Book Summary:

Research Findings on Gestalt Therapy
Uwe Strümpfel

Cologne: Edition Humnistische Psychologie

Data from 74 published research studies on therapeutic process and outcome are presented, which were re-analyzed in 10 meta-analyses by other authors and also in new calculations by the author. Thirty-eight of the studies presented in the content section reviewed published clinical studies and a further 24 unpublished clinical studies or other studies and investigations on other experiential approaches the efficacy of Gestalt therapy and its further developments in different clinical groups. The selected studies were conducted in sample sizes of up to several hundred patients.

Overall, the tests of efficacy were carried out on data from approx. 4,500 patients treated in clinical practice. Approx. 3,000 of these patients were treated in Gestalt therapy treatment conditions and the remainder were treated with other approaches or were untreated controls. Table 1 also shows 431 sources, including single case reports and analyses of single cases on various subjects. Roughly two thirds of the 38 outcome studies collected data on a control or comparison group. In line with clinical reality, some studies included subjects with more than one diagnosis. Three quarters of the studies included in the present review investigated „classical“ Gestalt therapy in at least one treatment condition. The remaining studies reflect modern psychotherapeutic practice in which Gestalt therapy is combined with other approaches, e.g. as in Process-Experiential Therapy.

1. Outcome Research

The studies confirm the effects of Gestalt therapy in a wide range of clinical disorders such as schizophrenia, other psychiatric and personality disorders1, affective disorders and anxiety, substance dependencies and psychosomatic disorders and for work with special groups and in psychosocial preventive health settings. The variety of different diagnoses confirms the suitability of Gestalt therapy for even difficult symptomatologies as are found in psychiatric patients and also in anxiety disorders, which are traditionally supposed to be more the domain of behavior therapy. In what follows I select and summarize some of the most important findings on individual groups of disorders.
  • Psychiatric patients with different diagnoses such as schizophrenia and severe personality disorders showed significant improvements in their main symptoms diagnosed individually, in personality dysfunctions, self-concept and interpersonal relationships after treatment with Gestalt therapy. The patients themselves evaluated the therapy as very helpful. Assessments by nursing staff indicated improvements in the patients’ contact and communications functioning.
  • The studies that obtained the largest effect sizes were those on Gestalt therapy for affective disorders. The studies provide evidence for the effect of Gestalt therapy on symptoms of depression, anxiety and phobias. The effect sizes for process-experiential therapy (P/E) enriched with Gestalt therapy interventions are 25% to 73% higher than those for relational client-centered therapy, depending on the measures employed.
  • Gestalt and social therapy for subjects with drug dependency showed a long-term abstinence rate of 70%, which remained stable for up to nine years after discharge. The results also document a reduction in depressive symptoms and an improvement in personality development at the end of treatment.
  • In the studies on functional disorders an average of approx. 55% of patients reported a reduction in pain after Gestalt therapy. The studies also demonstrated a marked reduction in the use of medication.
  • Further studies provide evidence of the effect of Gestalt therapy in school children with achievement difficulties, parents who see their children as having problems, couples with disturbed communication and – in psychosocial preventive health – old people with the problem of social isolation and pregnant women undergoing preparation for delivery.
  • Of 17 studies that obtained follow-up data and are reported on in the section on evaluation research, only one (with a very short treatment period of only a few hours in a group) failed to provide evidence of stable effects. The other follow-up data, which in most cases were collected ½ to 3 years after the end of therapy, the effects of the therapy proved to remain stable.
  • Further large follow-up studies with several hundred patients have been conducted on Gestalt therapy and experiential therapy in the last few years. In a study conducted by Schigl 63% of the patients asked reported that they had attained their initial goals either completely or to a great extent in Gestalt therapy. After the end of Gestalt therapy the use of psychotropic drugs was reduced by half and that of tranquillizers even by 75%. In Gestalt therapy the patients learned strategies to cope successfully with recurrent symptoms.
The results obtained by an independent research group from findings of an evaluation conducted by clinics of the Wicker group are of particular interest (Barghaan et al. 2002, Harfst et al. 2003). Based on follow-up data on 117 cases in a comparison between patients treated with a combination of psychodynamic and Gestalt therapy, psychodynamic therapy and/or behavior therapy, the authors arrived the following assessment of the Gestalt therapy:
  • The effect sizes for most of the improvements attained on in the different psychosocial and physical measures were large. Compared to other clinics of the Wicker group the effect sizes were in fact above average, however, this may be related to the fact that the patients in the Department of Psychotherapy and Psychosomatics have a longer average duration of treatment. 2
Thus these catamnestic studies conducted by independent authors, some of which were carried out in several hundred patients, provide evidence of the long-term stability of the positive results of Gestalt therapy.

