concept of “Experiential oscillation”

൸ Experiential oscillation ൺ To depressive experience

From depressive experience

“Experiential oscillation” started to serve as an overarching concept describing the changes of the therapists’ experiences. In the later phases this concept helped connect different parts of the growing theory into a coherent shape. When analyzing the text, I kept writing side notes on individual codes (Memos), which helped me focus on particularly important codes describing “experiential movement”. Using memos as seeds for the theory, I brought them together and conceptually united them. I moved from working with individual codes to working with categories. I merged categories describing similar phenomena into categories of a higher order. This way I thematically organized a large number of codes from the initial open coding into 30 categories. At this stage I moved from the initial coding phase into the phase of focused coding. I returned to the data and read the transcribed interviews again. After choosing the most useful concepts from the initial stage of open coding, I tested them by reverse correlation with the data and I coded larger segments of text. At the same time I searched for the most important data to answer the following questions: How did therapists respond experientially to the depressed client? What contributed to their various reactions? How did they manage their experiences? What contributed to their different ways of coping? These questions helped me to merge a previously large number of categories into three core conceptual categories: “Pulling in”, “Polarization”, “On the edge”. Let’s take a look at an example. The “Frustration” category described above was merged with other categories of “Aggression”, “Anger”, “Irritation” and “Impatience” into a category of higher order “Unbearable” (in vivo name), and along with the category “Two different worlds” (in vivo name) it created a parent category “Demarcating”. This, together with other categories led to a definition of one of the three core conceptual categories: “Polarization”.

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Figure 7-3: Creation of the core conceptual category “Polarization” Alienation

Fall back

Astonishment

No compassion

Agression Anger Irritation

Two different worlds

Unbearable

Frustration Impatience

Demarcating

Pulling in

Polarization

On the edge

I compared data describing each category to each other and sought connection between them. For example, when we look again at the above transcript of the therapist, Fanny, we can see that first she unsuccessfully tried to change the client’s depression (category “Attempt to change client’s depression”), followed by “Frustration” associated with feelings of “Helplessness” and “Anger”. Although all of these categories fall under the core conceptual category “Polarization”, it is now clear that “Polarization” can take different forms and that they are linked so that they follow one another in a particular order: Figure 7-4: Finding connections between categories

Attempt to change client’s depression

Frustration Helplessness Anger

Constant comparative method The constant comparative method (Boeije, 2002; Glaser & Strauss, 1967) is the very “heart” of GTM. It means that a researcher permanently and systematically compares words, codes, categories, events or whole narrations to each other, trying to distinguish whether they are conceptually different from each other or not. This process makes it possible to gradually establish conceptual

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properties and dimensions of emerging concepts, and thus helps to elaborate, solidify or even redefine these concepts. As the analysis goes on, researchers become less open and more focused in their coding. Instead of introducing newer and newer codes, some codes/concepts that have proven to be more useful than others, are used to code large portions of data. This is sometimes called focused coding (Charmaz, 2006).

Step 6: Axial coding and data re-analysis Theoretical concepts that emerged up until now needed to be theoretically linked. To achieve this, an axial coding method, using the axial coding paradigm helped. Axial coding Axial coding paradigm is a tool devised by Strauss and Corbin (1990, 1998) to facilitate searching for theoretical relationships among concepts. It consists of several theoretical types of concepts, which can be generally divided into conditions, actions/interactions and consequences, connected with a particular phenomenon. In other words, at this level of analysis, a researcher looks for ways in which the concepts he or she created are related to each other, stating that, for instance, Category A is best understood as a consequence of Category B. The axial coding paradigm is one of the sources of disagreement within the GTM proponents. While for Strauss and Corbin (1998) it serves as a useful tool that helps to produce rich theory, from Glaser’s (1992) perspective it represents a way of forcing the data into a prefabricated and potentially inappropriate form. Acknowledging Glaser’s argument, researchers should not confine themselves to a single paradigm but should rather adapt their method to their own data and research goal. Analysis so far, using the open coding method caused various kinds of categories to appear, which could be put into mutual relations and generalized into a simple sequence describing processes related to the experiential change: Figure 7-5: Axial paradigm

Situation o Experience o Coping o Consequence

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This sequence served as an original axial paradigm, which corresponded with the research question and the nature of analyzed data and it also served for the development of theoretical relations between found concepts. An axial paradigm describes a sequence, in which (1) The therapist finds himself in a situation with a depressive client that he describes in a certain way (category “Situation”). (2) The therapist experiences this situation (category “Experience”) and (3) The therapist copes with his experience in a certain way (category “Coping”), (4) The “Consequence” of this is a change of “Situation”. This further affects the therapist’s “Experience” and the sequence can start again. Returning to the transcribed therapists’ interviews, I used the axial paradigm to re-analyze the data, which resulted in newly ordered data creating a logically coherent whole. Finally I focused only on those sections of data that directly described the therapeutic session process. I chose 32 excerpts that described specific therapeutic events and I omitted therapists’ general comments and contextual descriptions of the situation. Out of all identified events, I took six out because they missed basic information on some axial paradigm component. I discarded another four events because detailed study showed that clients were not in fact depressed, even though their problems suggested as much. After this reduction, I worked with 22 events, which further served as units of analysis. Unit of analysis The unit of analysis determines “how large pieces of data” are compared to each other (Glaser & Strauss, 1967; Patton, 2002). In psychotherapy research, for instance, researchers may compare therapeutic cases over the course of the whole treatment, they may compare individual sessions (within or between cases), or they may focus on micro-process sequences (and compare twenty such sequences in a single session). In the present example we have defined the unit of analysis as a therapeutic event of variable length, describing a particular sequence of a therapist’s experiences in interaction with a particular client. In the course of analysis we compared all these events to each other to find their commonalities and differences.

Step 7: Selective coding and process model I compared analyzed events to each other and sought similarities and different variants, which allowed me to create a so-called makeshift theoretical construct, the model of Basic sequence that describes a general

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order of phases of therapists’ experiential reaction to their depressive clients: Basic sequence: 1. Pulling in (description of Situation: the therapist can feel he’s being drawn by the atmosphere into the situation with a depressive client) 2. Helplessness, regret (description of Experience of a therapist in a given situation) 3. Striving for symptom change (description of Coping: the therapist copes with the experience by trying to change the symptoms) 4. Permanence (description of Situation: the therapist can’t see the effect of his efforts) 5. Frustration (description of Experience of a therapist when the situation is unchanged) 6. Turning point (description of Coping: the therapist copes by accepting the situation) 7. Relationship (description of Situation: symptoms recede into the background and the relationship becomes the main focus) 8. Relief, ambivalence (description of Experience of a therapist) Then I went back to the data and compared sequences of individual events with the Basic sequence. I stressed the uniqueness of every event’s process and compared them to each other. It was important to follow the logic of the therapists’ narration and not my own idea of how the steps should proceed. New possibilities of the process, variants and details appeared during the analysis of events. I paid attention to slight variations and identified various process variants, which I compared with each other. Then I sought an explanation for why the process differed. It was interesting that after seeing the data so many times now I saw it differently, paying more attention to the process and interdependencies between individual phases. Let us return to the interview with Fanny (see above) once more and see how it looks compared to the Basic sequence: 1. Pulling in The therapist is drawn into the shared experience of depression from the first meeting with a depressive client. The experience is difficult without a hope for change: “I perceived it as difficult from the beginning. I had a question, whether the therapy has a chance to succeed.”

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2. Helplessness, regret The therapist experiences “big burden, boundedness, helplessness... such immobilization. Maybe numbness.” 3. Striving for symptom change The therapist tries to break free from the helplessness with her own activity. She experiences “a life-saving tendency”, she tries to help the client, to give hope, happiness, satisfaction: “And I had such a life-saving tendency. That I would like to help her somehow. The tendency to tell her that there is still something else in life... I tried to explore with her, if there was any other value in the life, if there was something, which she could be happy about. Something she could do and get satisfaction from. Something which she could still value.” 4. Permanence “In this sense I tried it but I absolutely didn't do well. It didn't work. Not at all... I tried to find some value. But there wasn't any. Or any which was strong enough.” Therapist experiences demotivation, loss of meaning: “It was like (...) in a garden... one is looking forward [to get the fruits] and then it rains and the strawberries rot anyway. Such [a feeling]: "nothing matters and nothing works out".” 5. Frustration The therapist is once again drawn into the shared experience of depression. At the same time she’s experientially polarized against the client and experiences helplessness and also anger: “Well, maybe [I felt] something like helplessness. Maybe some anger in this moment.” 6. Turning point The therapist recognizes these feelings and does not follow the impulse to experientially distance herself from the client, she holds on. She sees these feelings as a guide for further progress, a signal to stop and change the approach to his client: “What did you do with these feelings? ... I think that mostly I just held them [or] I simply did not recognize them. Mostly it was a signal for me (...) that I am pushing somewhere, where it is closed. I realized this and I stopped going that way. I just stopped.” 7. Relationship The therapist adjusts his approach, takes less responsibility for change, and is less active in trying to make the change happen. In contrast, she leaves more responsibility to the client: “Well, it was more like (...) I stopped activating her and more like I joined her.”

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8. Relief, ambivalence The therapist gives up the rapid change that she could actively induce. At the same time the relational aspect of the meeting comes into focus: “Such a feeling that I am with her.” ... “Despite the fact that nothing will improve, that we will not find any solution (...) but some kind of contact could arise.”; “Well, but this mostly ended in such a resignation. But I think that there were also some moments [when] some contact could arise. (...) Despite the fact that nothing will improve, that we will not find any solution (...) but some kind of contact could arise. Such a feeling that I am with her.” There are no more great experiential fluctuations in terms of pulling in or polarizing. The therapist moves on the edge and around it. The therapist feels a relief from the activity: “simply touch down”. She’s reconciled with sitting in sadness, hopelessness, futility, and fear: “And what happened with you then? How did you experience it? Well, [I felt] unpleasant anyway. (...) Or maybe not so unpleasant. Maybe it was like [when] you stand firmly on the ground. You touch down, you stop floundering in some activity, but simply touch down. (...) On the one hand, it is relief from that activity, but on the other hand I am sitting in something nasty. In some sadness, helplessness, inconclusiveness.” Complex theory. At this stage, a significant shift in the final theory construction happened. I added (horizontal) movement in the “To depressive experience” and “From depressive experience” to the description of Basic sequence (top to bottom movement). Dimensionalizing Dimension is an aspect of a concept that describes its inner variability. When a researcher is aware of the different forms a concept can take, he or she is better able to interconnect concepts on a “deeper” level and to show “how things work,” under which circumstances and with what consequences. Dimensionalizing is an advanced process of elaborating a concept and only the most important concepts will probably reach this level of elaboration. In our case, two separate categories (Connecting to and Disconnecting from a client’s experience) turned up to be two poles of Experiential oscillation – they form its basic dimension, describing what Experiential oscillation can look like under different conditions.

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By combining the Basic sequence and movement in “Experiential oscillation” I created a provisional version of complex theory, that describes the process of therapists’ experiences in psychotherapy sessions. I named the model of this theory “Depression co-experiencing trajectory”. This approach interconnected existing individual concepts and the theory “held together”. Figure 7-6: Depression co-experiencing trajectory

(1) Sharing depressive experience (2) Turning to oneself (3) Striving for symptom change

(4)

Distancing

from

depressive

(5) Turning to a client (6) Focusing on relationship

The process of the therapists’ “Experiential oscillation” between the two polarities gradually developed during a psychotherapeutic session. It was possible to distinguish individual stages of the trajectory and their typical sequence, as shown in the general model of “Depression coexperiencing trajectory” (Roubal & ěiháþek, 2014). This general sequence of stages appeared once or several times during one session, in some cases it was possible to find just parts of the sequence in an event description. Formulation of a theory This is the last and usually most difficult phase of the research process. In this phase, individual concepts are integrated into a coherent theory, often organized around a central concept. To achieve this goal, researchers try to relate all the concepts that they have so far created to the central concept and specify the nature of these relationships. However, they usually do not include

THE COURSE OF A THERAPY SESSION

to depressive experience ĸ Experiential oscillation ĺ from depressive experience

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all their concepts in the final theory but choose only those most effective in explaining the phenomenon under study. After a theoretical model is created, researchers have to give it a narrative form that would make the theory easily comprehensible to readers (Strauss & Corbin, 1998).

Step 8: Achieving theoretical saturation by theoretical sampling Since the model is based on a sample of therapists of mostly psychodynamic/psychoanalytic or humanistic/experiential orientation, I validated the model using the theoretical sampling principle. I filled the data in by conducting an interview with an experienced CBT therapist (with 24 years of experience working with depressive clients). I focused specifically on how a therapist, who, based on his background, is not primarily oriented to the relational aspect, but works primarily with symptoms, and copes with his experiences. My aim was to study one stage of the process specifically (“Striving for symptom change”) and also to fill in the polarized style of psychotherapeutic work against experiential or dynamic oriented therapists, who see the psychotherapeutic relationship as their main focus. Theoretical sampling Unlike traditional research designs that require researchers to have clearly defined their sampling strategy and collected their data prior to any analysis, GTM gives researchers the freedom and obligation to develop their sampling strategy in the course of analysis in reaction to emerging concepts and their dimensions. Thanks to this, researchers can deliberately search for different variants of a phenomenon and fill in “blank spaces” in their analytical “maps”. In a strict sense, one should speak about theoretical sampling if, and only if, the sampling criteria arise from the analysis itself (Hood, 2007), otherwise a broader term of “purposeful sampling” should be used. The interview was transcribed and I chose four more events from it, of which two were later excluded because they described therapy with clients whose primary diagnosis was not depression. I analyzed the remaining two events, which were described in great detail, using the process as detailed above. Results were fully consistent with the present theoretical model. A certain difference, however, which does not relate to the experience describing model was that the CBT therapist treated his experiences

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differently than therapists with psychodynamic and experiential orientation. He predominantly used a rational way of coping, particularly the cognitive restructuring technique. It can, however, be generalized that therapists use the same procedures from their professional background for coping with their experiences that they also draw on when working with clients. Psychodynamic therapists, for example, managed their experiences using interpretation, experiential therapists using grounding in their own awareness and CBT therapist using cognitive restructuring. Because the data obtained in the theoretical sampling from such different sources did not bring new information to the theoretical construct, one could infer that theoretical saturation was achieved. Further data collection was not needed and the resulting theory could be considered a result of the grounded theory research process. Theoretical saturation The process of data creation could theoretically go on forever, adding more interviews (stories, event descriptions, etc.) to the data set. At a certain point, however, new data contributes no new information about the phenomenon under study. In other words, the theory becomes saturated. Theoretical saturation is formally considered a criterion of grounded theory completeness, though on a practical level it is difficult to assess and it is sometimes regarded as idealistic (Williams & Morrow, 2009).

Step 9: Model validation Above I described several steps that I took to ensure credibility: (1) researcher’s self-reflection in respect to the studied topic, (2) repeated data analysis, which revealed more subtle meanings and allowed for more structured and detailed elaboration of the model, (3) inclusion of theoretical sampling and application of the theoretical saturation principle. Apart from that I took more steps which I will only briefly mention: (4) I asked the last respondent (CBT therapist) to evaluate the model from a clinical point of view, (5) I presented the final model in the context of a workshop at an international psychotherapeutic conference and used the feedback of 16 participants to consolidate the model, (6) the second author of this chapter did an audit that in particular included a comparison of initial data (descriptions of events) with the final model (inspired by Hill, 2012).

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Credibility and usefulness Every research study has to provide evidence for the trustworthiness of its results. In general, this is achieved by a thorough description of all phases of the research process. Furthermore, it is ensured by presenting results in a way that is comprehensible and shows their groundedness in data. Though credibility is usually assessed and commented on at the end of a research report, it represents an inseparable aspect of the whole research process. Charmaz (2006) defines four criteria that a study using the grounded theory method should meet: (1) Credibility: Results are sufficiently grounded in the data and this was achieved by systematic comparison; (2) Originality: The resulting theory brings new understanding of studied phenomenon; (3) Resonance: People who have experience with the studied topic find the final theory meaningful and beneficial; (4) Usefulness: The final theory describes the general processes through interpretations that are useful in practice and also for further research.

Step 10: Article writing I finished my research by writing an article for a research journal (Roubal & ěiháþek, 2014). I had to thoroughly and yet simply explain the resulting theory as to make it short, straightforward and accessible for journal editors and readers. I returned to the data for the last time and sought passages that aptly illustrated different parts of the presented theory. I put the whole study in a broader context and compared it with empirical and theoretical findings of relevant literature. I also described the limits of my research and made suggestions on how these results could be used for further research. At the end of the research, I now realize that this entire research process was important for me as a therapist. It allowed me to gain necessary distance from the suffering of my depressive clients, while not being entirely detached, keeping in touch with the topic of depressive suffering. Work on this research brought new enthusiasm into my work with depressive clients, which also served me well in preventing burnout. I now observe my experiences with curious fascination and look forward to the sessions with my depressive clients once again.

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Acknowledgement This study was supported by the Czech Science Foundation Grant GAP407/11/0141.

References Boeije, H. (2002). A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality & Quantity, 36(4), 391–409. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications. —. (2009). Shifting the grounds: Constructivist grounded theory methods. In J. M. Morse, P. N. Stern, J. Corbin, B. Bowers, K. Charmaz, & A. E. Clarke (Eds.), Developing grounded theory: The second generation (pp. 127–154). Walnut Creek, CA: Left Coast Press. Finlay, L. (2012). Five lenses for the reflexive interviewer. In J. F. Gubrium, J. A. Holstein, A. B. Marvasti, & K. D. McKinney (Eds.), The SAGE handbook of interview research: The complexity of the craft (pp. 317-331). Los Angeles, CA: SAGE. Finlay, L., & Evans, K. (2009). Relational-centred research for psychotherapists: Exploring meanings and experience. Chichester: J. Wiley. Francesetti, G., & Roubal, J. (2013). Gestalt therapy approach to depressive experiences. In G. Francesetti, M. Gecele, & J. Roubal (Eds.), Gestalt therapy in clinical practice. From psychopathology to the aesthetics of contact (pp. 433-459). Siracuse: Istituto di Gestalt HCC Italy Publ. Co.. Glaser, G. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press. —. (1992). Basics of grounded theory analysis: Emergence vs. forcing. Mill Valley, CA: Sociology Press. Glaser, G. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine Publishing Company. Hill, C. E. (Ed.). (2012). Consensual qualitative research: A practical resource for investigating social science phenomena. Washington, DC: American Psychological Association. Hood, J. C. (2007). Orthodoxy vs. power: The defining traits of grounded theory. In A. Bryant & K. Charmaz (Eds.), The SAGE handbook of grounded theory (pp. 151–164). London: Sage.