1) In contrast to earlier opinions, Gestalt therapy has proved to be suitable for work with patients with highly impaired patients. This requires a modification of therapeutic style in which the work is less polarizing and emotionally activating, but instead focuses on personality and stabilizing and building up structure (cf. Hartmann-Kottek, 2004)

2) The treatment duration in this department was an average of 1 week longer than at the other departments investigated, which the authors attribute to the fact that the treatments are funded by different sources.
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2. Results of meta-analyses

Elliott et al. (2004) compared the results of 112 studies on different humanistic procedures in a meta-analysis. Elliott’s meta-analysis on 112 studies includes 42 controlled studies with waiting lists or untreated controls and 55 comparison studies (including 74 comparisons with non-humanistic therapies) on various humanistic therapies.
  • If we compare the different humanistic approaches, it becomes clear that the process-experiential approaches, including Gestalt therapy, tend to show the largest effect sizes. Overall, at the present state of research it would appear that these therapy approaches that actively employ process- and emotion-focusing interventions, could in future prove to be the most effective humanistic therapies.
Comparison of effect sizes obtained for cognitive-behavior therapy and Gestalt therapy

On the basis of available therapy comparison studies the author carried out meta-analytic comparisons between process-experiential/Gestalt therapy and cognitive-behavior therapy.

  • In no study did the statistics show significant differences between process-experiential/Gestalt therapy and behavior therapy, except for one study in which process-experiential/Gestalt therapy led to a greater improvement in mastery of interpersonal problems than cognitive-behavior therapy.
For the meta-analytic comparisons the data from the studies were grouped according to three domains of change investigated: (a) symptoms, (b) personality/coping/somatic symptoms and (c) social/relational/interpersonal functions.
  • These domains of change also showed almost no differences between Gestalt and cognitive-behavior therapy. The lack of differences is worthy of remark since behavior therapy has traditionally been oriented towards achieving changes in the symptom domain, while Gestalt therapy sees itself as a holistic approach to therapy.
  • However, in the social/relational/interpersonal domain experiential/Gestalt therapy was found to be associated with a trend towards greater long-term sustainability at long-term follow-up.
Likewise, the process data showed differences in that psychiatric patients receiving cognitive-behavior therapy sought social contacts more frequently, while they were better able to maintain these contacts during treatment with a combination of Gestalt therapy and transactional analysis. In other studies the differences in process data between Gestalt therapy and cognitive-behavior therapy failed to reach significance or were difficult to interpret.

Further exploratory analyses conducted by the author revealed indications that the particular effectiveness of Gestalt therapy lies in the domain of social/relational/interpersonal functions.
  • Other clinical studies supported the findings of the exploratory analyses that Gestalt therapy leads to particularly marked improvements in the ability to establish personal contact and to sustain relationships and also in managing aggression and conflicts.
  • Gestalt therapy could also continue to play a special role among currently available therapies in the domain of social/interpersonal/relational functions if findings that it has a specific effectiveness, for example, with respect to successful work on dogmatically rigid principles, disturbances in appraisals of self, others and relationships and internal pressure to achieve, are substantiated.
This means that Gestalt therapy may be of special significance when it comes to the treatment of low self-esteem, strictness in evaluations of others and relationships with others, inner pressure to achieve and rigid principles.

The importance of the kind of experiential interventions developed in Gestalt therapy since the nineteen fifties for the future development of therapy in general cannot yet be estimated. However, psychotherapy comparison studies have provided evidence that the effects of Gestalt therapy are comparable to those of other forms of therapy - or even better.