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Konopásek, Z. (2008). Making thinking visible with Atlas.ti: Computer assisted qualitative analysis as textual practices. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 9(2), Art. 12. Retrieved from: http://nbn-resolving.de/urn:nbn:de:0114-fqs0802124. Patton, M. Q. (2002). Qualitative research & evaluation methods. Thousand Oaks, CA: Sage. Rennie, D. L. (1998). Grounded theory methodology: The pressing need for a coherent logic of justification. Theory & Psychology, 8(1), 101– 119. Rennie, D. L. (2000). Grounded theory methodology as methodical hermeneutics: Reconciling realism and relativism. Theory & Psychology, 10(4), 481–502. Rennie, D. L., & Fergus, K. D. (2006). Embodied categorizing in the grounded theory method: Methodical hermeneutics in action. Theory & Psychology, 16(4), 483–503. Rennie, D. L., Phillips, J. R., & Quartaro, G. K. (1988). Grounded theory: A promising approach to conceptualization in psychology. Canadian Psychology, 29(2), 139–150. Roubal, J. (2007). Depression - A Gestalt Theoretical Perspective. British Gestalt Journal, 16, 35-43. Roubal, J., & ěiháþek, T. (2014). Therapists’ in-session experiences with depressive clients: A grounded theory. Psychotherapy Research, Oxford University Press, 26, 206-219. Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative Phenomenological Analysis: Theory. Method and Research. London: Sage. Strauss, A. (1987). Qualitative analysis for social scientists. Cambridge: Cambridge University Press. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: SAGE Publications. Williams, E. N., & Morrow, S. L. (2009). Achieving trustworthiness in qualitative research: A pan-paradigmatic perspective. Psychotherapy Research, 19(4-5), 576-582.

CHAPTER SEVEN A GUIDE TO CONDUCTING CASE-BASED, TIME-SERIES RESEARCH IN GESTALT THERAPY: INTEGRATING RESEARCH AND PRACTICE IN A CLINICAL SETTING ALBERT J. WONG, MICHAEL R. NASH, JEFFERY J. BORCKARDT, MICHAEL T. FINN

Introduction Despite recent calls for an increase in the use of single case time-series research design (Borckardt et al., 2008; Laurenceau & Bolger, 2005; Laurenceau, Hayes, & Feldman, 2007), this methodology remains relatively under-utilized in psychotherapy treatment research. A thorough review of various methodologies can be found in Barlow and Hersen (1984). In this chapter, we focus on one of these methodologies: a simple A-B time-series research design consisting of two phases – a pre-treatment phase (Phase A) followed by a treatment phase (Phase B). This treatment design, in which patient symptoms are tracked over time, has been fruitfully, albeit sparingly, utilized in recent years to help elucidate the efficacy and the dynamic mechanisms of change in various therapeutic modalities. Cognitive-behavioral therapies (Elkins & Moore, 2011), therapeutic assessment (Smith, Handler, & Nash, 2010), psychodynamic approaches (Frankel & Macfie, 2010), and other therapeutic modalities have been clarified through this single case study time-series approach. In this research design, the subject is assessed at regular periodic intervals during both Phase A and Phase B, i.e., during pre-treatment and treatment phases of the therapy. The time-series data that is accumulated from this regular assessment generates a semi-continuous set of data points

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that characterizes the dynamic process of change (or non-change) of the client over the course of treatment (or pre-treatment). This cumulative, sequential time-series data is referred to as a data stream. Improvement and efficacy. By comparing the behavior of the time-series data stream between phases, i.e., during pre-treatment (Phase A) and treatment (Phase B), we can typically ascertain whether the onset of treatment had a statistically noticeable effect on the data stream. We can begin to address the questions regarding improvement. Was this treatment effective? That is, did the treatment significantly impact the target symptoms? Mechanism of change. Additionally, when two or more different variables are repeatedly assessed at each periodic interval, we will have multiple data streams. In this case, we can then ask questions regarding the interaction of the data streams. How do the different variables we are measuring influence and impact one another? How do symptoms dynamically resolve over time? That is, what leads to what? When we compare how multiple data streams interact with one another over time, we can gain crucial insight into underlying mechanisms of change. Why, one might ask, should any of this matter to Gestalt therapists? Gestalt therapists have historically been rather disinterested in scientific research. However, this is changing somewhat by necessity. One of the current, critical challenges facing Gestalt therapists is demonstrating credibility as an evidence-based treatment. Numerous pressures from governing agencies, accountable care organizations, and insurance companies have converged to make the need to evidentially justify Gestalt therapy a matter of urgency. Philip Brownell puts the challenge in sharp relief in the following description: Then one day people realized that in Germany the government had gone to regulating the practice of psychotherapy – and they had not accredited Gestalt Therapy based on the fact that it didn’t have a research base. And so in Germany, the people there had to re-certify as psychoanalysts in order to keep practicing … and everyone went “uh-oh”. (Fitzpatrick, 2013).

The survival of Gestalt therapy as a legitimate psychotherapeutic treatment modality depends upon developing its foundational base of evidence. The ability of Gestalt therapists to practice, to be reimbursed by managed care organizations, and to influence the dialogue surrounding psychotherapeutic best practices has been significantly curtailed due to the lack of an evidence base. Regardless, it is important for Gestalt therapists

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to rigorously review their treatment cases in order to determine what the underlying mechanisms of Gestalt therapy are, how to improve their own treatment success with Gestalt therapy, and when, how, and under what circumstances Gestalt therapy works (see Roth & Fonagy, 2006). While Gestalt therapists are deeply in need of evidential confirmation regarding the efficacy of their chosen treatment modality, they typically do not have access to the financial and human resources to conduct largescale randomized control trials (RCTs) that are the bread and butter of most efforts to evidentially justify treatment modalities. Additionally, the culture of Gestalt clinicians is ruggedly individualistic and prizes treatment that is idiographically tailored to the specific client. Because of the dispositional qualities of Gestalt clinicians and their limited access to large randomized control trial populations, a mode of evidential justification that dovetails with Gestalt’s emphasis on the richness of individuality is needed if they wish to provide an evidential basis for the Gestalt approach. The single case time-series experimental research design, when conducted with sufficient replication, has been cited by Chambless and Hollon (1998) as a legitimate criterion for establishing a treatment modality as an empirically supported treatment. A single case experimental research design would appear to be a mode of empirical inquiry that is much more congruent with Gestalt therapy’s underlying values. With sufficient replication, single case experimental research designs can be utilized to provide empirical justification for Gestalt practice. Under the guidelines set forth by Chambless and Hollon (1998), in order for a treatment modality to be deemed “efficacious”, it must be validated by ten or more single case design studies; in order to be considered “possibly efficacious” pending replication, it must be validated by four or more single case design studies. Though Gestalt therapists do not generally have access to large research laboratories, they do frequently have thriving clinical practices. Because the single case experimental research design focuses on individual cases rather than randomized control trials, it allows Gestalt clinicians to utilize the therapeutic setting as a natural laboratory to conduct research. The recent interest in single case experimental design within the Gestalt community is largely due to the fact that it is a research methodology that seems most congruent with the community’s mode of practice, as it is more equipped to capture the crucial nuances of the Gestalt therapy process. The single case research design may, in fact, provide Gestalt therapy with its most auspicious avenue towards gaining credence as an evidence-based treatment.

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The single case experimental design So, what, exactly, is the single case experimental design (SCED)? In order to clarify what a single case experimental design is, let us first state what it is not. It is not simply a “case study.” A case study is traditionally a narrative report of a therapeutic intervention and how a patient responded to that intervention over the course of treatment. In a case study, data is sometimes provided but frequently there is only a qualitative description of the treatment. More importantly, in the vast majority of psychotherapeutic case studies, there is no experimental control. By contrast, SCEDs always have an experimental control, namely baseline data stream measurements. Moreover, SCEDs utilize statistically rigorous methods to ascertain the presence of a treatment effect. All the while, SCEDs retain the rich qualitative tradition of narrative case studies, which can be seamlessly integrated with the empirical data. Single case experimental designs, unlike case studies, must adhere to standards of treatment fidelity, must specify the sample population via inclusion and exclusion criteria, and must utilize good experimental design. SCEDs must have an experimental control, must establish a representative baseline, and must manage the nonindependence (i.e., the autocorrelation) of sequential observations – the fact that change in a symptom in one week will almost invariably mean that the patient will maintain some of this improvement in the next week. Researchers who utilize SCEDs must be able to utilize appropriate statistical methodologies to know how much their treatment works (the effect size) and be able to analyze short data streams (which is almost impossible to do accurately without special statistical models). A SCED is different from a group experimental design. In a group experimental design, one group is compared to another, i.e., the experimental and the control groups. It is called a “between subjects” design, because the comparison is between two separate groups of subjects. By contrast, in a single case experimental design, one person is compared to himself or herself. In particular, the individual’s baseline data stream phase of reported symptom severity is compared to symptom severity during their treatment phase. It is called a “within subjects” design because the comparison is between a single person’s baseline and treatment phases. The benefits to Gestalt therapy of SCEDs are manifold. Congruent with underlying core values of Gestalt therapy, there is no generic lumping of people into groups and no random assignment of clients into manualized treatments. All that is needed to conduct a single case

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experimental design is one Gestalt therapist, doing what he or she does in their own practice with one of their clients. Moreover, SCEDs strongly link science to practice and practice to science, as practitioners are encouraged to be more scientifically rigorous in their assessments of progress and to incorporate those findings into their future work. It is inexpensive and it provides a way for research to be added easily into existing clinical settings. Additionally, the process of determining what set of symptoms the client wishes to target – a primary part of SCED studies – may promote the working alliance and may enhance motivation for clinicians and clients. Single case experimental designs are characterized by repeated measures of the client’s symptoms taken over the course of time. In this way, SCEDs find an interesting point of contact with early behaviorist values of evidence and science. As B. F. Skinner (1966) has stated, “Instead of studying a thousand rats for one hour each, or a hundred rats for ten hours each, the investigator is likely to study one rat for a thousand hours” (p. 21). Historical disagreements aside, a Gestalt therapist can find some common ground with Skinner in valuing an individual’s process. These successive measurements of client symptoms are taken over both baseline and treatment phases. Importantly, within the context of the experimental design, only one variable changes at a time. For example, in the generic A-B single case experimental design, the variable that changes is whether treatment is being administered or not.

Single case design: Threats to validity One of the principal concerns regarding single case experimental design is whether or not the design is internally valid, i.e., whether or not the effects are in fact due to the treatment intervention. Unfortunately, it is not always safe to conclude that change in the administration of treatment (the independent variable), is in fact what has caused the observed changes in symptoms (the dependent variable). There may be historical confounding variables: an unanticipated event may occur while the treatment was in progress which may affect the dependent variable. There may also be attrition confounds: a participant might have begun a treatment, but may have failed to complete it for some reason. These threats to the internal validity of the treatment study can compromise our confidence that a relationship exists between the independent and dependent variables in a single case treatment. In as much as possible, efforts should be made to minimize confounds in the experimental design in order to enhance its internal validity. For example,

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one needs to keep a healthy scepticism with regard to alternative explanations (e.g., an unrelated change in patient’s physical health or environment). Psychotherapy process notes can provide crucial history in helping to understand shifts in the change in symptoms at particular points in time. There are also threats to the external validity of the study, including population validity and ecological validity. If a patient is not representative of the population, then the study will be more difficult to generalize to other individuals (population validity). Additionally, if the treatment setting of the therapeutic interventions is not representative of typical treatment settings, then it will be difficult to apply the findings to other treatment settings (ecological validity). Clearly, the more frequently the findings of a single case experimental design are replicated across a range of contexts, the greater the external validity and generalizability of the findings will be.

Single case design: Step-by-step There are seven basic steps to constructing a single case experimental design. These steps are as follows: (1) make a hypothesis, (2) select a client, (3) choose a target complaint (or several target complaints), (4) measure target complaint(s) continuously over a baseline period, (5) systematically apply or alter treatment interventions, (6) measure target complaint(s) continuously over the treatment period, (7) determine if there is a statistically significant effect. We will go over these steps, one by one. The reader may find that the actions involved in some of these steps are quite obvious and may even seem like natural background assumptions, though it is important to explain each one in detail for the sake of clarity. Step 1: Make a hypothesis. The hypothesis of a single case experimental design is the conjecture that a study is designed to test. For psychotherapy treatment efficacy studies, a hypothesis will typically involve two basic elements: the claim that a particular treatment intervention that is being tested is effective, e.g., Gestalt therapy, and a particular population that the treatment is being tested upon, e.g., individuals who suffer from major depression. For example, a simple hypothesis might look something like this: Gestalt therapy is an effective treatment for major depression for adults. A hypothesis might examine a treatment modality as a whole, e.g., Gestalt therapy, or a specific aspect of a treatment modality, e.g., the empty chair technique. There are many different ways to construct a legitimate hypothesis.

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Step 2: Select a client. Next, a client must be selected. In particular, the SCED must provide inclusion and exclusion criteria that specify how an individual would qualify as being a member of the particular population that is under investigation in the hypothesis and how that individual will be chosen to be the subject of the study. The participant who is selected to be eligible for the study must be selected based on specifically delineated, predefined, and measurable inclusion and exclusion criteria. If, for example, a study is targeting individuals who exhibit depression, it may require that participants have a depression cut-off score above a certain level on the Beck Depression Inventory (BDI). If a study is targeting individuals who exhibit marital distress, it may utilize the Dyadic Adjustment Scale (DAS), or some comparable marital distress measure, to provide a criterion for whether or not an individual qualifies for inclusion in the study. Any patient who is selected for a single-case study must be selected based on specifically delineated, measurable inclusion and exclusion criteria. Frequently, these inclusion criteria measures can also be utilized as pre-treatment measures in order to ascertain if there is a pre/post treatment effect. It is important to also make sure that the participant does not meet any of the exclusion criteria for the study. Typical exclusion criteria, i.e., criteria which would prohibit the participant from being appropriate for the study, may include items, for example, such as the client being actively psychotic, being a child, actively using substances, and being in concurrent other psychotherapy, etc. The client must be provided with informed consent forms to insure that he or she is willing to participate in the study. Step 3: Choose target complaints. The next step in SCEDs is to select specific target complaints of the client. This will typically be done through a collaborative process during the intake interview with the client. The therapist will attempt to ascertain what complaints the client wishes to target over the course of treatment and to put the complaints into operationalizable form. These complaints should be as concrete and quantifiable as possible, they should be able to be measured frequently, and they should be, essentially, stable in the absence of treatment. These target complaints will then be consolidated into the Target Complaints (TC) measure (Battle, 1966) so that the client can track their symptoms periodically over the course of treatment. Step 4: Measure Target Complaints continuously over a baseline period. Once the Target Complaints measure has been formulated, the client will

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be asked to complete it periodically, e.g., daily, over the course of a pretreatment phase of the study. Ideally, there would be seven baseline data points, though it is possible to conduct the statistical analyses with as few as three baseline data points. Frequently, patients are asked to monitor target complaints on a daily basis in the time between an intake session and the first bona fide treatment session. TCs can also be measured on a weekly basis or other periodic basis, though usually in these instances it is more difficult to establish a substantial baseline stream of data. Step 5: Systematically apply or alter treatment interventions. Once a data stream of target complaints during the baseline (pre-treatment) period has been established, the client should be systematically provided with the treatment intervention. The treatment intervention serves as the experiment’s independent variable: during the baseline period (Phase A), there is no treatment that is provided, whereas during the treatment period (Phase B), treatment is in fact provided. The change in intervention is what separates the data stream into separate phases: pre-treatment (baseline) and treatment phases. Frequently the pre-treatment phase is simply called “Phase A” and the treatment phase is called “Phase B.” This overall design is called an “A-B Single Case Design.” In the administration of the treatment, it is important to ensure that the treatment that is reported to be administered is in fact administered, i.e., that treatment fidelity is maintained. This can be done in a number of ways, i.e., ensuring that the individual who is administering the treatment has been appropriately trained in the methodology, conducting external peer review of recorded sessions to determine whether or not the methodology has been followed, etc. Step 6: Measure Target Complaints continuously over treatment period. Over the course of the treatment period, patients will be asked to monitor target complaints at regular periodic intervals, e.g., daily or weekly, over the course of treatment. Given how time-based statistical analysis works, the same periodic interval as was used for measuring target complaints in the baseline phase must be used for measuring target complaints during the treatment phase. At least seven data points during the treatment phase are needed, though clearly more data is better. Single case experimental design studies frequently have over thirty data points in the treatment phase. Additionally, at the end of the treatment period, post-treatment outcome measures are administered to the client in order to determine if a pre/post treatment effect has occurred. Here, one should simply re-

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administer the original screening measures. These bookend the time-based symptom data and can very much bolster the empirical findings. Step 7: Determine if there is a significant effect due to treatment. Once the data has been collected in the baseline and treatment phases as well as the pre/post measures, the data can be analyzed in order to determine if there is a significant statistical effect due to the treatment. The pre/post treatment measures and the baseline/treatment data streams are analyzed using statistical methodologies appropriate to the data. The pre/post treatment measures that were given to the client are typically analyzed using single case pre/post statistical methods, such as the Reliable Change Index (RCI; Jacobson & Truax, 1991), in order to determine if the client’s change is significant. The baseline/treatment data TC data streams, on the other hand, require a specific kind of data analysis. One that is well-suited for our purposes is called Simulation Modeling Analysis (SMA), which was developed specifically for psychotherapy process research, which usually deals with short streams of data. A brief discussion of the SMA methodology is provided below. Because short data streams, as are typically found in clinical therapeutic office settings, are particularly difficult to analyze, SMA is a preferred method of analysis for many SCEDs. Additionally, SMA data analysis allows researchers to compare underlying dynamic changes between symptoms; that is, whether abatement of one symptom is temporally prior to another. In this way one is able to complement a general analysis of Gestalt therapy treatment effect with an interesting exploration of the mechanisms of action which underlie Gestalt therapy.

Simulation Modeling Analysis In this section we introduce the specific statistical analytic procedure called Simulation Modeling Analysis (SMA; Borckardt et al., 2008) and describe how it can be used to test claims of treatment efficacy and mechanisms of action. Extensive exposition regarding the computational details of this methodology, however, lies beyond the scope of this chapter1.

1

For detailed discussion regarding this method, including multiple real-life and hypothetical examples, see the American Psychologist article by Borckardt et al. (2008).

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Efficacy of treatment: Simulation Modeling Analysis phase-effect analysis. The SMA approach is a bootstrap statistical methodology that has been designed to provide adequate power and good Type I error control for short data streams in order to ascertain if and when significant phase effects and cross-variable time-lagged correlations may occur (Borckardt et al., 2008). When we are asking whether or not a treatment is effective, we are, in essence, asking if there is a significant phase effect. Has there been a significant change in a treatment outcome variable – for example, depression – when comparing Phase A (pre-treatment) to Phase B (treatment)? To implement the SMA methodology, the data stream is divided into two phases: the pre-treatment baseline and the treatment phase. The stage of treatment (i.e., the phase) is considered to be the independent variable and is represented by a binary phase vector, v, in which the pre-treatment (baseline) phase is represented by v = 0 and the treatment phase is represented by v = 1. The dependent variable (DV), in this example, is each daily rating of overall depression which might be measured on the TC questionnaire. If our data stream (shortened for the purposes of illustration) consists of daily measurements of depression taken over 5 baseline, pre-treatment days and 7 days of treatment, the hypothetical depression data stream might look something like this: 18, 18, 19, 17, 18, 16, 15, 16, 13, 14, 12, 11 The independent variable (IV; phase vector, v) data stream would look like this: 0, 0, 0, 0, 0, 1, 1, 1, 1, 1, 1, 1 Using these two data streams, the SMA phase effect analysis proceeds as follows: Step 1. The correlation between DV (overall depression) and IV (treatment phase) is calculated. Step 2. The autocorrelation (AR) for the DV is calculated. (Typically, a Lag 1 autocorrelation is used, as a Lag 1 autocorrelation most closely represents the natural tendency of clinical process variables to remain constant over time.) Step 3. Presuming an initial DV starting value identical to the actual initial DV starting value (in this instance DV0= 18), a large number of randomly generated data streams are generated using the autocorrelation (AR) value for the data stream found in Step 2. After each data stream is generated,

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the correlation between the data stream (DV) and the phase vector (IV) is calculated. When the absolute magnitude of the correlation of the randomly generated data stream with the phase vector exceeds that of the actual correlation calculated in Step 1, the data stream is considered a “hit.” Otherwise, the data stream is considered a “miss.” Step 4. From this repeated generation of “hits” and “misses,” a p-value is determined using the equation: p-value = [ hits / (hits + misses) ] This p-value, in conjunction with the designated critical alpha value, reveals whether or not the treatment effect is statistically significant.

Mechanisms of change: Time-series research design One of the great advantages of an SMA based data stream analysis is that it can address questions regarding the underlying mechanism of change over the course of treatment. Questions of mechanism of action are different from questions of efficacy and consequently require a different research design and analysis. For questions of efficacy, we compare two phases of one data stream. We take the pre-treatment phase (Phase A) of an outcome variable, such as level of depression, and compare it against the treatment phase (Phase B) of that same outcome variable. If there is a significant difference between Phase A and Phase B of that data stream, as determined by the SMA phase-effect analysis described above, then it is likely that the treatment had an effect. In order to study questions regarding the mechanism of change, however, we compare two separate and simultaneous data streams, each of which tracks a different process variable. By comparing these two data streams with one another over time, we can determine how these data streams impact one another. Which data stream leads the other? How much do changes in one data stream affect another? Through this comparison, we gain insight into mechanisms of action. For example, we might track two variables that are thought to be integral to the mechanism of Gestalt: level of client self-awareness and the client’s capacity for contact. These process variables may be measured, as before, through regular, periodic self-reporting. This periodic assessment of these process variables will result in two data streams. Because two (or more) processes are simultaneously tracked, the analysis is called multivariate as it must be sensitive to how multiple

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variables change in relation to one another over time. These data streams can be compared with one another using an analytic procedure called cross-lagged correlational analysis which we describe below. The results of the cross-lagged correlational analysis can help us determine if a hypothesized mechanism of action appears to be valid. Mechanism of action: Simulation Modeling Analysis multivariate analysis. A slight variation of the SMA statistical methodology that has previously been described for phase-effect analysis can also be utilized in a multivariate cross-lagged correlational analysis. This kind of crosslagged analysis can address issues related to how different process variables impact one another. For example, this analysis allows us to address the question: does the client’s level of self-awareness precede increased capacity for contact? We use this question for purposes of illustration and will presume that we begin with two data streams: one for self-awareness and one for capacity for contact. Step 1. The cross-correlation between the first data stream (SA; selfawareness) and the second data stream (CC; capacity for contact) is calculated across a series of lags. In this instance, we expect that the primary effect between these two variables will occur within 5 days, and so we will calculate the cross-correlation between SA and CC data streams across a series of lags from 5 to +5. Step 2. The autocorrelation for each of these data streams (self-awareness and capacity for contact) is calculated (ARsa¬; ARcc). Step 3. A large number of pairs of data streams are randomly generated where the generation of each data stream pair is based on the respective autocorrelation values ARsa¬ and ARcc for self-awareness (SA) and capacity for contact (CC) as determined in Step 2. After each pair of data streams is generated, their cross-correlations are calculated. When the absolute magnitude of the cross-correlation of the randomly generated data streams exceeds that of the actual cross-correlation calculated in Step 1, the data stream pair is considered a “hit.” Otherwise, the data stream pair is considered a “miss.” This procedure continues across the entire series of lags, in this instance, from -5 days to +5 days. Step 4. From this repeated generation of “hits” and “misses,” a p-value is determined using the following equation: p-value = [ hits / (hits + misses) ] Step 5. The critical alpha is adjusted due to the presence of multiple comparisons. In this instance, there are 11 comparisons, as crosscorrelations have been calculated from lag -5 to +5. With the Bonferroni adjustment, the critical alpha is divided by 11.

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Step 6. Using the modified critical alpha and the p-values from Step 4, a determination can be made regarding whether or not the various cross-lag correlations between self-awareness and capacity for contact are statistically significant. Fortunately, a computer program has been developed by Borckardt et al. (2008) that streamlines the SMA analytic process, both for phase effect and cross-correlational analyses. This program may be freely downloaded at http://clinicalresearcher.org.

Discussion The single case experimental design is a frequently overlooked, but empirically rigorous, manner of testing the efficacy of a therapeutic modality and its underlying mechanisms of action. Gestalt therapy, with its emphasis on individualized clinical care, is well-suited to the single case experimental design research methodology. This chapter has been intended to serve as a brief primer on how to implement a single case research design methodology in a clinical setting, with an eye towards aiding Gestalt therapists in their efforts to develop Gestalt therapy as an empirically validated therapeutic methodology. This chapter also describes how to analyze the data streams that are generated from a single case experimental design. Simulation Modeling Analysis (SMA), a particular statistical methodology designed specifically for single case experimental designs in clinical settings, can help elucidate (1) whether or not a treatment is efficacious and (2) what the underlying mechanisms of action of a particular treatment may be. It is hoped that by introducing the reader to these novel research methodologies that further insight into the efficacy and the mechanisms of action of the Gestalt approach might be gained.

References Barlow, D. H., Nock, M. K., & Hersen, M. (2008). Single case experimental designs: Strategies for studying behavior change (3rd edition). Boston: Pearson. Battle, C. C., Imber, S. D., Hoehn-Saric, R., Stone, A. R., Nash, E. R., & Frank, J. E. (1966). Target complaints as criteria of improvement. American Journal of Psychotherapy, 20, 184-192. Borckardt, J. J., Nash, M. R., Murphy, M. D., Moore, M., Shaw, D., & O’Neil, P. (2008). Clinical practice as natural laboratory for

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psychotherapy research: A guide to case-based time-series analysis. American Psychologist, 63(2), 77–95. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18. Elkins, S. R., & Moore, T. M. (2011). A time-series study of the treatment of panic disorder. Clinical Case Studies, 10(1), 3–22. Fitzpatrick, L. (2013, January 24th). The evolving role of research in Gestalt therapy: An interview with Philip Brownell and Joseph Melnick. Retrieved from http://www.gisc.org/giscblog/?p=177 Frankel, M. R., & Macfie, J. (2010). Psychodynamic psychotherapy with adjunctive hypnosis for social and performance anxiety in emerging adulthood. Clinical Case Studies, 9(4), 294 –308. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12-19. Laurenceau, J.-P., & Bolger, N. (2005). Using diary methods to study marital and family processes. Journal of Family Psychology, 19(1), 86–97. Laurenceau, J-P., Hayes, A. M., & Feldman, G. C. (2007). Some methodological and statistical issues in the study of change processes in psychotherapy. Clinical Psychology Review, 27(6), 682–695. Roth, A., & Fonagy, P. (2006). What works for whom: A critical review of psychotherapy research. New York: Guilford Press. Skinner, B. F. (1966). Operant behavior. In W. K. Honig (Ed.), Operant behavior: Areas of research and application (pp. 12-32). New York: Appleton-Century-Crofts. Smith, J. D., Handler, L., & Nash, M. R. (2010). Therapeutic assessment for preadolescent boys with oppositional defiant disorder: A replicated single-case time-series design. Psychological Assessment, 22(3), 593– 602.

CHAPTER EIGHT THE CONSTRUCTION OF A GESTALT-COHERENT OUTCOME MEASURE: POLARITIES AND THE POLARIZATIONINTEGRATION PROCESS PABLO HERRERA SALINAS

Introduction Much progress has been made evaluating psychotherapy’s efficacy and results, establishing that it’s generally beneficial to patients and that different theoretical orientations show similar results (Lambert, 2013). Humanistic psychotherapies have also shown robust evidence of their efficacy, although they tend to be dismissed or overlooked in scientific and political circles (Elliott, Greenberg, Watson, Timulak, & Freire, 2013). For example, Gestalt therapy is not recognized as possibly efficacious for any specific diagnosis. Therefore, more outcome-based research is needed. One limitation with psychotherapy outcome studies is that, in order to compare different theoretical approaches, the use of common or generic outcome instruments has been privileged. Generic instruments neglect the fact that different psychotherapy approaches target different therapeutical objectives. This means that, for us as Gestalt therapists, the measures and instruments we use are not consistent with the way we work in the therapy process, and neither with what we aim to accomplish with our clients. So, for example, we end up doing research using DSM–5 for diagnosis, the Beck Depression Inventory for measuring outcomes, and focusing on Gestalt techniques during the therapy. We are facing an issue which has been labeled Problem-Treatment-Outcome (P-T-O) congruence (Strupp, Schacht, & Henry, 1988). In this context, in the Gestalt Institute of Santiago de Chile, we are conducting a research project aiming to contribute to Gestalt theory and

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research, with special emphasis in improving P-T-O coherence. For this, we are focusing on the concept of client’s polarities, and the polarizationintegration process. Before continuing, a word about how we work with polarities at the Chilean Gestalt Institute (Schnake, 1987). For us, one of the first tasks in getting to know the patient is exploring his or her main polarities. Using dialogue, dreamwork, projections, etc., we observe that patients identify with one end of a spectrum of their experience and behavior while rejecting the other end. With this information, we often discuss this polar pair with the patient, exploring if he or she is willing to integrate this previously neglected pole. Then, we use two chair dialogue and other techniques to help the patient embody the “other” polarity, and then establish dialogue and cooperation between both poles. After this interlude, let’s present the objectives of this chapter: 1. Explore and integrate existing literature about polarities in order to arrive at a conceptual definition; 2. Present the initial version of an instrument to assess clients’ main polarities in actual psychotherapeutic processes (useful as a prepost outcome measure, and as a process outcome measure); 3. Share our methodology and development process, so that other colleagues can learn from our mistakes, difficulties and achievements. We have chosen to work with the concept of polarities for several reasons: first, it’s a key concept for the therapeutic work we do in the Gestalt Institute of Santiago, but there is little written about it. Also, in Chile, Adriana Schnake (2002) has developed a psychotherapeutic process to work with physical illnesses, and this technique is based on the integration of clients’ main polarities. So, in order to research Schnake’s technique, first we need to work on the polarities concept and possibilities of its measurement. There have been many developments regarding process diagnosis in humanistic-experiential therapies (Greenberg, Rice, & Elliot, 1996) and this outcome oriented diagnosis could complement it. Finally, in recent years, dialogical self theories have expanded, and we think Gestalt therapy can contribute effectively to that theoretical debate with the concept of polarities.

Method In order to develop the instrument we have devised a 6 stage plan:

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Conceptual research The first stage was a literature review, aiming to explore different theoretical models that suggest that the self is composed of different “parts”, describe what has been written in Gestalt literature about polarities and inner conflict, and compare the Gestalt model with other related theories. In order to do this, PsychInfo, Proquest, Amazon bookstore and Google Scholar databases were consulted, using the keywords: psychotherapy + polarities; Gestalt + polarities; Gestalt + self; multiple self; subpersonality; subselves. Books and articles in English and Spanish were included. The results of this literature review are presented in this chapter.

Qualitative, empirical research We interviewed 8 experienced Gestalt therapists (with more than 10 years' experience), using a semi-structured interview script, focusing on how they understand, explore, and work with patients’ polarities. Our goal was for the instrument to capture what most experts do implicitly when they “diagnose” and work with polarities. A detailed description of this study will be published separately. However, the main conclusions are considered in this chapter.

Creation of the instrument This phase required operationalizing the polarities construct in a measurable way and creating a methodology for its assessment. We have just finished this phase, with a first prototype procedure that we are beginning to test.

First “Alpha” test of the instrument After creating the first prototype of the instrument we are beginning to test it using experienced Gestalt therapists as subjects. This allows us to observe how the instrument works in real life, but also to receive very valuable feedback in order to improve it.

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Second “Beta” or “Pilot” test of the instrument After the initial “alpha” test, we will do a pilot run with a small sample of patients (10–20). We aim to evaluate the instrument according to its simplicity and economy, inter-rater reliability (also comparing it with the expert assessment of the therapist), and usefulness for the clinician.

Corrections and presentation of version 1.0 After the pilot runs, we’ll correct the instrument, considering the provided feedback and publish it with a manual as version 1.0. We’ll use this version to start an initial round of research using the instrument.

Theoretical background Polarities in Gestalt literature The concept of polarities or polarization doesn’t appear often in Gestalt therapy literature. For example, there is no mention of it in the classic Perls, Hefferline and Goodman (1951). In his talks, Perls (1974) mentions Friedlander’s concept of creative indifference as a state in which a person has the freedom to reach both opposite behavioral poles. He also speaks about how, when we are neurotic, we develop a rigid and predictable character, losing our ability to creatively adapt to the demands of the situation. This relates to the idea of holes in the personality, experiences and personal resources that are not available, because the neurotic has projected them as a way of resolving the basic society vs self conflict. The only time he describes a specific polar conflict is when he talks about the top dog vs under dog conflict. Later, he explicitly states that the aim of Gestalt therapy is to increase human potential through the integration process (Stevens, 1978). Other Gestalt writers, such as Gary Yontef, Joseph Zinker and Barry Johnson have described explicitly the Polarities concept. Here we’ll try to summarize their contributions. Polarization as a process towards neurosis Polarization is defined as the product of a process, in which the person actively excludes certain conflictive parts from his or her experience and behavior. This is a defensive way of resolving the basic conflict between organismic needs and societal demands (or, from a more modern point of view, attachment needs). So, the child sacrifices negatively perceived parts of him/her self, in order to preserve his/her caregiver’s love and

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protection. This is not a discrete event, but a systematic process of avoiding certain sensorial and motor figures in the field (the ones that produce emotional pain and rejection), while maximizing others (those that bring approval and prevent contacting the pain). The cycle of experience is repeatedly interrupted for certain conflictive figures and needs (Zinker, 1979). This leads to a person with “holes in his personality” (Perls, 1974), who is not in touch with some of his/her personal resources, losing self-regulation. Also, the polarized individual projects the positive and negative rejected parts of him/her self to other people, developing dependence and/or aversion towards those who personify those disowned traits (Schnake, 1987). Flexibility vs rigid character A healthy individual shows flexibility and adapts his or her behavior to the characteristics and demands of the specific situation (Perls, 1974; Zinker, 1979). As Perls says: “All control, even interiorized external control -‘you should’- interferes with the healthy functioning of the organism. There must be only one thing that controls: the situation” (1974, p. 19). The idea of creative indifference also implies this, stating that a centered person stays creatively in the center, being able to move freely towards each end of the opposite poles (Schnake, 1987). So, when someone is polarized, his/her self-concept is rigid and unilateral, and his/her behavior predictable. Also, polarized responses are fragile and don’t allow successful adaptation to changing circumstances (Zinker, 1979). Integration vs inner struggle The integration of dismissed polarities into the self can be considered for the aim of Gestalt therapy. Both the neurotic solution (prioritizing societal needs and demands, neglecting own needs and the psychopathic solution (prioritizing organismic needs, neglecting others) are partial and incomplete (Perls, 1974, 1976). Both the top dog and under dog are part of the whole person, and they both need to hear and understand the other (Perls, 1974). This means that there are no good and bad parts in the polar conflict. Yontef (1993) states that the therapist must be careful to empathize and ally with both polarities in the patient. Zinker (1979) goes beyond that, saying that if a person does not allow him/herself to contact one pole, it will express itself in a disturbed or exaggerated manner. As he says, “if I don’t let myself be evil, I won’t be able to be truly good” (1979, p. 267). Complementarily, Greenberg states that “polar parts when brought into contact interact to produce transformation. Novelty then emerges from dialectical synthesis” (Greenberg, Rice, & Elliott, 1996, p. 55). However,

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as Zinker (1979) stresses, this integration doesn’t mean reaching a middle ground (as warm water is a mixture of hot and cold). Integration implies being able to fully contact each pole, without losing the other in the ground. A relatively new contribution is Barry Johnson’s (1992), who defines polarities as a pair of opposites that, in the long term, are interdependent. This implies that the person or organization needs to successfully manage both poles, not choose between them. Finally, he uses a “Polarity Map” to explore both the upside and downside of each polarity, assuming that integration means having access to the upside of each polarity and managing or minimizing their downside (which comes from lack of development of the complementary pole). The concept of self in Gestalt theory In Gestalt theory, the self is not an intra-psychic, central, static structure. Instead, it is presented as a contact process between organism and environment (Perls et al., 1951). This is a non-reified, relational perspective, based on Lewin’s field theory (Burley, 2012). Field theory proposes that reality is essentially inter-related, and everything occurs in a context. Applied to psychology, it means that behavior (both healthy and pathological) is a function of the interaction between a person and his/her environment, so it can’t be understood in isolation. This also means that there is no nuclear or integrative self, as it emerges in specific contexts. This conceptualization is radically different from the modernist perspective (including most humanistic and psychodynamic schools of thought) that sees the self as possessing a central, reified structure, and stable traits (Hermans, Kempen, & Van Loon, 1992). It also differs from popular theories that assume a “central, core personality”, “true vs false self”, “real vs ideal self”, etc. Instead, it’s closer to Buddhist ideas and new developments in cognitive science. For example, the Buddhist notion of the Ego argues that it’s not solid (reified), and if it were, its immutability would block the constant ascent and descent of experiences (Varela, Thompson, & Rosch, 1992). Authors who adhere to a modular view of the mind claim that behavior and preferences are a function of one’s current organismic state, the specific context, and the recent history of preferences and consequences (Kurzban, 2011). So, behavior is contextdependent, and not a function of a central and rigid set of preferences (traits, values, “real self”, etc.).

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Gestalt as a multiple self theory Polarities do not appear explicitly in other theoretical models. However, there are many theories that challenge the modernist notion of a single, unitary and coherent self. They argue that the self is not a uniform entity, but a collection of different and somewhat autonomous parts (HonosWebb & Stiles, 1998). These have been called subselves, parts, modules, subpersonalities, voices, I-positions, ego states, self-schemas, roles, among other names (Honos-Webb & Stiles, 1998; Lester, 2007; Rowan, 2010). These diverse authors share the idea that these different parts can interact and dialogue, producing inner coherence or conflict. Although some of these theories have important similarities with the Gestalt approach, they also have crucial differences and limitations. The main one is that most of them accept an infinite and completely idiosyncratic number of inner “voices” or “sub personalities”. This means mixing specific attitudes towards an object (e.g., the conflicting voices “I’m mad at my mother” and “I need my mother”) with roles (e.g., “daughter” and “teacher”) and character traits (e.g., the polar opposites “strong independent woman” and “needy and weak”). Also, methodologically, this makes it difficult for different raters to agree on the names and characteristics of these voices (see, for example, Osatuke et al., 2005). Finally, most dialogical self models don’t place an emphasis on perceptual, emotional and motor aspects of the discarded voices, focusing on linguistic and representational dimensions. For a Gestalt clinician or researcher, all of this makes it difficult to find these alternative conceptualizations useful enough for his/her practice.