Comparisons of effects sizes of humanistic and other forms of therapy

Many academic psychotherapy researchers and especially cognitive-behavioral therapists were long of the opinion that humanistic therapies are less effective than cognitive-behavioral therapy. In a series of meta-analyses, Elliott re-analyzed studies comparing humanistic and behavior therapies on the basis of the school of therapy to which the researchers belonged (most recent meta-analysis: Elliott et al. 2004). The factor of the allegiance of a research group proved to be so decisive that there were no further differences between the schools of therapy when it was partialed out of the calculations. This is consistent with the findings of Luborsky et al. (1999, 2002, 2003), who compared behavior therapy, psychodynamic therapy and pharmacotherapies.

The comparisons conducted by Elliot (2001) and Elliott et al. (2004) showed that:
  • humanistic and cognitive-behavior therapy did not differ in effectiveness
  • humanistic therapies are not inferior to other schools of therapy
  • humanistic therapies are more effective than an unspecific group of non-humanistic and non-behavioral therapies.
According to the present state of the art the group of humanistic therapies is thus overall no less effective than the cognitive-behavioral methods.

The following bias factors and previously unknown associations were identified in the author’s re-analyses of older meta-analyses which came to the false conclusion that behavior therapies were the most effective.
  • A total of 37% of the differences between humanistic and behavior therapies tested in comparison studies are attributable to the allegiance of a group of researchers to one of the schools of therapy under investigation (Elliott et al. 2004).
  • Roughly half (at least 48%) of the nominal differences in effect size between the therapies in the older meta-analyses can be attributed to the measures preferred by the respective schools of therapy. The proportion of symptom scales employed proved to be the strongest predictor, because symptom scales are the most likely of all data collection instruments to produce significant results.
  • In the overall pool of studies conducted prior to 1984, symptom scales were used approx. 40% more frequently in studies on behavioral therapies than in studies on humanistic and psychodynamic therapies.
According to the present estimations presented in this book, the larger effects sizes found by the older meta-analyses (Smith et al. 1977, 1980, Shapiro & Shapiro 1982, Nicholson & Berman 1983) for the behavioral therapies as compared to dynamic and humanistic therapies are solely attributable to the differences in the measures employed. This is already more specific than the findings reported by Smith et al. (1977), which showed that the nominal superiority of the behavioral modalities was cancelled out if the conditions under which the different pools of studies were tested were included in the analysis.

Grawe et al. (1994) did not evaluate most of the study data included in their meta-analysis by calculating effect sizes. Instead, they used the effect sizes calculated by the older meta-analyses to substantiate their arguments. Here this has been criticized as a lack of stringency in their line of argument. In fact, if the effects of therapy are estimated using the frequencies of significant results reported in the result protocols of the respective therapy modalities, this even gives a contradictory picture of the older and less comprehensive meta-analyses. On the basis of the frequencies of significant results relative to the number of measurements carried out, in the pre-post comparisons the interpersonal therapies (particularly systemic family therapy) and humanistic therapies rank first and second on the scale of effect sizes calculated on the basis of the significant results. In the comparisons with a control group the eclectic and humanistic therapies rank first and second, although at the eclectic therapies had not conducted enough research to be able to present sufficient data, and the pre-post comparisons for the behavioral and psychodynamic therapies ranked lower than these two forms of therapy.
  • In sum, relative to the number of measurements undertaken, significant results were found more frequently for the humanistic therapies than for the behavioral and – even more clearly – the psychodynamic approaches. The summarized data of the result protocols thus contradict the authors’ conclusions, in which they claim that the behavioral therapies are superior. No effect sizes were ever calculated for most of the studies included in the meta-analysis by Grawe et al. (1994).
  • According to the meta-analysis by Grawe et al. (1994) the behavioral therapies have by far the greatest number of empirical studies. However, they are followed by the humanistic therapies, for which at the time that the literature review was concluded more than twice as many studies had been carried out as for the psychodynamic modalities. The data used to compare the state of research between the different schools of therapy needs to be up-dated.
  • To date there are no direct comparisons of psychodynamic and experiential therapies or, specifically, psychoanalysis, Gestalt therapy and the further developed process-experiential therapies, which included interventions used in Gestalt therapy.
  • In comparisons with psychodynamic modalities, future research should specifically investigate the process characteristics at different levels of process, contrasting them with those of the experiential therapies.
A comparison between the effects of experiential therapies and high-frequency psychoanalytic treatment on structural and personality disorders or a comparison of the effectiveness of experiential and psychodynamic (in Germany termed „tiefenpsychologische“ or „depth-psychological) therapies in helping to solve conflicts and reduce symptoms would be particularly interesting.