Psychotherapy process and outcome measures In order to develop a new outcome measure, it’s necessary to review and analyze the ones that are being used today. First, we’ll explore Gestaltspecific measures, followed by other measures related to polar conflicts and integration between parts of the self. Gestalt diagnosis and outcome measures In Gestalt therapy literature, there is growing consensus about the clinical usefulness of a diagnosis process, if it is coherent with Gestalt theory, epistemology and anthropology (Brownell, 2010; Roubal, 2012; Yontef, 1993). However, a literature search for specific Gestalt outcome measures yields meager results.

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Greenberg’s work with conflict between parts of the self has generated several markers for these “splits” within the therapy session, but is much more focused on measuring process, not outcome (Greenberg & Foerster, 1996). Other contributions describe a Gestalt way of doing diagnosis but don’t include a specific instrument or measure that can be used for research (Brownell, 2010; Roubal, Gecele, & Francesetti, 2013; Yontef, 1993). Almost all outcome research in Gestalt therapy uses non-specific instruments such as the Outcome Questionnaire or the Beck Depression Questionnaire (Elliott et al., 2013). One of the few Gestalt measures is the GIRL (Woldt, Prosnick & Kepner, 2013), a self-report instrument that assesses the patient’s use of contact-interruption mechanisms. Another recent development is a theory based test for diagnosing depression in children, which was being developed by Todd Burley and his team (Burley, 2013). Other measures from different theoretical backgrounds One widely used psychotherapy process measure is Stiles’ Assimilation Model (Stiles et al, 1990). Although it uses different terminology (“voices” instead of poles; “assimilation” instead of integration levels), its underlying theory is similar: if a part of the self or experience is disowned and excluded, it becomes problematic. So, the therapy must help the patient assimilate and integrate that outcast part of the self. However, it presents difficulties that prevent us from adopting it to study polarities: (1) it requires in depth microanalysis of therapy transcripts in order to rate it; (2) also, a “voice” can be a specific attitude towards a topic or person (e.g., “resentment towards mother”), and not necessarily a character trait rooted on specific sensory or motor experiences. Another extensively used measure is Kelly’s Repertory Grid (Feixas, 2008; Feixas, Gutiérrez, Espada, & Rodríguez, 2001). It is a semistructured interview that assesses patients’ conflicts towards change. It includes a procedure for eliciting idiosyncratic polar pairs that represent the patient’s construction of the world (e.g., “depressive vs cheerful”, “superficial vs profound”, “independent vs weak”). However, it has shortcomings for our purpose: it doesn’t put special emphasis on bodily and emotional aspects of the inner conflicts; and although it has a polar view of character traits, they are seen as a continuum (i.e. a person can be very depressive, a little depressive, neither depressive nor cheerful, a little cheerful, or very cheerful), so the two poles are not regarded as separate polarities, each deserving full expression within an integrated individual. This is the same problem with other commonly used measures that assess

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polar character traits as continuous variables, like the NEO Pi-R (McCrae & Costa, 2004). A third related diagnostic system is the Operationalized Psychodynamic Diagnosis (OPD; Cierpka, 2008). The OPD is rated by expert observers and, although it is rooted in a different theoretical background, is valuable for our task. First, it includes a “Conflict” axis, describing common polar conflicts such as “dependency vs autonomy” and “submission vs control”. Also, it contains an interesting circumplex model for assessing interpersonal relations (Benjamin, 1974). Finally, it is a good example of a diagnostic system that can pay respect to its theoretical roots, help the therapist in the clinical task, and yield data usable for research purposes.

Results Conceptual definition of the polarities construct Now we get to the heart of the matter: a proposed conceptualization of polarities. In brief, using Greenberg’s terminology (Greenberg, 1979), they can be defined as a “conflict split”, personified using two opposite characters, each representing different cognitive, emotional and behavioral processes. The specific characters are selected because at least one of them exhibits sensorial and motor processes that are being systematically interrupted by the patient in contexts where they are needed, thus making unavailable certain resources and limiting the patient’s experience and creative adaptation. The characters’ names and specific traits can change during the therapy, but always represent polar opposites that in the long term are interdependent. They represent basic ways of being in the world and will “show up” in symptoms, dreams and interpersonal conflicts, until those processes stop being systematically interrupted or the patient changes their context and doesn’t need those inhibited resources anymore. Besides this brief definition, the conceptualization implies: a description of character traits, a relational, emergent view of the self, regarding polarities as systematic interruptions of ongoing process, and the need to distinguish different dimensions or components when we discuss “polarities”. A description of character traits When we assess, discuss or work with patients’ polarities, we are working at a character level. We are looking at the intra-psychic aspect of a relational phenomenon, distinguishing relatively stable traits or ways of

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“being in the world”. We are not talking about a specific attitude (as a “voice” in the Dialogical Self tradition), neither are we working at a symptomatic level. Polarities encompass ways of interpreting the world, values, the ability to perceive certain experiences, and both intra and interpersonal behavioral resources. Also, in order to “diagnose them” we need to consider a wide spectrum of situations and a broad timeframe. A relational, emergent and multiple view of the self Our vision of polarities is based on a conceptualization of the self rooted in field theory (Burley, 2012) Buddhist emergentism (Varela et al., 1992), the Modular Mind Theory (Kurzban, 2011) and Herman’s Dialogism (Hermans et al., 1992). This philosophical viewpoint is very important because basic Gestalt theory is explicitly relational (Burley, 2012; Perls et al., 1951). Each polarity does not work in isolation from others and its context. Clinically, this means that each polar opposite is not only a collection of traits, emotions or personal resources, but it is a way of being in the world, perceiving others and the surroundings. In the Chilean Gestalt Institute we call this, the patient’s “existential vision”. For example, a client whose main polarities were labeled the “diplomat” and the “caveman”, is more identified with the first one. When the diplomat polarity is active, the world is perceived as a chess match, where others are dangerous if they get upset, and the person needs to navigate carefully all these dangers and needs of others. In the caveman polarity, survival does not require careful planning or observation, as only the strongest survive. So, each polarity’s individual traits and characteristics are not fully understood if we isolate them from the subjective construction of the world or “existential vision” to which they fit. In other words, a polarity only makes sense if we understand its existential subjective context. Process and structure: Polarities as systematic interruptions of an ongoing process So, the self is “naturally” flexible and dynamic, but many patients show rigidity, behaving and feeling as if they had a reified self. How do we reconcile these ideas? We think that the polarization process, in which the person systematically and actively excludes certain aspects of his/her experience, produces the illusion of a static self, with behavior being more predictable by stable traits, than by a shifting set of circumstances. This means that a neurotic person would manifest the external signs of a reified self and a rigid self-concept. However, a healthy individual would show behavior more coherent with the dynamic, emergent view of the self that

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we are adopting here. Thus, his/her behavior wouldn’t be predictable by stable traits, showing creative adjustment to the specific context and active figures in the field. In traditional personality measures, his/her answers wouldn’t be easily categorized, and his/her identity could be considered unstable and not fully developed. The focus on the interruptions of the contact cycle and the focus on polarities are two different ways of looking at the same phenomenon, but with a narrower or broader timeframe. For example: if the patient rejects his/her “dominant” traits, s/he will not be aware of some sensorial figures (e.g., anger, desire to command others) and/or not engage specific motor resources (e.g., defend him/herself, direct others, assert his/her needs directly). When we focus therapeutically on the interruptions of contact, we are also working with patients’ polarities, and vice versa. We need to distinguish different components when we discuss “polarities” Polar pair as the therapy focus The first component of any polarity work is the polar pair, or the specific names and characteristics of the two opposite poles. They can be selected from elements of a dream, interpersonal conflicts, difficult decisions, or any markers of a conflict split (Greenberg, 1979). The specific names can change in different Gestalt experiments, but the main characteristics (and processes involved) of the poles should remain relatively stable. Returning to the “diplomat vs caveman” polarity: although those specific characters didn’t appear in every session, the processes of expressing aggression, setting boundaries, letting go of self control, and not assuming immediately a conciliatory stance towards conflict, were the main focus of the whole therapy process. After a while, the “caveman” was re-baptized with the patient as “the protector”, helping him acknowledge the positive aspects of that pole. Each pole can have both egosyntonic and egodystonic aspects Another component is the patient’s valuation of the poles. Each one can be egosyntonic or egodystonic to the patient (this appraisal is not fixed, as it often changes even within a therapy experiment). Also, each pole or “way of being” has both positive and negative aspects (Johnson, 1992). When the patient dismisses one part of his/her experience, s/he doesn’t want some of these “negative” qualities or consequences, as s/he has learned that they are dangerous or produce rejection. However, by disowning those, s/he leaves important “holes” in his/her personality because s/he also loses critical resources associated with those egodystonic qualities

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(Zinker, 1979). For example, if we dismiss our “weak” side, we can also lose our ability to recognize our vulnerability, to grieve and ask for help. Different and dynamic levels of integration Each specific pole can be integrated or disowned, with several intermediate levels. This is the most important aspect in order to assess the effectiveness of the therapy process, as we expect the patient to move forward in the integration process. Although we expect an evolution towards integration, this is a dynamic process that can go forward or backwards. Basically it depends on how the patient is taking care of certain needs and using certain resources, associated with each pole’s positive “mission” or “purpose”. For example, patient “Sara” has a dominant controlling pole that helps her protect herself and achieve her goals, and an emergent more relaxed side that helps her let go more easily and open herself to contact others. With therapy, she learns to contact her “letting go” pole in her job, and not try to control everything her subordinates do. This helps her diminish her headaches. However, after a stressful period in which some colleagues are fired by her company’s management, she resorts to her more controlling ways and the headaches return. She regressed from a more integrated level towards the dominance of her controlling pole.

Construction of the polarities instrument Following the discussion on understanding polarities conceptually, we will share our developments in the construction of an instrument to measure them. The following paragraphs present our current “alpha” version. This segment contains a section for identifying the polar pair(s), and another for assessing its integration level. Section 1: Identification of the polar pair Our first task is to identify the polar opposites that we will work with. Currently, we have a working prototype of the procedure, inspired by the Repertory Grid Instrument and also by the psychotherapeutic procedure for identifying patients’ main polarities that we use in the Chilean Gestalt Institute. It has 3 main following steps: eliciting constructs, classifying constructs in common topics and co-constructing and naming the polar characters.

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Eliciting constructs 1. Use a list of elements (see Table 10-1 below) related to the patient, and ask him/her the following questions. 2. Personal qualities (character traits, not physical characteristics) that s/he admires and doesn’t have fully developed, that s/he perceives in those elements. 3. Personal qualities (character traits) that s/he dislikes or despises, that s/he perceives in those elements. Table 10-1: Example of table for eliciting constructs Positive trait you have underdeveloped

Negative trait you dislike

Element

Name of the element

Father

Roberto

Tendency to act fast

Brutality

Mother

Eliana

Lack of ambition

Brother/close friend

Fernando

Concern for others Passion for certain topics

Romantic partner

Magdalena

Attention to detail

Passivity

Very different person

Marcelo

Person the patient doesn’t get along with (conflict)

Cristian

Self confidence Capacity for defending himself

Narcissism Aggressiveness

Admired person

Jorge

Assertiveness

Closed mindedness

Kind of people that show an attitude or behavior the patient dislikes

Complainers

Capacity for getting what they want

Tendency to annoy others

Kind of people that show an attitude or behavior the patient admires but doesn’t have fully developed

Salesmen

Self confidence

Dishonesty

Someone not previously mentioned who shows an attitude or behavior the patient dislikes

Alberto

Calmness

Passivity

Disorder

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Someone not mentioned who shows an attitude or behavior the patient admires but doesn’t have fully developed

Susan

Leadership

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Aggressiveness

Others

Classifying Constructs in Common Topics 1. Transform the previous table into a list of polar constructs (e.g., Brute vs Intellectual; Impulsive vs Mild-mannered) with a third column for the “common theme”. 2. For each trait (positive or negative), ask the patient for its opposite, according to his/her own definition (not the dictionary’s). 3. Classify all pairs of constructs in common themes. Ask the patient which traits go together, or are associated. Table 10-2: Example of table for classifying constructs in topics Construct

Polar opposite

Theme

Brutality Assertiveness Aggressiveness Calm Lack of Ambition Passivity Self Confidence Concern for Others

Diplomacy Diplomacy Weakness Stress Drive Energy Low self esteem Narcissism

Brute vs. Diplomat Brute vs. Diplomat Brute vs. Diplomat Active vs. Passive Active vs. Passive Active vs. Passive Narcissist vs. Humble Narcissist vs. Humble

Co-constructing and naming the polar characters 1. Ask the patient to put a name on each group of constructs, as if they were characters who exhibit those character traits. 2. For each character, ask the patient to imagine someone with those traits. Then, review with the patient its perceived positive and negative traits, asking about the character’s positive and negative characteristics. Do not force the patient to describe both kinds of traits for each character. It’s possible that some roles only have positive or negative traits according to the patient (and this is important diagnostic information). 3. If there are different characters, choose one to use as the therapy focus.

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After all these steps, we have an idiographic description of the poles, with a main label and both egosyntonic and egodystonic characteristics. Table 10-3: Example of table for co-constructing polar characters Pole A

Pole B

Main label

Diplomat

Caveman

Egosyntonic traits and consequences

- Minimizing conflict. - Getting along with others. - Giving a “cool” impression.

- Setting boundaries. - Having energy. - Directing others.

Egodystonic traits and consequences

- Being regarded as “passive”. - Being weak. - Stressed.

- Hurting others. - Making others angry and being vindictive.

Section 2: Integration levels for each polar pair As previously mentioned, our instrument must capture the integration level of each polar pair. For this purpose we are developing a 5 point ordinal scale, organized in three main levels of integration, that we present in its current form. However, in order to evaluate the polar conflict, the patient must show signs of a relatively integrated identity. If there is identity diffusion, it’s impossible to rate levels of integration because it’s very difficult to identify the main polar pair(s). So, the first task is to discard identity diffusion. Here the issue of identity diffusion appears. It’s difficult to differentiate a “main” polar conflict, because the individual’s identity is not stable enough. This is different from having the flexibility of the fluid integration level, as personal resources are not easily available and the person isn’t able to respond adequately to the needs of the field. This crucial difference has been described by Wilber in his writings about the pre/trans fallacy (Wilber, 2002). Once discarded, we can rate each polar pair using the following categories, and considering the patient’s behavior and experience in the past 2–4 weeks: Monologue Only one pole is acknowledged, the other is silent. Identity is rigid. Patient doesn’t feel tension about the topic, or the need to integrate the disowned

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pole. However, the needs and purpose of the silent pole are not being met, and the patient suffers from the consequences of rejecting these experiences and resources (unless he manages to stay only in contexts that don’t require the use of those disowned resources). Domination This second level represents situations where there is a power struggle between both poles, creating internal tension, anxiety or self criticism. Both are acknowledged, but one or both are being rejected. Most times we can recognize a dominant pole and an emergent one, while there are situations where both poles dominate in different moments (but in constant tension and internal war). There are three ways in which this dynamic can be expressed, and in neither of them are the needs and purpose of the emergent pole being satisfied: a. Dominance & Rebellion: Oscillation between one pole and the other, constant tension and unadaptive, extreme behavior. Both poles are expressed but in a destructive manner, and their needs are not adequately satisfied. Using the previous example: the Diplomat pole lets his boss bully the patient, but then the Caveman pole appears with rage and impulsivity. Both the need for avoiding conflict, and the need for defending oneself are not adequately met. b. Egosyntonic Dominance: When the person identifies with certain traits and likes them, but notices another side of himself (the emergent pole) that he wishes to extirpate. c. Egodystonic Dominance: When the person identifies with certain traits but doesn’t like them, wishing to be different. Here the emergent pole is valued and the dominant pole rejected. For example, a person who has a passive dominant pole, and hates that way of being, wishing to be more active. Integration This third category includes three different levels. Common to all of them is that both poles are valued and at least cognitively accepted. These three specific levels represent the most common path that patients show in their journey towards integration: Value & Inhibition: The emergent pole is accepted and valued, but still can’t be expressed enough, or in a satisfactory way. It is only expressed when absolutely necessary (or when pushed to do so), with high energy cost and anxiety. The patient is learning how to express it in adaptive ways, sometimes going too far, and still without flexibility to adjust

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appropriately to changing circumstances. The patient still feels ambivalence and anxiety. The needs and purpose of the emergent pole are still not being met adequately. Incipient Integration: The emergent pole is being valued and accepted, but still not fully available as a resource when needed. The patient can express it, but without fluidity, requiring reminders or planning. The patient feels proud and a bit afraid of the steps being taken. The needs and purpose of the emergent pole are often being met, but require special attention and energy. Fluid Integration: The pole is available as a resource in appropriate occasions. The patient can tolerate occasional contact with the negative consequences of expressing the pole, and can adjust its expression to new and different circumstances. Its expression neither threatens the previously dominant pole nor vice versa, as both can coexist in harmony. It’s now difficult to observe stereotyped polarities as behavior becomes less predictable. Previously conflicting topics and situations are treated now with neutral affect, and energy is not being wasted warding off certain experiences. Interpersonally, there is little difficulty relating and empathizing with people who express opposite characteristics. Also, close relationships are not characterized by rigid complementarity, with more inter-changeable roles. Using these categories, we can say that in a successful therapy process, the patient will be able to move from a monologue or dominative relation with self, towards an incipient or fluid integration. In our clinical practice we have noticed that many patients are satisfied and don’t require more therapy when they reach the incipient integration stage, so we don’t regard the final fluid integration stage as the only criteria for success. Section 3: Questions to explore the integration levels In order to explore and determine the level of integration that best describes the current state of the patient, we are including 4 more specific questions. Each can be answered using a 5 point Likert scale. Below we present the questions and their extreme alternatives: 1st Owning: Do I recognize this pole (trait, experience, emotion, etc.) as part of me? (1) No, I never feel/do/desire that, it’s not part of me. (5) Yes, I feel/do/desire that, it is part of my experience.

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2nd Valuation: Do I value this pole as positive, do I recognize something useful in contacting this pole? (1) No, I reject it, wish to get rid of it as it isn’t good or positive at all. (5) Yes, I recognize this pole as valuable and a useful resource that I need to acknowledge and take care of. 3rd Effectiveness: Can I express it adaptively? (1) No, when I contact this pole, I express it in inappropriate ways that conflict other personal needs or don’t fit the specific context. (5) Yes, I can contact it and satisfy this pole’s needs in an appropriate way, according to the specific context. 4th Availability: Do I have easy access to this pole’s resources? (1) No, expressing it requires enormous effort and energy, or having absolutely no other option. (5) Yes, in order to contact this pole’s associated resources I don’t need too much effort, reminders or planning. Note: As part of the testing phases of the instrument, we will explore if it’s more useful to apply the levels directly (as a categorical or ordinal variable), or use these questions to explore them, later assigning the final category.

Conclusion In this chapter we have argued the need to develop measures that are coherent with our theory of change, and also helpful to the clinician. Then, we have presented a review of literature related to the construct of polarities. Also, we have demonstrated our conceptual definition of polarities and their different components. Finally, we have shared our current ideas of how to operationalize these concepts in a measurable way. For the future, we will first finish the “alpha” and “beta” testing stages of the instrument, improving it as we get more feedback. Then, we will apply it to measure the outcome of different psychotherapeutic processes, comparing its results to other more “generic” measures (e.g., OQ–45). Also, our goal is to use the instrument to explore, test and refine Schnake’s theory and technique for working with somatic illnesses. Furthermore, we intend to develop and test other complementary modules, especially to assess patients’ “Existential Vision” and the perceptual and motor processes that are being systematically interrupted when they are polarized. Although this is a work in progress and needs refinement before its publication, we think it’s useful to share our development process with

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fellow psychotherapists and researchers. At least it has forced us to deepen our conceptual understanding of this key construct, because in order to measure it, we need to be able to define it in detail. For us, this has already been a fruitful endeavor.

References Benjamin, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81(5), 192–425. Brownell, P. (2010). Gestalt therapy: A guide to contemporary practice. New York, NY: Springer Publishing Company. Burley, T. (2012). A phenomenologically based theory of personality. Gestalt Review, 16(1), 7–27. —. (2013, April). A Gestalt process theory of depression with test construction validation. Paper presented at the conference The Challenge of Establishing a Research Tradition for Gestalt Therapy. Cape Cod. Cierpka, M. (2008). Diagnostico psicodinamico operacionalizado (OPD2): Manual para el diagnostico, indicacion y planificacion de la psicoterapia. Herder. Elliott, R., Greenberg, L. S., Watson, J., Timulak, L., & Freire, E. (2013). Research on Humanistic-Experiential psychotherapies. In J. McLeod (Ed.), Bergin & Garfield‘s Handbook of psychotherapy and behavior change (6th ed., pp. 495–538). New York, NY: Wiley. Feixas, G. (2008). Un estudio naturalista sobre el cambio de los conflictos cognitivos durante la psicoterapia. Apuntes De Psicología, 26(2), 243255. Feixas, G., Gutiérrez, L. A. S., Espada, A. Á., & Rodríguez, V. S. (2001). Implicaciones terapéuticas de los conflictos cognitivos. Revista Argentina De Clínica Psicológica, 10, 5–13. Greenberg, L. S. (1979). Resolving splits: Use of the two chair technique. Psychotherapy: Theory, Research & Practice, 16(3), 316. Greenberg, L. S., & Foerster, F. S. (1996). Task analysis exemplified: the process of resolving unfinished business. Journal of Consulting and Clinical Psychology, 64(3), 439–446. Greenberg, L. S., Rice, L. N., & Elliott, R. (1996). Facilitando el cambio emocional. Barcelona: Paidós. Hermans, H., Kempen, H. J., & Van Loon, R. J. (1992). The dialogical self: Beyond individualism and rationalism. American Psychologist, 47(1), 23–33.

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Honos-Webb, L., & Stiles, W. B. (1998). Reformulation of assimilation analysis in terms of voices. Psychotherapy: Theory, Research, Practice, Training, 35(1), 23–33. Johnson, B. (1992). Polarity management. Amherst: Human Resource Development Press. Kurzban, R. (2011). Why everyone (else) is a hypocrite: Evolution and the modular mind. Oxford: Princeton University Press. Lambert, M. J. (2013). Outcome in psychotherapy: The past and important advances. Psychotherapy: Theory, Research, Practice, Training, 50(1), 42–51. Lester, D. (2007). A Subself theory of personality. Current Psychology, 26(1), 1–15. McCrae, R. R., & Costa, P. T., Jr. (2004). A contemplated revision of the NEO Five-Factor Inventory. Personality and Individual Differences, 36(3), 587–596. Osatuke, K., Humphreys, C. L., Glick, M. J., Graff Reed, R. L., Mack, L. T. M. K., & Stiles, W. B. (2005). Vocal manifestations of internal multiplicity: Mary's voices. Psychology and Psychotherapy, 78(1), 21– 44. Perls, F. (1976). El enfoque Gestaltico y testimonios de terapia. Santiago: Cuatro Vientos. Perls, F. S. (1974). Sueños y existencia (F. Hunneus, Trans.). Santiago: Cuatro Vientos. Perls, F., Goodman, P., & Hefferline, R. (1951). Gestalt therapy. Middlesex: Penguin Books. Roubal, J. (2012). The three perspectives diagnostic model. Gestalt Journal of Australia and New Zealand, 8(2), 21. Roubal, J., Gecele, M., & Francesetti, G. (2013). Gestalt approach to diagnosis. In G. Francesetti, M. Gecele, & J. Roubal (Eds.), Gestalt Therapy in Clinical Practice. From Psychopathology to the Aesthetics of Contact (pp. 79-106). Siracuse: Istituto di Gestalt HCC Italy Publ. Co.. Rowan, J. (2010). Personification. London: Routledge. Schnake, A. (1987). Sonia, te envío los cuadernos café. Santiago: Cuatro Vientos. Schnake, A. (2002). La voz de síntoma. Santiago: Cuatro Vientos. Stevens, J. O. (Ed.). (1978). Esto es Gestalt. Santiago: Cuatro Vientos. Stiles, W. B., Elliott, R., Llewelyn, S., Jenny, F.-C., Margison, F., Shapiro, D., & Hardy, G. (1990). Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 27(3), 411–420.

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Strupp, H. H., Schacht, T. E., & Henry, W. P. (1988). Problem-treatmentoutcome congruence: A principle whose time has come. In H. Dahl, H. Kächele, & H. Thoma (Eds.), Psychoanalytic process research strategies (pp. 1–14). Verlag: Springer. Varela, F. J., Thompson, E. T., & Rosch, E. (1992). The embodied mind: Cognitive science and human experience. Cambridge, Mass: The MIT Press. Wilber, K. (2002). El proyecto atman. Editorial Kairós. Woldt, A. (2013). Mining for crystals. From Gestalt Q-Sort to the GIRL, creating valid and reliable measures of Gestalt contacting processes. Paper presented at Internation Conference on The Challenge of Establishing a Research Tradition for Gestalt Therapy, South Wellfleet. Yontef, G. M. (1993). Awareness, dialogue & process: Essays on Gestalt therapy. Zinker, J. (1979). El proceso creativo en LA Terapia Guestaltica. Buenos Aires: Paidos Mexicana Editorial.

CHAPTER NINE STRESS AND ORGANIZATIONAL WELL-BEING: A GESTALT ORGANIZATIONAL CONSULTING METHOD SUPPORTED BY GROUNDED THEORY MARGHERITA SPAGNUOLO LOBB

Introduction Research can help Gestalt therapists demonstrate the efficacy of their approach (usually via outcome research), and to improve their understanding of which dimensions and aspects create change in psychotherapy (process research). A third purpose of research for Gestalt therapy is to support clinical models. In this chapter I will present the use of research as applied to a model of organizational consulting. My purpose is to highlight what managers of organizations think of their group of workers and cooperators and to combine this data with observational data taken from the group of workers. We have used text analysis to describe the thoughts of managers. This research method is consistent with Gestalt therapy, since it gives us information on what is figure to the client (the manager of the organization in our case), and also from what experiential ground the figure is formed. First, I will demonstrate the compatibility between Gestalt therapy language and that of organizations. Then I will describe the model of organizational consulting, adapting Gestalt group theory to organizational life. Finally, I will provide an example of organizational consulting, supported by text analysis research. Every human being, if recognized in his intent of helping with his uniqueness, is happy to give his very best to the organization he is part of. No organization can work without the phenomenology of individuals and without their need to identify with and to feel recognized as part of their workgroup. The relational void that characterizes the life of our social

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communities becomes a “basic disturbance” for organizations that quickly leads to the demotivation of work and to the disowning of a common goal. In this paper, I will describe the birth and evolution of a Gestalt model for organizational well-being. I will also highlight how the characteristics of the Gestalt approach, centered on the experience of contact, on the phenomenological, aesthetic and integrative perspectives, can make an original contribution to business consulting studies. Gestalt language focuses on supporting resources rather than on analyzing group dynamics, on the intrinsic “beauty” of organizational efforts rather than on the causes of discomfort. Thus, it is ego-syntonic with the organizational mentality. The phenomenological perspective of Gestalt therapy focuses on the nowfor-next, and thus it is a good fit for the proactive mentality of companies. On the other hand, it is also enriching for emotional factors. Gestalt therapy regards emotions as a necessary support to the creativity of each individual and to the desire to give the very best to the company to which one feels he belongs. This point of view gives weight to the “emotions in the company” as opposed to the logic of Western technology, which instead views emotions as a sort of “monkey wrench”.

How the model was born In September 2009, in Rome, I first held a seminar on organizational wellbeing according to Gestalt therapy. I had been invited by a group of psychologists and psychiatrists enlisted in the Italian army, engaged in the care and leadership of workgroups, for the most part related to emergency activities (in countries with political unrest or at war). As such, they were at high risk of stress as regards the management of trauma and losses (of people, places, etc.). They were either persons in charge of peacemaker groups or emergency therapists. Taking into account the Cleveland model created by Ed Nevis (2003), then developed by other US colleagues (e.g., Frew, 1997, 2006; Newton, 2002), as well as other European studies (cf. for example, Meulmeester, 2009), I took the opportunity to apply Gestalt therapy to organizational groups and to their relational climate, starting from the model on groups detailed in Spagnuolo Lobb (2012, 2013b) and from the concept of group function in contemporary society (Spagnuolo Lobb, 2013c, 2013d). What I presented in that first program was then further analyzed (also through an exchange with colleagues from the Istituto di Gestalt HCC Italy) during other training courses, this time aimed at psychiatric facility managers at the ASL (Healthcare Center) in Turin.

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These early experiences have since evolved into an authentic Gestalt model of observation and intervention for workgroups that has been taught during various training courses. Subsequently the model has been taught in the Higher Education programs funded by the Regione Sicilia (Region of Sicily) for internal communication and corporate leadership consultants held in 2012 in Syracuse, Caltanissetta and Palermo. The warmth with which companies have welcomed the internship of these young Gestalt consultants (the course students) was viewed as important feedback. Corporate culture, especially in Sicily, usually takes for granted the communication processes within the work group, and sometimes even looks with suspicion on psychologists or relational process consultants – perceiving them as outsiders, who bring with them a different language and one extraneous to corporate logic. In view of this, the curiosity that business groups have shown the interns, and the openness with which they were able to address their relationship problems have brought out an important social need (to be acknowledged in their relational intentionalities), as well as the possibility of a dialogue between the Gestalt model and the corporate world. The business managers who became acquainted with these students were impressed by the language they used, and by the positive and aesthetically pleasing outlook that they brought to the company. Previously, when talking to a psychologist or a counselor, the business manager would tend to focus their attentions on what is not working; in this case, however, business managers were told what was working in their work groups – and how to make them even better!

The use of grounded theory in the operating business consultancy model A business consultancy model has emerged in the past three years, which includes grounded theory in one of its two basic parts. In this paper, I will present a preliminary analysis of it, until a more exhaustive analysis can be presented. The theoretical model we utilize is Gestalt intervention with groups (cf. Spagnuolo Lobb, 2013a, 2012). It takes into account two macrocriteria as regards group observation: the synchronic, which looks to the here-and-now of the presence of the group members, and the diachronic, which looks at the evolution of the experience of being-in-group, i.e., the intentionality of contact between its members. Regarding the synchronic criterion, I identify three indices of wellbeing related to the group as a single entity:

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1. The vitality and presence of the group members; 2. The flexibility of the leadership; 3. The ability to accept the novelty and diversity of the group members. As to the diachronic criterion, it consists of observation of what happens in the group through the lens of the intentionality of contact, shared at a given moment in time (cf. Spagnuolo Lobb, 2013a, p. 229). This allows us to understand the personal experience and behavior of each participant, in the context of the personal experiences that pertain to that particular developmental stage of the group. For example, just as the other participants are beginning to open up and talk about themselves, a female participant might say: “Sorry, but I probably will have to go get my son in a little while.” If we were at the beginning of a group session – when the intentionality of contact tends, on one hand, towards the presentation of oneself and, on the other, to “sniffing out” who's around – this communication would be the epiphenomenon of a self-presentation experience and plausibly one of the acts of safeguarding oneself from the emotional involvement with other members. Conversely, if we were at the end of a group session, it might mean “I’m sorry but I have to go, much as I’d like to spend more time with you” (i.e., the epiphenomenon of a separation experience). The model provides training in the principles of Gestalt counseling with groups; in listening to oneself and the other; in the observation of the group process, with regard to physical experience; in verbal manifestation and to intentionally shared experiences; in communicative effectiveness; and in personal style as an integration of the contact skills of the consultant. It is transmitted with a theoretical and experiential teaching method, in which educational moments are followed by relevant moments of personal experience (such as feeling listened to by and listening to the other, or observing what happens in one’s own class group, and so on). Finally, moments in which the same particular consulting strategy is “staged”, in simulated situations, allow the student to use that particular tool in a professional context. An important role was played by the presence of corporate managers – who took turns in each didactic module, demonstrating how a particular aspect covered in class can actually be experienced within a company (for example, the difficulty of managing emotions in business groups). This presence of the corporate world has aroused a great deal of curiosity in the students; their responses were important to the learning process.

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Trained in this way the class groups experienced moments of deep transformation: the students experienced the risks and benefits of relying on the group firsthand and on a highly personal level. Experiential education allowed each student to open up to the others with honesty, putting faith in the teaching staff. The staff garnered their respect, infusing this into the personal experience of each student, modeling the ethics of non-judgmental listening by allowing the group to achieve a sense of group intimacy (cf. the different phases of the group process, Spagnuolo Lobb, 2012), and by creating profound experiences that brought them closer as human beings. They were able to experience strong feelings of humanity and trust in the context of a didactic group, and they entered the company (as interns) still surrounded by a strong aura of deep humanity and desire to discover the other, which they transmitted to the corporate group. The course opened up their senses and heightened their awareness in contact with group situations. Proof of this is their development of keen sensitivity to the corporate groups to which they were assigned. They were able to gain everyone’s trust and respect, both for the tact with which they entered into the company, and for the positive quality of their observations. It was obvious that what their trained senses were looking for was not blame for the company’s fragility, but rather the “beauty”, and harmony of everyone’s efforts to achieve better business results, to highlight unnoticed efforts, and to support their positive development. During the internship, the students had three tasks: 1. To observe the work group following the track shown in a grid (see Tab. 8-1); 2. To interview the company manager (see the interview in Tab. 8-1 and the chapter of Romano in this book); 3. To draft and return to the company (see the example above) feedback that combined the perception of the manager they had interviewed with phenomenological observations of the manager. When the internship began, the first thing the interns had to do was observe the “group spirit” of the company. To do this, the students had to open their senses and “breathe” the emotions they perceived in the shared phenomenological field of the company. For example, their perception of the general mood in the company: did it feel like being in a market or in a church? On a beach or near an assembly line? They had to orient their perception towards the harmony of human and work relationships within

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the group rather than to the problems that emerged. At this stage, they were allowed to interview a few employees to learn about historical factors of the group (such as the difficult times it had gone through, or the times in which it was forced to change), or the workers’ point of view on the needs of the company and on the state of the working environment. After about a week, they were asked to interview one or more managers. The interview (Romano, 2015) was created by extrapolating an observational point of view from the Gestalt model for groups on which this application to business consulting is based (Spagnuolo Lobb, 2013a, p. 229). The experiential fields that were placed under the observation of the consultant, and investigated in the interview are (see Tab. 8-1): x The representation of the ideal and the real work group; x The perception of strengths and weaknesses of the work group; x Obstacles preventing a greater vitality of the group, as perceived by the group itself, by the interviewed leader and by the consultant; x The representation of an ideal leadership; x The way in which the work group expresses the three well-being criteria of the Gestalt model. In this way, the training course has been enriched by the results of a field research, which on the one hand explores the concepts of leadership and of the group of business managers, and on the other hand serves as an interface between these data and the phenomenological observations of the experts. The semi-structured interview – the content of which is analyzed on the basis of grounded theory – was the preferred choice, with the aim of making sense of large amounts of information, collected by means of qualitative tools, identifying recurring themes and relationships between them, in an ideal movement that goes from the data to the theory, rather than the other way around. ATLAS.ti was the software of choice. The interview was the consistent tool of choice, given the didactics of the model as well as with its phenomenological and relational theoretical reference. It allows us to understand the point of view of the manager interviewed and his vision of the world. By vision of the world is meant the set of values and meanings which he attributes to experiences, regardless of the expectations and the theories of the researcher. The interview template, as well as the observation grid, allow cataloguing of the dialogue content and the observations in discrete categories, and leave open the possibility of examining in depth its key

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passages, of accepting the suggestions of the interviewee as well as of the observed group, and finally of completing and redefining the content. The third task that the consultants-in-training were asked to carry out was to combine the manager’s answers - expressions of his culture of leadership, group processes and relationship between his company and the group – with observations of the manager documented in the predefined grid. In this way, the consultant necessarily had to consider both her/his perception (as external expert) and that of the manager, in order to define an integrated form of business consulting that takes account of the phenomenological fields of the manager, of the group and of the consultant him/herself. Once again, as already pointed out, the observation and the consultancy must be based on what is effective in the work group and how it could improve, rather than dysfunctional aspects and their causes. In this way, consultants cannot refrain from allowing their own creativity and personal style to come into play, constituting an attractive element in the model and the human “juice” of the relational consulting work. The managers appreciated this kind of feedback so much that when the course and the internship ended, some of them contracted to keep the students in their companies. This is also very rewarding feedback, because it validates the work potential offered by this model (especially in this historical moment of crisis), and proves how much it adapts to corporate logic.

An example of feedback at the conclusion of the internship1 The internship, the final phase of the advanced training course in “Relazioni Umane in Azienda” (Human Relations in the Company), organized by the Istituto di Gestalt HCC Italy, was held from June 7 to June 28 2012 for a total of 70 hours at the private clinic XXX. The aim of the internship was to analyze, through interviews with the managers as well as direct observation, the organizational well-being of the company, and possibly provide it with Gestalt consulting. In particular, the morning activity in the three departments of the structure was monitored. 1

This study was carried out by Dr Francesco Lotta, psychologist, who is currently specializing in Psychotherapy at the Istituto di Gestalt HCC Italy in Palermo. For privacy reasons, the names of the doctors and the clinic were omitted.

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The private clinic operates with a high level of complexity, both for the quality and the quantity of health services provided on a daily basis, with a medical center, a surgical center, and diagnostic activity. This kind of organizational complexity requires flexibility at work, and the staff was able to develop it optimally. The ability to cope with the heavy workload is guaranteed by the mutual support that the various professionals in the work group can give each other, both on a professional-technical and on a personal-emotional level. Managers developed both a sense of belonging, thanks to the proximity that the clinic owners are able to express to the individual employee, and a sense of confidence in their own professionalism, thanks to the guarantee of autonomy in their work. The general mood that reigns inside the clinic is strongly characterized by passion, attention, as well as care for one’s own work and for the welfare of the patient. A good aptitude for communication and collaboration was also noticed between doctors and nurses of the different departments. Each department has some peculiar characteristics which are linked to the members of the work group, to their relational skills, to the resources of the group, but also to the type of work itself and the demands that it entails. During the observation, it was possible to see how the departments, which are the largest sub-systems in the organization, can find their own adaptation. The observation in the wards was performed taking into account three main phenomenological criteria (cf. Spagnuolo Lobb, 2013a, p. 239): x the vitality and presence of the group members, identifiable in the responsiveness and energy with which each group member brings his/her own personal contribution; x the flexibility of the leadership, understood as a spontaneous and positive function of the group that allows the various members to voice shared needs and to implement behaviors which are capable of aggregating the members; x the ability to accept the novelty and diversity of the group members, which is fundamental in order to understand how the group is able to deal with novelty and to grow by integrating it. Within the various departments located on different floors of the building, a few interesting elements were detected during the internship; they are described below.