Confrontation through experiencing

Orlinsky, Grawe und Parks (1994) link characteristics of therapeutic processes with therapeutic outcomes. One of their important findings is that a therapeutic approach that promotes „processual experiencing in the here-and-now“ is positively associated with a good therapeutic outcome. The authors term this approach of directing attention to the patient’s experience and behavior that are directly activated in the session process „experiential confrontation“.
  • According to the meta-analysis by Orlinsky, Grawe and Parks (1994) experiential confrontation is a strong predictor for positive therapeutic outcome. Gestalt therapy is based mainly on this mode of intervention.
In light of the results of Orlinsky, Grawe & Parks’ (1994) meta-analysis the therapeutic method of guiding clients towards their immediate self-experiencing in the process and promoting emotional activation, which was developed in Gestalt therapy, has proved to be an effective mode of therapeutic work. The active Gestalt therapy interventions have proven to be suitable for intensifying qualities of experience within the therapy session and today can be associated with improved conflict resolution by our patients and a reduction in symptoms and problems. In light of these findings and the data on the breadth of its application and efficacy, a number of previous appraisals of Gestalt therapy, e.g. regarding restricted applicability, can be revised.
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3. Process Research

Relevant process characteristics of experiential Gestalt therapy interventions have been analyzed on different process levels (the micro and macro levels).
  • Dreams, metaphors, body images. Various authors show that work with dreams, metaphors and body images help clients to achieve greater awareness of implicit feelings and convictions in the therapeutic relationship and to access forgotten childhood memories, fantasies and feelings. The process studies provide evidence that metaphors and dreams are a good basis for in depth therapeutic exploration and working through.
  • Good moments. Several research groups have addressed the issue of how deepening of emotion, important therapeutic moments and existential moments arise in a therapy session which may be so central for the patient that they constitute a turning-point in the therapeutic relationship, e.g. in the sense of an increase in trust, which is often associated with important insights and experiences.
A number of variations on therapeutic micro-strategies have been identified which lead to changes in terms of an intensification of emotional tension in the client during therapy.
  • Changes in focus between foreground and background. Changes in focus from foreground to background, which are typical for the Gestalt therapy style, e.g. from the content of a narrative to the patient’s current perception of self and other or his mode of expression frequently precede the deepening of emotion in a session and important therapeutic moments.
  • Expression of emotion. When therapists directly address the emotional level this often provides the client with a bridge that helps him to access his feelings which have hitherto been only faintly perceptible and to give them expression. When feelings emerge in therapy, surprising and direct insights can arise. This occurs when a client accepts his emotion and starts to take responsibility for it, instead of denying, suppressing or projecting it. Evidence has also been provided of the therapeutic importance of anger in working through traumatic experiences, particularly when the aggressive feelings are mixed with inner pain and grief. Several studies have demonstrated that the expression of aggression, while cathartic, is less curative than originally thought.
  • Spontaneity and authenticity. It is frequently the surprising, highly authentic interventions that lead to deepening of emotion in a session. Analyses show that it is not only the therapist who surprises the patient with unexpected interventions, but rather the client, too, who can surprise the therapist, e.g. with direct honesty, which leads to a deepening of the subsequent therapeutic process.
In addition, relationships were found between dialogical polarization of conflicts, activation of emotions, gaining access to underlying (primary) feelings and needs, dissolution of conflict and therapeutic outcome in the form of (long-term) reductions in symptoms. In a series of investigations conducted by Leslie Greenberg at York University, Toronto, it was consistently demonstrated that the interventions of Gestalt therapy evoke deeper levels of experiencing and emotional activation than (a) empathic reflection, (b) focusing and (c) cognitive problem-solving.