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First floor: Department of Oncology and Hematology, Ophthalmological day surgery. On the first floor, there is good integration between the medical and paramedical staff. The distribution of roles of the medical team allows it to work in an integrated and organic way. The person in charge, attentive towards research activities, allows the group to have a broad vision as regards the work that is carried out daily in the department. Dr. XXX, who organizes the day-to-day activities of the department, represents operational stability, with regard also to the relationships with the patients’ relatives. Dr. YYY brings her strong vitality to the group. During the meetings, communication is immediate and circular, and this shows a harmony that is the result of a high level of preparation and a flexible leadership. At the clinical operational level, there is good teamwork, also in front of the patients, who receive information about their treatment as well as emotional support. In this respect what proves to be crucial is the contribution of the educational psychologist, Dr. VVV, who accompanies the patients throughout their treatment and attends to medical staff. The nursing staff is vital, capable of mutual support in the daily work routine, and especially flexible as regards carrying out their role in patient care and leadership. Additionally, during the period of observation, a particular excitement was noticed regarding the impending retirement of Nurse G: her colleagues arranged a moment of group sharing to say goodbye to this person who, with her professionalism, energy and humanity, had been an important point of reference for them. The only critical aspect of the general mood in the department is a low degree of vitality, probably due to the high workload and to the particular activity of the department – which brings operators into contact with the theme of death on a daily basis. A possible solution may be to introduce some kind of support in order to allow the staff to integrate and come into contact with the emotional aspect of the experience with oncology patients. It would also be interesting to use the occasion of the retirement of the colleague in order to experience loss as a transitory phase that enables the story of the group to go on. Second floor: five surgical departments (General, Thoracic, Orthopedic, Neurosurgical, Plastic). The presence of several surgical departments implies the intersection of different needs and makes life within the department particularly active. A

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high degree of flexibility by the paramedics is needed. It is possible to observe a strong capacity to cope with new situations, which require prompt intervention. The leadership is flexible, although the head nurse remains a constant point of reference, especially from the point of view of emotional support. The overall climate is characterized by a great vitality and a good cohesion. As for the doctors, the meetings are irregular because of the surgical activity in the individual departments, but the mood is friendly: whenever possible they exchange views and seek opportunities for sharing. The critical issue in this department is the difficulty a few doctors had in meeting the administrative demands. During the observation period, after an irregularity was found during a check, a doctor expressed the difficulty in writing a change of therapy in the clinical record of a patient who was in the ICU because his case was urgent. One possible solution would be to improve the dialogue between the doctors and the operators of the computer system. Third floor: general medicine, respiratory and vascular diseases. The working environment is characterized by a good vitality. Doctors integrate their various competences by discussing cases and creating an atmosphere of personal harmony. An important moment is the morning rounds of the department, during which the harmony between them and the charge nurse, as well as their attention for the hospitalized, are evident. An important aspect is the coordination role of Dr. ZZZ, who manages to maintain flexible leadership with full confidence in the abilities of his colleagues, who continually give voice to the needs and requirements of the group. The medical team shows a number of resources: welcoming novelties, taking care of the group, and a high degree of professionalism. Even among the paramedics, it is possible to note a fully flexible leadership and peer support as regards concerns, work and obligations, transferring tasks among them and integrating novelties. A few critical issues are, the lack of space and resources with regard to the members of the group, a low interaction between doctors and nursing staff (except for the charge nurse), the medical staff’s difficulty in coping with the administrative aspects, and the lack of dialogue from the administration. Possible interventions may be to rethink the organization of the working space with the doctors (for example by moving the clinical record cabinet in the nurses’ room), and other possible solutions with regard to the fulfillment of administrative procedures.

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Moreover, a few critical aspects are common to all departments. Specifically: the need for a filter to regulate access to the department of the patients’ relatives, whose presence often hinders the work of doctors and nurses; the need for a greater amount of dialogue between healthcare and administrative personnel; and a workload which is perceived as burdensome. It is believed that the changes suggested for each floor are achievable, first of all because the common goal is clear to all and everyone identifies with it, but also because there is a considerable wealth of resources. On the first floor, there is opportunity within the team to express the emotions that every operator feels towards oncological pathologies; as regards the second floor, there is clear dialogue between the group of doctors and the administration; and a better use of space on the third floor. These are the specific suggestions for each department. In addition, a valorization of the resources of the staff – which already allow workgroups to do their job with a sense of belonging and responsibility – will enable the creative ability of the operators and a sense of recognition of their intent to give their best to the company, and to feel like significant members of internal corporate security.

Conclusion The application of this Gestalt model of organizational consulting satisfied beyond expectation both the staff who taught it and the students who learned it. The most successful aspect of this model is its phenomenological-aesthetical and relational approach, according to which the consultant focuses not on the contents, but rather on the modes used by the people in the company to achieve self-fulfillment through the company mission. To tell the managers what works in their team – something clearly visible to eyes which have been trained to discern the beauty of relationships – relaxes them, increases their motivation at work, and makes them more willing to focus on what works in the human interactions within their team. A research tool integrated in this model of consulting is extremely useful as, on the one hand, it provides an insight into what managers think of their company (their desires and disappointment resulting from comparing reality with an ideal they would like to achieve); on the other, it allows us to learn more about the employees’ experiences, their desires as regards the functioning of the company and the recognition of their contribution to the team – desires which are at times suspended, but ready to be reawakened by a sign of appreciation.

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The integration of this research tool makes it possible to: speak the constructive corporate language and, more specifically, the language of that manager and that group; take into account the managers’ culture; take into account the unspoken voices in the group and encourage them; and formulate a creative proposal including not only the manager’s vision and the group’s experiences, but also the consultant’s creativity. In fact, it is essential to include in the consulting the consultant’s personal style - the “icing on the cake” which will give the company the feeling that the consultant is actively and authentically participating in and creatively identifying with the corporate logic and needs.

References Frew, J. E. (1997). A Gestalt therapy theory application to the practice of group leadership. Gestalt Review, 1(2), 131-149. —. (2006). Organizational leadership theory has arrived: Gestalt theory never left. Gestalt Review, 10(2), 132-139. ͒ Meulmeester, F. (2009). My home is my castle: The use of the Gestalt approach in changing the culture of a nursing home organization in The Netherlands. In J. Melnick & E. C. Nevis (Eds.), Mending the world. Social healing interventions by Gestalt practitioners worldwide. Cape Cod, USA: Gestalt International Study Center, 310-332.͒ Nevis, E. C. (2003). Blocks to creativity in organizations. In Spagnuolo Lobb M. & Amendt-Lyon N. (Eds.), Creative license: The art of Gestalt therapy (pp. 291-302). Vienna & New York: Springer. Newton, M. (2002). A practitioner‘s perspective on the applicability of Gestalt-oriented organization development and organizational change. Gestalt Review, 6(2), 101-108. Spagnuolo Lobb, M. (2012). Il now-for-nextnella psicoterapia di gruppo. La magia dello stare insieme. Un modello di intervento Gestaltico nei gruppi. Quaderni di Gestalt, XXV(1), 57-70. —. (2013a). The now for next in psychotherapy: Gestalt therapy recounted in post modern society. Siracuse: Istituto di Gestalt HCC Italy Publ. Co. —. (2013b). Le now-for-next dans la psychothérapy de groupe (J. Caccamo, Trans.) [Special issue]. Au coeur des groupes. Explorer et penser les pratiques en Gestalt-thérapie, 2, 25-38. —. (2013c). From the need for aggression to the need for rootedness: A Gestalt postmodern clinical and social perspective on conflict. British Gestalt Journal, 22(2), 32-39.

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—. (2013d). Human rights and social responsibility in Gestalt therapy training. In G. Klaren, N. Levi, & I. Vidakoviü (Eds.), Yes we care! Social, political and cultural relationships as therapy’s ground, a Gestalt perspective (pp. 71-83). The Netherlands: European Association for Gestalt Therapy.

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Appendix Table 8-1: Grid to observe the work group, experiential fields parallel to the interview with the leader. Consultant’s observational field

Experiential field

Question to the leader

1 – Ideal group

1. How would you describe a good work group or the ideal work group? How is it in your opinion? Could you describe it?

Describe the work group spontaneously, starting from the feeling that that group evokes in you.

2 – Actual group

2. What are your group’s strengths ?

Describe the strengths that you can see in the work group while it functions (how each member is able to bring his/her positive contribution to the organization and how it is welcomed and recognized by the group and the manager).

3. What are its weaknesses?

Describe the weaknesses that you can see in the work group while it functions (how some of the individual initiatives are undeveloped, unseen and unrecognized by the group and the manager)

3 – History: the group’s evolution

4. How has your group changed through the years? What phases has it passed through?

On the basis of brief dialogues and interviews with members of the work group, describe the history of the group, that is the way intentionalities of contact have developed among members.

4 – The present

5. What does your group need now in its actual phase?

What do you think the group needs now? Are there individual spontaneous initiatives that need to be recognized?

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6. How can the leader move towards these needs (of the group)?

How might the leader support the unfolding of these retroflected intentionalities of contact?

5 – Metaphor and mentalisation (how the leader integrates the experience with his/her working group into his/her mentality)

7. How would you describe, with a metaphor; the work group that you belong to/lead? Why did you think of this metaphor? 8. What metaphor come to mind, if you were to describe your ideal group? Why?

Which metaphor comes to your mind if you try to describe the work group while you observe it?

6 – Novelty, excitement and growth (how does the group integrate novelties)

9. In what way does the group handle novelty? (if necessary, give examples of novelty: admission of new hirees, retirement, lay-offs, change of location, etc) could you give me some examples? (stimulate the specification of which novelty and telling of some examples passing from general to specific)

Observe how the work group copes with novelties during your internship. Describe the times of rigidity and the times when spontaneity is possible.

7 – Vitality: Climate/ Spontaneity/Creativity (how the group’s climate supports or opposes individuals’ and group’s creativity and lets leadership flow)

10. How would you describe the climate that you breathe within the organization/company? 11. In what way, from your point of view, does the group express its spontaneity? In what way do they express their individual contribution?

How would you describe the climate that you sense within the organization?

Try to picture this group as if it were functioning very well. Which metaphor comes to your mind to describe the group at its best?

In what way does the work group express its spontaneity? How does each individual feel free to express his/her own contribution to the work group? How does the group welcome the contribution of each individual in a relaxed/unstressful way?

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Chapter Nine 12. Does a certain episode, moment, or situation come to mind in which your group best expressed its creativity? 13. In what way does your group generally express its creativity?

14. In your opinion what are the greatest obstacles for an increase in creativity? 8 – Now for Next and intentionality (awareness and leaning into the future)

9 – Feedback to consultant

Describe an episode, a moment during your internship, in which the work group, in your opinion, has fully expressed its creativity. In general, would you say that this group feels “at home” when it is at work, and acts creatively? Describe bodily and verbal cues, including movements. In your opinion, what are the biggest obstacles/major obstacles preventing a greater degree of creativity?

15. According to you, what do your collaborators feel towards this company? How much do they feel they belong? 16. According to you, what would your collaborators want for this company? What are their desires for the future of this work group? 17. What is your desire for this work group? (how would you like it to change/what change would you like to see? What is missing? In what could it improve?) Why?

In your opinion, what do the members of the work group feel towards the organization? To what degree do they feel they belong to it?

18. How did you feel answering my questions? What did you like and what bothered you?

How do you evaluate your internship? What did you like most and what did you find unpleasant about it?

In your opinion, what would the members of the work group want the organization to accomplish? What do they desire for the future of their work group? According to your observations, what does the leader wish for the work group? How would s/he like the group to change? Is what the leader wishes and likes in line with the desires of the group members? In what way do you think that the leader could practically help?

CHAPTER TEN STRATEGIC RESEARCH: USING CORE TO ESTABLISH AN EVIDENCE BASE FOR GESTALT THERAPY CHRISTINE STEVENS, KATY WAKELIN

Introduction The strength of Gestalt therapy is its creative attention to what is happening now in the present encounter. The training of the therapist is focused on developing awareness and the capacity for being present and energetically available. A coherent theory of self, aspects of phenomenology and field theory along with contemporary psychological and neurological contributions form a working matrix of knowledge on which the therapist draws. However, it is the lively experiential, experimental, dialogic nature of the relationship, finely balanced between challenge and support and open to new possibilities of thought and behaviour which attracts many people to train as Gestalt therapists. These are not necessarily the same attributes which are required for research projects, and for many in the Gestalt community there is a tension between the satisfaction they receive from the intrinsic interest of their work, and the idea of the rigour and constraint of academic research. Yet the climate has changed, and without an evidence base for our work, even the most highly qualified and experienced Gestalt therapists find they are disadvantaged when competing for work and contracts with other modalities who have established a well-published research trace. In this chapter we give an account of how a part of the UK Gestalt community mobilised itself over a three-year period to complete an outcome study using the CORE measurement as a research tool. We used voluntary effort and minimal funding but our research was methodical and rigorous and our results can be compared with an extensive national data base. Our findings show that Gestalt therapists are as effective as

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therapists from other modalities working in the UK National Health Service.

CORE As we wanted our research to contribute towards an evidence base for Gestalt therapy, the choice of methodology was a strategic one. The CORE (Clinical Outcomes in Routine Evaluation) system is now the most widely used approach for audit, evaluation and outcome measurement for psychological therapy and counselling services in the UK. It was developed from 1995-1998 in the Psychological Therapies Research Centre at the University of Leeds by a multi-disciplinary team of researchers and therapists, and became a self-financing initiative in 1998. The CORE National Research Database currently holds data for about 50,000 clients. The details of the development and application of CORE have been discussed in detail elsewhere (Barkham, Mellor-Clark, Connell, & Cahill, 2006). To summarise, the system is basically a self-report questionnaire filled in by the client at the beginning and end of therapy, on how they have felt over the past week; and assessment and end of therapy forms completed by the therapist. The 34 items measured cover four dimensions: subjective well-being; problems or symptoms; life functioning; risk or harm. The scores from the questionnaire are averaged to give a mean score to indicate current levels of psychological distress from “healthy” to “severe”. The comparison of pre and post therapy scores offers a measure of outcome – whether the level of distress has changed – and by how much. The system is designed to be completed for each client by their respective practitioner in a service, thus providing comprehensive profiling rather than selecting only the clients likely to do well. The CORE measurement is primarily designed to provide managers and practitioners with evidence of service quality and effectiveness. It is not specifically Gestalt orientated; indeed, from the list of possible therapy types stated on the end of the therapy form for the practitioner there is no box to specify Gestalt apart from “other”. However, the decision was made to use this system as it is the most widely used across psychological therapy services on a national level. Many Gestalt therapists working within the NHS teams already contribute data in this way, but their Gestalt identity is subsumed within the team as a whole in these settings. What was different about this particular project was that the data would be collected by Gestalt therapists across workplace contexts, to include public

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sector, voluntary and private practice. This would enable us to compare this data with that collected by other therapy approaches, including CBT.

How we designed and carried out the project The motivation to get started arose out of concerns about the lack of research available on the effectiveness of Gestalt therapy expressed on the discussion list hosted by GPTI (Gestalt Psychotherapy Training Institute, one of the largest professional membership groups for Gestalt therapists in the UK). One discussant, Jane Stringfellow, volunteered to look at options for addressing this, and CORE was identified as a suitable approach. One of the immediate challenges was to plan and co-ordinate a medium scale research enterprise using voluntary effort and relying on the professional interest and motivation of members of the Gestalt community. To get this going, a steering group of six people was formed and information disseminated via the GPTI online list. John Mellor-Clark, one of the developers of the CORE system, attended the GPTI conference in June 2007 and gave a presentation to delegates. This was followed up with a training day later in the year in Birmingham attended by over 30 therapists interested in participating in the research project. A Gestalt Practice Research Network was formed to support the project, with an online group to share information among the participants. The GPTI Executive Committee agreed to fund the CORE software licence and cover training costs for the first year to set the project up. In all, about 40 Gestalt therapists registered and agreed to send in data sets. We wanted to be able to analyse the data in terms of the setting in which the therapist worked, whether in private practice, primary care or another setting, and to ascertain the level of experience of the therapist. A member of the group, Ros Gilham, developed a coding system so we could collect this information when participants registered. We leased the used of the software, and this was held on a central computer installed in Christine Stevens’ office in Nottingham. This became the physical hub for the project and the place where the completed hard copy data were posted to. For most of the research period, there was no paid data entry clerk, so periodically over the three-year collection period, volunteers, including Jane Stringfellow, Judith Waring, Ros Gilham, Carole Ashton among others, came to Nottingham for “CORE days” to enter the data into the database. In November 2009, a CORE representative, Bill Andrews, visited to review the data with us and give us training on how to analyse it using the software provided. We felt well supported by staff from the CORE team throughout our study.

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An interim presentation was made at the UKAGT conference in June 2009 by Christine Stevens and Judith Waring. At that stage 105 data sets had been input. In June 2010, we stopped collecting data. We had collected information on 249 clients, of which 180 were complete data sets that we could use for analysis. The reason for this difference was because participants were asked to send in data for all their clients during the collection period, not selected ones. This meant that some clients only came once or ended suddenly, so that the end of therapy form could not be collected. Some of the total (10.4%) not included in the analysis is accounted for by long term client work which had not been completed by the end of the study. Other reasons for sets not being complete include the therapist forgetting to administer the end of therapy form. Both pre and post therapy CORE scores are needed to measure outcome. In terms of the data sets collected, about 50% of the participating therapists were advanced students on placement in a primary care setting, and they provided 25% of the useable data sets. The information collected in the research study can be used in two main ways: firstly to describe some aspects of the client population, and secondly, to compare the findings in this study with results from other published studies.

Data description It is important to note that most of the clients, just over 70% seen in this study, were referred by GPs and probably mainly seen by therapists practising in primary care teams. The next largest source of referral, nearly 14%, was self-referral, perhaps more usual for private practice. Others were referred by another therapist (7.3%), family member or friend (3.2%), psychiatrist, (1.9%), or education-based service (1.2%). About 70% of the clients seen were women, and they were predominantly white British or European (90.4%). Just under a third of the clients were caring for children, and 24% lived alone while 34% were living with a partner. In terms of age, the biggest group of clients in this study were in their thirties (31%), followed by those in their forties (27%). More clients in their twenties (19%) were seen than those in their fifties (12%), and after age fifty-nine the percentage drops off to almost 9%. Most clients, about 83%, were seen weekly, and 91% of planned sessions were attended. The CORE therapist assessment form has categories for the therapist to record the problems the client presents with at assessment. These are given in the table below for this study. The therapist can tick as many of these categories that apply. This spread of problems is typical for clients referred

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in primary care and reflects the fact that the majority of Gestalt therapy recorded in this study took place in this context. Table 11-1: Problem assessment Problems at assessment

100% N = 722

Anxiety/stress Depression Interpersonal relationship Self esteem Bereavement/loss Work/academic Physical problems Trauma/abuse Living/welfare Personality problems Addictions Eating disorder Other Psychosis

22.4% 18.7 % 18.4% 11.5% 7.1% 5.4% 4.3% 4.3% 2.9% 2.2% 1.7% 0.7% 0.3% 0.1%

Comparative results Another way to use the CORE data collected is to compare the average over the 34 questions before and after therapy. The lower the score for an individual, the higher the client’s self-classified well-being, with fewer symptoms, better life functioning and lower risk of harm. By comparing the score at the beginning and end we can see if clients classified themselves as doing better on these four criteria following therapy. In addition to seeing if the clients classify themselves as doing better in our sample, we can also compare the outcomes measured in this study with those for other studies. The results from three papers are used in Tables 11-1 and 11-2 (see Appendix) as comparisons to the Gestalt sample used in this paper. By using very large data sets, two of these papers— Stiles, Barkham, Mellor-Clark, and Connell (2008) and Stiles, Twigg, Mellor-Clark and Cooper (2006) and Mullin et al. (2006)—provide benchmarks against which other services and practitioners can compare themselves. The first two compare the effectiveness of cognitivebehavioural, person-centred and psychodynamic therapies in primary care and NHS settings using the CORE measures. They find that theoretically

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different approaches appear to have equivalent outcomes – this is known 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. The Mullin et al. (2006) paper aims to provide benchmark results for a large sample of clients who have filled in the CORE papers. The clients were seen in primary care by a variety of therapists and for a variety of reasons. The authors used as broad a sample as possible in order to set benchmarks that can be used for comparison by other studies. Table 11-2 (see Appendix) shows the mean (average) score over the 34 questions asked by the CORE survey both before and after therapy. Before therapy the average score was 18.3, this is a little higher than the average score in the main benchmarking study of 17.5 and higher than the two comparison studies of 17.4 and 17.6. What this means is that, on average, the clients seen in this Gestalt study appear to be more distressed than those being seen in comparable studies, although we should not make too much of this slight difference as it is within one standard deviation (7.4). After therapy, the average scores declined to 9.9 for the Gestalt study showing a slightly smaller fall than the comparison studies and the benchmark study. The pre-post difference is the difference between the before and after CORE measures. At 8.4 this is comparable to 8.8 and 8.9 in the comparison studies for CBT, person-centred therapy and psychodynamic therapy and to the benchmark result of 8.4. Gestalt appears to be as effective as other modalities using the CORE method of assessment. The effect of therapy is measured by effect size. Effect size is given by the mean of the difference between pre-counselling and post-counselling scores over the pre-counselling standard deviation. This is slightly lower in our Gestalt study than the other comparison studies with the exception of Armstrong (2010) where unqualified personnel were used as therapists. Nevertheless, keeping in mind that in this study around a quarter of the data were generated by practitioners who had not yet completed their training, the effect size is still broadly comparable at 1.12 to the other effect sizes of 1.36, 1.39 and 1.42.

CORE Outcome Data There are additional standard measures used in the CORE literature to assess the effectiveness of therapy. Two measures of improvement are reported in Table 11-3 (see Appendix), which are:

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Reliable improvement – defined as a decrease (i.e., improvement) in the CORE outcome measure score of 5 points or more. This measure was developed to show change that is large enough so that “we can reasonably discard the alternative explanations that this could have happened by chance” (Mullin et al., 2006, p. 69). Some of these will also show clinical improvement (see below) “only improvement” gives those clients that show reliable improvement but not clinical improvement. Reliable and clinically significant improvement (RCSI) – defined as a decrease in the CORE outcome measure score of 5 points or more (as above) AND movement from the clinical (above 10) to the non-clinical (below 10) population. This means that the client now looks as if they belong to the general population rather than to the “clinical” population of those people normally entering psychotherapy services. Crudely put they can now be considered “recovered”. Both counts are included in column (1) to show the overall percentage of clients that showed improvement. For this Gestalt study that is 74.1% or around three quarters of the clients1. Another potential category is reliable deterioration i.e. a CORE final score five points higher than the start. While some clients did deteriorate in the sample, no clients fitted this category of reliable deterioration. Only clients for which both pre and post CORE scores were available were included, leaving 135 clients2. Other studies’ results were included for comparison. In Table 11-3 (see Appendix) the average improvement rates from Stiles et al. are given across modalities as there did not appear to be significant differences between modalities. As you can see from Table 11-3 (see Appendix), the result for Gestalt therapists – with 56.3% showing reliable and clinically-significant results - appears to be similar to those for the benchmark studies with 53%, 58,3% and 61.0%. A fourth study was also included. The result from Armstrong (2010) shows a much lower level of RCSI at 30.5%. The explanation for those low CORE figures is that they represent the outcome when using minimally trained/experienced volunteer mental health counsellors. The paper concludes that: “the overall effect of counselling was roughly half of 1

The Mullin et al. (2006) benchmark study uses 5 as the criteria to measure reliable change as in this paper. Both the Stiles et al. (2006, 2008) use a figure of 4.8. This is unlikely to have a large impact on the results. 2 Only clients who had filled in at least 30 of the 34 measures are considered to be “valid” outcome measures. In addition, we do not include those clients whose pretherapy scores were below 10 as they could not, by definition, achieve clinically significant improvement. See Stiles et al. (2006, 2008).

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that achieved by professional therapists in the benchmark studies” (p.27, Armstrong, 2010). They also appear to be considerably less effective than the present sample of Gestalt therapists, some of whom are trainees. In our sample, approximately 74% show recovery or improvement; 56% achieved reliable and clinically-significant improvement; and around 18% achieved reliable improvement alone. Approximately 26% of the sample experienced no reliable change. The closest comparisons are probably with the Stiles et al. (2008) as they looked at therapists working in primary care (a similar sample to the one used here), and Mullin et al. (2006) which established the CORE outcome measure benchmarks in relation to brief counselling in primary care settings. In those studies approximately 78% and 72% showed recovery or improvement – comparable to the 74% for our sample of Gestalt therapists. Overall, the results support the equivalence paradox found elsewhere in the literature (Stiles et al. 2006, 2008): Gestalt therapists appear to be as effective as other therapists working in primary care.

Reflections This was an innovative experiment using low-cost methods by a wellmotivated community of Gestalt therapists, showing that collaborative research projects can be undertaken in this way. Even so, there were difficulties. Motivation is hard to sustain over time, and there are limits to what busy practitioners can sustain on a voluntary basis. Researching real world activity as it happens requires academic rigour and accurate and consistent data collection. This boils down to the often tedious chore of careful form filling and the collating of data sets, ensuring they are as complete as possible. For therapists trained in relational skills who enjoy the richly textured nuances of contact with others in their daily work, this additional requirement can seem antithetical to what they feel their work is about. There are always issues with the research methods, for example, some of us would argue that clients who gain significant awareness through work at relational depth may feel worse in their last week of therapy than they did at the beginning despite being in a more functional life-space. Yet the reality is that we cannot be complacent about issues of public accountability and demonstrable effectiveness. 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 (Stevens, 2008, p. 315).

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We chose to use the CORE system because it is the most widely used outcome evaluation measure currently used in the UK, and some Gestalt therapists already use it in their work places. What our study shows is that when this measure is used with work done exclusively by Gestalt-trained therapists, the results are very similar to other modalities the system codes for, i.e., person-centred, cognitive behavioural therapy and psychodynamic approaches. In fact, this is consistent with what CORE has shown over the years it has been running: the equivalence paradox. Research has also shown that the outcome difference between individual therapists (regardless of modality) can be as much as a factor of 10. It may be then that having established an evidence base for Gestalt as a therapeutic modality, we might go on to ask: “How can I become a more effective Gestalt therapist?”

What next? Since our UK study, interest has been growing in the international Gestalt community to participate in research studies as each national group faces the political and economic demand to demonstrate an evidence base for Gestalt therapy practice. Several countries, such as Norway, have begun their own CORE projects, and the measurements have now been translated into over 20 languages, with responsibility for ensuring accuracy and quality control being held by Chris Evans ([email protected]). Our UK study was presented at the EAGT Research Conference in Rome, May 2014, and there was interest and energy to conduct a European-wide Gestalt CORE study. National Gestalt organisations could develop their own projects using the standard measurement tools in translation, which could then be combined at a pan-European level. The strength of having a large reference database and a common measurement tool used by the international Gestalt community could amplify small-scale local effort into a powerful multi-national evidence-based study. This could help the position of Gestalt in each national context, showing that Gestalt is an effective modality across a wide range of clients.

Acknowledgements The authors would like to thank all those who participated in the UK Gestalt CORE research project in whatever capacity. We gratefully acknowledge three year’s grant funding from GPTI. Our thanks to the CORE team for their help and support.

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In memoriam Ros Gilham who gave generously of her energy and enthusiasm in setting up this project and who sadly died before it was completed.

References Armstrong, J. (2010). How effective are minimally trained/experienced volunteer mental health counsellors? Evaluation of CORE outcome data. Counselling and Psychotherapy Research, 10(1), 22-31. Mullin, T., Barkham, M., Mothersole, G., Bewick, B. M., & Kinder, A. (2006). Recovery and improvement benchmarks for counselling and the psychological therapies in routine primary care. Counselling and Psychotherapy Research, 6(1), 68-80. Barkham, M., Mellor-Clark, J., Connell, J., & Cahill, J. (2006). A CORE approach to practice-based evidence: A brief history of the origins and applications of the CORE-OM and CORE System. Counselling and Psychotherapy Research, 6(1), 3-15. Stevens, C. (2008). Can CORE measure the effectiveness of Gestalt Therapy? In P. Brownell (Ed.), Handbook for theory, research and practice in Gestalt therapy. Newcastle, Cambridge Scholars Publishing. Stiles, W. B., Barkham, M., Mellor-Clark, J., & Connell, J. (2008). Effectiveness of cognitive-behavioural, person-centred, and psychodynamic therapies in UK primary-care routine practice: Replication in a larger sample. Psychological Medicine, 38, 677-688. Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555-566.

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Appendix Table 11-2: Comparison of mean differences N

Study

Gestalt results 180 Mullin et al. (2006) 11953 Stiles et al. (2006) 1309 Stiles et al. (2008) 5613 Armstrong (2010) 118 (a) information not given

Pre-therapy Mean SD

Post-therapy Mean SD

Pre-post difference Mean SD ES

18.3 17.5 17.4 17.6 18.1

9.9 8.5 8.5 8.7 13.4

8.4 9.0 8.9 8.8 4.7

7.4 6.3 6.5 6.3 6.6

6.7 6.3 6.2 6.4 7.9

6.8 (a) 6.8 6.6 6.5

1.12 1.42 1.36 1.39 0.70

Table 11-3: Reliable and clinically significant improvement compared to other studies Column

Present study Armstro ng 2010 Stiles et al. 2006 Stiles et al. 2008 Mullin et al. 2006 a)

(1)

(2)

(3)

(4)

Recovered or improved

Reliable and clinically significant improvement (RCSI) Count %

Reliable improvement only

No reliable change

Count

Coun t

N

Count

135

100

118

57

1309

905

4954

3847

1195 3

(a)863 0

% 74. 1 48. 3 79. 5 77. 7 72. 2

76 36 693 2887 (a)633 5

56. 3 30. 5 61. 0 58. 3 53. 8

24 21 212 960 (a)219 9

% 17. 8 17. 8 18. 5 19. 4 18. 4

35 52 210 1047 (a)21 5

% 25. 9 44. 0 19. 3 21. 1 1.8

not provided in Mullin et al. (2006), numbers author’s own calculation

CHAPTER ELEVEN A GESTALT PROCESS/ACTION BASED THEORY OF DEPRESSION AND TEST CONSTRUCTION VALIDATION IDA BABAKHANYAN, TODD BURLEY

Introduction The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and is meant to provide a common language and standard criteria for the classification of mental disorders. For decades since the mental health profession started using the DSM, it has influenced professionals’ thinking about the meaning of disorders. A list of symptoms has come to define the understanding of mental illness and guides how treatment is provided and who is treated. This approach of labeling individuals and making inferences for treatment from such labeling can be problematic for a number of reasons. Scholars have agreed that psychiatry now adheres to the medical model, which advocates consistent application of modern medical thinking and methods (Black, 2005) and in which psychopathology is considered to represent “the manifestations of disturbed function within a part of the body” (Guze, 1992). Psychology has adopted this medical model and the DSM is the most important tool used to diagnose mental illness and guide treatment for both children and adults.

The diagnostic problem Researchers have noted various reasons why the current diagnostic approach is problematic. One problem with the current system is that the measures used for assessment include significant number of physical symptomatology which are associated with various psychological and

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medical conditions. For example, symptoms such as fatigue, headaches, disruption in sleep pattern, increased or decreased appetite, muscle and joint pain, impaired concentration, difficulties with memory, sleep disturbances, shortness of breath, and gastrointestinal problems commonly present with other medical conditions; however, they are typically included in commonly used depression measures (Conradi, Ormel, & de Jonge, 2012; Hyams, 1998). In addition, symptoms associated with PTSD, grief, anxiety, and general feelings of sadness can all overlap, making identification of a disorder challenging (Burley, 2012). Because of the broad range of human pathology, the result of complex interactions between numerous diseases and diverse biologic processes, diagnosis of distinct clinical entities is difficult (Cooper, 2004). The current diagnostic approach shows a general lack of concern for etiology. The criteria used to diagnose a disorder very often are actually outcomes or side effects of the disorder. They indicate little about the development, process, and maintenance of any particular disorder. Gestalt theorists would also argue that, when looking at the current diagnostic process, nothing describes what the person does, only how the person is because of what he or she has already done. The diagnostic criteria do not describe the psychological process but are side effect or symptoms (Burley, 2012). Each diagnosis in the DSM is supposed to represent malfunction in some mental, physical, or behavioral trait, yet the diagnosis itself is made without regard for what the underlying process/action malfunction might be. In medicine, when diagnosis is made concerning medical symptoms, there is a known factor for the cause of the condition; so general conclusions can be drawn concerning treatment for that condition. In psychology, the use of the DSM can completely separate the diagnosis from its etiology, which is often more important than the symptoms themselves. Although derived from the medical model, this symptom-based approach is far from identifying the underlying reality of disease as a genuine psychological or biological process; thus, it has been called the minimal interpretation of the medical model (Murphy, 2010).

Need for a process-oriented measure As a result of where the current state of assessment and diagnosis stands, the development of a new measure, which is separate from what is currently used in assessment, is warranted and proposed. Rather than building on models established decades ago using the DSM symptomology or using purely projective measures that are subjective and difficult to score in a quantifiable manner, a bottom-up approach in

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measure development would allow for a new perspective. The bottom-up approach starts with specific observations related to an area of research (e.g., children’s depression), which is derived from the population of interest (e.g., depressed and non-depressed children). One of the key components of the bottom-up approach is that items are constructed based on theory, the Gestalt theory of depression. This approach provides valuable contextual and linguistic information that can be used for the development of items relevant to childhood depression. This method is more likely to produce psychometrically sound instruments that ensure measurement equivalence (Knight et al., 2009). A new measure would be able to capture what projective measures attempt to capture by being less face-valid; however, answers could be quantified for scoring and norming purposes. In an effort to assess depression in a new way, the new approach should avoid incorporating DSM symptomatology, the observable symptoms, (e.g., loss of appetite, change in sleep patterns) and focus on understanding how a depressed child perceives his or her situation and functions in his or her environment.

Depression in children Assessing for children’s emotional states specific to depression has long been an important area in psychology. As awareness of children’s depression came to the forefront, standardized measures were developed in the 1980s to assess and identify depression in children. Most measures currently used were developed over 2 decades ago, although knowledge of child pathology has changed since that time. Professionals now agree that depression in children occurs; however, several controversies remain regarding its clinical signs and the best approaches for assessment and diagnosis. Areas of agreement include, first, the understanding that identification of depression in childhood should occur as early as possible to allow for early intervention. Second, given the heterogeneous presentation of depressive symptoms across different age groups, an empirically based developmental approach to diagnosis is necessary (D’Angelo & Augenstein, 2012). Childhood depression has long-term implications for adult psychological functioning in addition to current risk. Children and adolescents who experience early onset of depression are more likely to experience recurrences and experience severe depression as adults (Kessler, Chiu, Demler, & Walters, 2005). Childhood depression has lifelong consequences and costs both for children and for society (Mash & Wolfe, 2008). The prevalence rate for major depressive disorder (MDD)

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for children aged 4–18 is 2–8% (Mash & Wolfe, 2008). In 2010 the National Institute of Mental Health (NIMH) estimated that as many as 11.2% of persons 13-18 years old are affected with depressive disorder. Of those, 3% have experienced a seriously debilitating depressive state (Merikangas et al., 2010). One of the strongest risk factors for suicide in youth is depression (Shaffer & Pfeffer, 2001), and suicide is the third leading cause of death in the United States for adolescents, accounting for 11% of the deaths. As many as 27% of children with depression (Stark et al., 1991) and 60% of adolescents with depression (Wetzler, Asnis, Hyman, & Virtue, 1996) have serious suicidal ideations. Currently, much research on childhood depression is at this descriptive level (Novell, 1986). For example, researchers have attempted to distinguish the essential features of childhood depression from the associated features (Cantwell, 1982). Essential features are consistent with the DSM, such as anhedonia, whereas associate features could be behaviors and attitudes (e.g., worrying about aches and pains). All measures for childhood depression, including the CDI, were constructed within the current diagnostic framework. The goal of having a valid method of measuring childhood depression or any other psychological phenomenon has been to facilitate the process of description (Novell, 1986). Although description is an important precursor to understanding the causes and mechanisms of a syndrome or disorder, understanding disorder is often terminated when the description appears to be completed. The commonly used face-valid measures primarily used in assessing children are not always valid approaches to understanding children’s feelings. Research has shown that children have a tendency to develop an internal dialogue based on what their parents say and often respond to selfreported items in a manner that would please their caretakers. In addition, because of fear of being ostracized, children can hold back their true feelings on self-report measures. With children, often the biggest problem in assessing pathology using self-report measures is that they lack insight into their own process. Therefore, items that directly question whether they feel tired or sad can exclude those children who are not in touch with their sensations and perceptions. Even when children are facing physical pain, it is not unlikely for them to report symptoms different from what is observed (Beyer, McGrath, & Berde, 1990). Some children will report that they are happy even in very dire situations while continuing to have nightmares and perform poorly in school because of emotional distress. A study, which looked at medically ill children in acute care hospital setting, found that while hospitalized, children reported few symptoms of depression on a well-established depression scale compared with the

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normative sample (Babakhanyan, 2012). Self-report measures require some level of insight that some young children may not have. Given that children may not be aware of their own struggles, lacking insight into their own emotional states, questions that ask children to define specific symptoms appear counterintuitive for this population.

Gestalt theory Gestalt theory is a holistic perspective that emphasizes that the whole is different from the sum of the parts. Lewin’s field theory has been described as the pillar of Gestalt therapy (O’Neill & Gaffney, 2008), emphasizing that all individuals exist in an environment that is in relation to others. Lewin (1952) stated that “the totality of coexisting facts which are conceived of as mutually interdependent” comprise the individual’s life field (p. 240). In addition, field theory is grounded in phenomenological observation and places behavior as a function of the person and the present field. Furthermore, the existential perspective suggests that every individual in the world shares the world with every other resident so that all the ways that they share contribute to meaning and value in the lives not only of the individual but of everyone he or she touches. This perspective is one of the guiding tenets of Gestalt because the therapist must realize that he or she is part of the client’s world and must taken into account his or her effect on the client simply by existing and interacting with him or her (Plummer, 1997). In general, no individual can be understood without first understanding the issues that surround him or her (Applebaum, 2012). With this model, understanding pathology would require awareness beyond an individual’s specific symptoms. It would require the understanding of how the individual functions in his or her world. Therefore, assessment of the current psychological state should take into consideration how one is relating to his or her environment. Every individual has needs that guide his or her perception of the surrounding world. In Gestalt theory, needs are based in the individual and arise based on the person’s biological processes. Burley (2003) suggested they are organized in a manner similar to the hierarchy of needs described by Maslow (1970). Needs organize the perception of the field, and human activity is understood as interactive and partly a reaction to the perceived conditions of the field, so there is a constant dynamic interrelatedness of the elements of the field (Levine, 2012). As people continuously scan the environment for input, which may or may not be familiar to them, they are more likely to attend to stimuli that are unfamiliar or that may alert them to some danger. The principles of Gestalt theory can be best described as

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“the needs and interests of the individual in his or her context will determine what is central to that person’s awareness and will guide that person’s cognitive/affective and physical behavior to resolution for that need or interest so that the need driven figure ceases to be central in the person’s awareness” (Burley, 2003). Yontef and Simkin (1993) stated that the major pillar of Gestalt therapy is awareness: “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” (Yontef & Simkin, 1993). The client is taught to value what is, rather than what would be, could be, or should be (Yontef & Simkin, 1993). Gestalt therapy is built on the central idea that it is only possible to know one’s self against the background of one’s relationship with his or her environment (Latner, 2000). It focuses on what is happening, what is being done, thought, and felt at the present moment. The direct experience is more telling than an indirect or secondary interpretation of an experience. For example, direct experience can be considered one’s present experience in a room. In contrast, indirect experiences measured in assessment are symptoms, which may or may not meet diagnostic criteria (i.e., inability to sleep, loss of appetite, excessive crying). Being aware of these direct experiences requires awareness of one’s sensory perceptions (seeing, hearing, smelling, etc.) and the processing of these perceptions provides the ground work for interpretation (Brownell, 2010). The holism of Gestalt theory refers to the organization of sensory experience (Levine, 2012). It is through sensory experiences that humans experience themselves and make contact with the world. The areas of assessment and treatment appear to be divided. Such established theories as Gestalt tend to avoid diagnosis; therefore, avoiding assessment models. In addition, assessment models are often not based in theory. Closing this gap could lead to increased precision in diagnosis and better outcomes for treatment. In Gestalt theory, the very concept of assessment could create a dilemma (Joyce & Sills, 2006). The idea of diagnosis can run counter to many of the fundamental principles of Gestalt practice because it implies a sense of structure in that a “person is fixed and static and can be evaluated at a distance” (Joyce & Sills, 2006, p. 57). Although a relevant point, this should not create a division in the field of assessment and treatment. In terms of Gestalt principles, diagnosis is most useful if it remains descriptive, phenomenological, and flexible, rather than simply defining and naming. A definition of diagnosis within existential theory would be to say that it is a dynamic description of a fixed Gestalt in the life of the client, which has become static. The fixed

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Gestalt is described as a “description of creative adjustment made, at some time, to previous life circumstances, which has become habitual and inappropriate in the present” (Joyce & Sills, 2006, p. 60). To make the diagnosis, the therapist must separate the client’s symptoms from etiology. Because Gestalt theory’s goal is to put the individual together and to consider the patient holistically, these two goals can be seen as mutually exclusive. However, if researchers focus only on validating what has already been validated instead of finding new ways to measure constructs, the science of psychology will lack important grounded theories to drive its practice.

Gestalt theory on depression Although depression is not extensively defined in literature related to Gestalt theory, the defining principles of the theory have important implications for the process of how one reaches a depressed state. Because figure formation and resolution form the basic phenomenological unit in Gestalt theory (Burley, 1981), when a need is present, depressed individuals have a difficult time creating its form and are unable to follow the need through to its resolution. Procedural memory has consistently been defined as the kind of memory that is not held in awareness yet it is there to guide behavior when situations arise that are similar to previously encountered and mastered situations (Burley & Freier, 2004). What is in the person’s awareness at any given moment is based on biologically rooted needs or interests, which polarize the field into figure and ground. There is an initial awareness of the need (figure formation), followed by figure sharpening (the need becomes more clear to the individual). At this point, the individual scans his or her environment for the most appropriate means of finding a resolution for the figure (Burley & Freier, 2004). The resolution from this process is stored into memory of how a need was met if, in fact, it was met. Although this process is generally a smooth one— needs are brought to awareness and resolutions for these needs are found— at times, the process is interrupted and a resolution is not made, creating a problem within the individual. This situation is interpreted as psychopathology in Gestalt theory. Gestalt theory views the depressed individual as one who has unsatisfied needs. All individuals have needs, and their well-being springs from the ability to recognize their needs and satisfy them. Thus, if an individual is unable to satisfy his or her needs or is blocked from that development, it may cause a disruption in the system. Perls, Hefferline, and Goodman (1990) asserted that humans are creative, with a creative

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self. Symptoms are created to divert the individual from having contact with others. Thus, someone who is depressed lacks self-confidence and ability to establish and maintain relationships with others. This explanation is more process driven in terms of understanding what may lead to depression. Depressed individuals believe that there is no use in doing anything because they are helpless and things are hopeless (Burley, 2012). Procedural memory plays a role here in that it automatizes the hopeless response. Needs go unmet, and at some point, the individual stops recognizing his or her needs because there is no point in having that level of awareness. Therefore, when faced with situations that could be distressing or cause discomfort, learned helplessness causes one not to have a reaction (need), allowing things to be just as they are. This state of unawareness may have served a purpose at one time in the person’s life. For example, a child with an unresponsive mother may have learned not to have a need to be held or comforted. As an adult, this individual now does not feel the need of physical comfort from others. Similarly, depression may have once fulfilled a need; however, the depression is limiting and can prevent growth (Burley, 2012). The original pain that created the depression served a need. As such, it was a creative solution to the individual’s problems. However, it gradually became a suppressed or depressive adjustment. It can also be argued that depression is an unfulfilled need and chronic depression is a result of ongoing needs that are ignored. A process-descriptive approach has been suggested for understanding psychological diagnosis (Burley, 2012). The Gestalt formation resolution process defines depression as a needing disorder in which needs are not adequately noticed or acted upon and are developed as an outcome (Burley, 2012). The ethological principles regarding the process of depression include negative interjects, learned helplessness, hopelessness, and procedural memory. The process can explain how depression is formed, knowledge that can be very helpful in treatment because it will help explain how a set of symptoms is developed. Lacking this depth of understanding concerning how symptoms develop is a weakness of most depression measures and an area to be explored in research. Helplessness, hopelessness, and depression in children Although literature addressing the implications of using Gestalt theory with children is limited, Gestalt therapists use many of the same principles of general Gestalt theory when working with children. The salient principles are pertinent in work with children, such as awareness and

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experience, the use of the senses and body, and the sense of self. Experiments with children in sessions are often conducted with play-based interventions (Stadler, 2009). It has been suggested that therapists meet the child at his or her level in terms of how abstract or concrete the child is able to be in session and adjust interventions accordingly (Oaklander, 1997). Although theory has indicated the best approaches for interacting with children, some of these techniques have not been verified as evidence based. Similarly, assessment tools have not evolved beyond assessing DSM symptomatology to incorporate theory. However, given that the goal of this study is to bridge this gap by creating a measure based on theory, many of the techniques used in Gestalt will be used in creating items to capture the process of what depression is like for a child in the process of creating a new measure of assessing depression in children. Contact with the world through the senses (sight, sound, touch, taste, and smell) is a key element in Gestalt therapy for both adults and children. Experience is believed to be more important than awareness with children (Oaklander, 1995). At some point in adulthood, people lose full awareness of their senses by over-thinking and analyzing. “We come to operate in life almost as if our senses, bodies, and emotions don’t exist—as if we are nothing but giant heads, thinking, analyzing, judging, figuring things out, admonishing, remembering, fantasizing, mind-reading, fortune telling, censoring” (Oaklander, 1988, p. 109). Children are generally viewed as being better at being connected to their senses, but in cases of trauma, children can also be cut off from their senses. Therefore, intervention in Gestalt therapy focuses on reconnecting children to their sensory experience by heightening their sensory functions through such activities as playing with clay. To apply this concept of the sensory experience in establishing a measure, focus should be on the child’s experiences rather than on his or her awareness of his or her emotional state. For example, questions regarding specific situations the child has experienced should be asked rather than general questions. According to Kirchner (2000), the goal of Gestalt is to assist the individual in restoring (or discovering) his or her own natural ability to self-regulate as an organism and to have successful and fulfilling contact with others (environmental others), as well as with disowned aspects of one’s self (internal others). In addition to sensory input, affective states can influence cognitive processes, which is explained by a phenomenon referred to as cognitive bias (Gotlib & Joormann, 2010). Information is attended to, interpreted, and recalled in a way that certain emotional valence or meanings are favored during the processing of that information (Richter, 2012). Processing input from one’s environment has been shown to be very

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relevant for depression (Mathews & MacLeod, 2005), and it can continue to maintain the disorder (Beck, Weissman, & Kovacs, 1976). Learned helplessness is used to describe how a living organism learns to behave helplessly, during which time it fails to respond even when opportunities are present for it to help itself by avoiding unpleasant circumstances or by gaining positive rewards. Clinical depression is believed to result from a perceived absence of control over the outcome of a situation (Seligman, 1975). In the classical experiments on learned helplessness, an animal is repeatedly exposed to an adverse stimulus it cannot escape. Eventually, the animal stops trying to avoid the adverse stimuli and behaves as though it is helpless to change the situation. The next step in the experiment is that the animal is presented with an escape option; however, the learned helpless state prevents the animal from displaying any action to prevent further pain. The coping mechanism used by animals in these experiments was to be stoic and put up with the discomfort of the adverse stimuli. Similarly, depression is theoretically understood as a state of helplessness in which the individual does not feel that he or she can have an effect on his or her environment by changing outcomes of events. The Gestalt theory of depression takes this perspective one step further in understanding that, if depressed individuals give up trying to have an effect on their environment, at some point they may become unaware of what the adverse conditions are. Withdrawal, as a symptom of depression, has been described in children as a means of survival: “So the child who is withdrawn has perhaps needed to retreat from a world which is too painful” (Oaklander, 1988, p. 231). At one point, the child learned that withdrawing was something he or she had to do, and although the circumstances may be different, he or she is continuing a learned behavior. Along with helplessness, the idea of hopelessness is also described in literature when discussing depression. There is a strong agreement that hopelessness plays a major role in depression; however, attempts to understand and measure hopelessness have lagged behind, with little research focusing on understanding its use in evaluation of depression (Lewis et al., 2011). Levine (2012) defined hopelessness as an embittered, dark state that can lead to feelings of emptiness and despair. In addition, some writers have conceptualized hopelessness as the absence of hope while others view hopelessness and hope as distinct constructs. Hope is typically conceptualized as an optimistic outlook on the future, whereas hopelessness represents an attachment to goals or aspirations that have been lost (Lewis et al., 2011). However, these definitions have rarely informed measure development.

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Overall, Gestalt theory addresses how to interact with children and provides an understanding that can be used in creating a measure. To remain true to theory, items asked of children should include assessment of the level of awareness and contact a child is making with his or her environment. As described above, depressed children are in a state of not noticing their needs by not making contact with their sensory experiences. Additionally, items should be based on the principle of learned helplessness. It is believed that children who find themselves in distressing situations will feel powerless to have an effect on their circumstances that cause the distress, in a sense giving up rather than seeking to find solutions and change what is distressing. These aspects of Gestalt theory and how it is applied with children were used in compiling items for a new measure for evaluating depression in children.

The development of a new measure The present study began with a thorough review of the literature on childhood depression, current measures used to assess depression in children and Gestalt theory. In addition to a literature review, a bottom-up approach for measure development was used to develop items. The bottom-up approach starts with specific observations related to an area of research (e.g., children’s depression), which is derived from the population of interest (e.g., depressed and non-depressed children). Items for the new measure were compiled from (1) conceptual understanding of Gestalt theory (2) focus group input (3) expert opinion. This study went through three phases of measure development. Phase I (Identification of depression consistent with Gestalt theory) involves the process of gathering items for the measure which was done through the three ways of information gathering including information from Gestalt theory, focus groups and expert opinion. Depression was conceptualized utilizing Gestalt theory through published writing from founders of the theory as well as the use of a model of depression called Gestalt Formation Resolution Process. Described in the literature review above, items were created based on themes of hopelessness, helplessness, negative perspective on the future, and an inability to recognize own needs. Key themes which emerged from the focus group were related to the following: hopelessness, ability to self-regulate, future perspective and planning, inability to differentiate between figure and ground, ability to be present and respond, interpretation of events, loss of contact with self and environment, inability to detect needs, external verses internal events, depression as a creative process, sense of giving up, etc.

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In Phase II (Item refinement), items were compiled together as the Depression Process Scale for Children. A thematic content analysis framework (Walker & Avant, 2005) for data reduction was used where the experts reviewed the compiled items, which conveyed unique aspects of children’s presentation of hopelessness and awareness. The research team discussed the data generated from this phase and a consensus was reached on the different themes elicited. The final form of the Depression Process Scale for Children (DPS-C) was developed from an initial bank of 30 items based on expert agreement on which items best captured the construct. Agreement was made on 23 items, which were true to theory and the final 23 items were included in the final version of the new measure (see Figure 12-1). In Phase III, (Administration of measure and preliminary psychometric validation), the measure underwent preliminary psychometric testing on a sample of depressed and non-depressed children who also completed established measures of children’s emotional functioning. An exploratory factor analysis and correlation analysis were conducted to examine the structure, reliability, predictive validity and measurement equivalence.

Procedure Participants were consented by research assistants and signed a written consent form. All children who participated in the study completed the newly created measure, DPS-C, as well as an already established measure for childhood depression, Children’s Depression Inventory 2 (CDI 2). Parent’s completed a demographic form and the Behavioral Assessment System for Children-2 (BASC-2), to further assess the child’s behavioral and emotional functioning. Participants in the control group (nondepressed sample) were recruited from the community. In order to be in the control group, participants had to be between seven and 17 years old, present with a parent or caretaker willing to complete the caretaker questionnaires and consent, as well as capable of reading and writing in English. Inclusion criteria for the control group also included those children who did not have a psychological diagnosis or have a parent concerned about depression for the child. If a parent/caretaker reported they were concerned that the child was depressed on the demographic questionnaire they were included in the depressed sample. The depressed group was recruited from several locations including inpatient and outpatient treatment facilities where children who are identified with depression were receiving mental health services.

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Results Descriptive Based on the recommendation that the number of participants for factor analysis should be five times the number of variables (Bryant & Yarnold, 1995), a measure with approximately 20 items should have at least 100 participants. The final sample included 168 participants of which 109 were identified in the non-depressed group, 58 in the depressed group, and data was missing for one. Caregivers with an education below college level were more likely to report concerns for a child’s depression (48.6%) then caregivers with an education level of college or beyond (31.6%). Caregivers born in the US were also more likely to identify their child as being depressed (53.5%) than those not born in the US (20.8%). The two groups are not differently distributed on the remaining categorical demographic variables (age, income, gender, caregiver’s relationship to child, marital status, and immigration status of the child). Table 12-1 displays the demographic variables. Statistical analysis for item reliability prior to the Exploratory Factor Analysis (EFA) identified four items which decreased the overall reliability of the new scale and the items were removed. Reliability analysis revealed Cronbach’s Alpha of .830 for the non-depressed group, .914 for the depressed group and .963 for the total sample, which suggests that the measure is considered reliable. Table 12-1: Participant Characteristics for Depressed and non-Depressed Group

Child’s Age Mean (SD) Child’s Gender Female Male Reporter’s Relationship to Child Mother Father Legal Guardian Other Missing Marital Status Married Widowed Divorced Separated

Non-depressed n=110

Depressed n=58

Total n=168

12.99 (3.16)

12.24 (3.24)

12.73 (3.20)

51 (46.4%) 59 (53.6%)

28 (48.3%) 30 (51.7%)

79 (47.0%) 89 (53.0%)

80 (72.7%) 19 (17.3%) 2 (1.8) 6 (5.5%) 3 (2.7%)

48 (82.8%) 10 (17.2%) 0 0 0

128 (76.2%) 29 (17.3%) 2 (1.2%) 6 (3.6%) 3 (1.8%)

90 (81.8%) 0 7 (6.4%) 7 (6.4%)

43 (74.1%) 1 (1.7%) 9 (15.5%) 4 (6.9%)

133 (79.2%) 1 (.6%) 16 (9.5%) 11 (6.5%

A Gestalt Process/Action Based Theory of Depression Never Married Missing Household Income $90,000 Missing *Caregiver’s Education Level No Schooling Completed 8th grade level High School, No Diploma High School Diploma/GED Some College Bachelor’s Degree Master’s Degree Doctorate Degree Missing Racial/Ethnic Background White Asian Hispanic/Latino Arab American Indian/Alaskan Native Native Hawaiian/Pacific Islander Other

191

4 (3.6%) 2 (1.8%)

1 (1.7%) -

5 (3.0%) 2 (1.2%)

18 (16.4%) 24 (21.8%) 18 (16.4%) 20 (18.2%) 30 (27.3%)

7 (12.1%) 26 (44.8%) 8 (13.8%) 14 (24.1%) 3 (5.2%)

25 (14.9%) 50 (29.8%) 26 (15.5%) 34 (20.2%) 33 (19.6%)

0 0 8 (7.3%) 10 (9.1%) 28 (25.5%) 52 (47.3%) 10 (9.1%) 1 (.9%) 1 (.9%)

1 (1.7%) 0 6 (10.3%) 10 (17.2%) 19 (32.8%) 15 (25.9%) 6 (10.3%) 1 (1.7%) 0

1 (.6%) 14 (8.3%) 20 (11.9%) 47 (28.0%) 67 (39.9%) 16 (9.5%) 2 (1.2%) 2 (1.2%) 1 (.6%)

39 (35.5%) 29 (26.4%) 20 (18.2%) 6 (5.5%) 3 (2.7%) 8 (7.3%) 5 (4.5%)

23 (39.7%) 11 (19.0%) 18 (31.0%) 0 2 (3.4%) 4 (6.9%) 0

62 (36.9%) 40 (23.8%) 38 (22.6%) 6 (3.6%) 5 (3.0%) 12 (7.1%) 5 (3.0%)

**Country Caregiver Born In US Other

34 (30.9%) 76 (69.1%)

38 (65.5%) 20 (34.5%)

72 (42.9%) 96 (57.1%)

Country Child Was Born In US Other

86 (78.2%) 24 (21.8%)

51 (87.9%) 7 (12.1%)

137 (81.5%) 31 (18.5%)

Reside LA County Other

103 (93.6%) 7 (6.4%)

54 (93.1%) 4 (6.9%)

157 (93.5%) 11 (6.5%)

*p