It was demonstrated that the successful solution of a (neurotic) conflict can be predicted from session process on the basis of four specific process variables.
  • Build-up of oppositional tension: the conflict is fully developed, the opposing sides build up, in each case associated with the activation of emotion.
  • Emotional activation of the conflicting parts of the self. Clear and unambiguous expression of feeling on both sides of the conflict in the course of the session has proved to be a relevant factor for the dissolution of the conflict at a later stage.
  • Reciprocal representation of the other part of the self. In the next stage it is helpful for conflict dissolution within the session if the oppositional tension is dissolved, followed by reciprocal representation and mutual understanding of the opposing sides of the self.
  • Access to the underlying (primary) feelings and needs. In the confrontation contact finally occurs, which leads to the dissolution of what is conflictual, the patient gaining access to his or her buried „primary“ feelings and needs in the course of the session.
In neurotic conflict disorders, the typical Gestalt intervention is to go into the conflict instead of avoiding it. The emotional and cognitive development in the session of the parts of the self that are in conflict helps patients to gain access to their primary feelings and needs and thus to their processes of mental healing.

4. Implications: New models on the importance of emotions in psychotherapy

In general, the psychotherapeutic approaches of the different schools are increasingly recognizing the importance of the emotions. A model developed by Greenberg, Rice & Elliott (1993, 2003) is of particular importance In analogy to Piaget’s concept of the schema, „emotion schemes“ always also contain situational and action aspects that go as far as concrete plans for behavior.
  • Emotion schemes are understood as structures that develop in the course of personal development, contain emotional, cognitive and behavioral elements and govern the meaning formation, experience and actions.
Epistemologically, Greenberg, Rice & Elliott’s (1993, 2003) model is based on the conceptualization of a dialectical process.
  • Meanings develop in a bottom-up direction on the basis of immediate sensations and also cognitively and conceptually in a top-down direction, in a dialectical act of construction.
The starting point for the emotion-focused approach of the experiential therapies is current brain research.
  • Innate primary affects and behavioral patterns are the basis for the development of the emotion schemes. Secondary affects develop as a reaction to personal experience.
  • Emotion schemes can be adaptive, i.e. suitable and realistic action plans oriented towards need satisfaction. In contrast, if they are maladaptive, they put a break on action impulses and disrupt and interrupt the construction of meaning and need satisfaction, e.g. by blotting out perceptions.
Thus, there is a link between Greenberg et al.’s model and both Rogers, who emphasized the meaning-building function of the emotions, and Perls and Goodman, who stressed the action-orienting nature of emotion. Gendlin and Perls had both already defined the concept of maladaptiveness in interaction between the organism and its environment against the background of disturbed emotional processes.

The development of research-based, integrative therapies, exemplified by process-experiential therapy

Process-experiential therapy integrates empirically supported knowledge gained from clinical experience in the various humanistic therapies in an independent therapeutic approach.
  • From the Gestalt and client-centered therapies process-experiential therapy takes an orientation towards experience and process, the basic attitude of client-centered therapy and the Gestalt therapy attitude of focusing on the here-and-now, also using this focus to activate experiencing.
  • As in Gestalt therapy, the authors believe that experience and meanings result from a constructive process which integrates sensory, perceptual and emotional information and memories. It is this constructive process which is the target of therapy.
  • Process diagnosis is a central aspect of the therapeutic work.
The therapist’s task is to pay attention to diagnostic criteria of emotional process in the therapeutic process. These are indications of specific difficulties of the client and are termed „cognitive-affective markers“.
  • Six different markers describe the client’s emotional and cognitive problems: (1) problematic reactions to a certain event, (2) impaired self-understanding, (3) conflictual self-appraisals, (4) self-interrupting conflicts, (5) unfinished processes and (6) enhanced vulnerability.
If the criteria for a marker are fulfilled, the therapist helps the client to re-live an experience with all aspects that belong to an emotion scheme.

The focus is on changing emotional processes by changing emotion schemes and the associated meaning constructions, actions and solutions. Accordingly, the therapist’s support is oriented towards helping clients to find and implement their own action plans and solutions after re-living the experience. Thus, the therapy is not only oriented towards experiencing and clarification, but also intervenes on the level of action.
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5. Conclusions

The results published in this book are evidence that Gestalt therapy does not lag behind other forms of therapy in regard to efficacy and breadth of applications and even demonstrates particularly good treatment outcomes in certain areas of change. The analyses of therapeutic processes and effects presented in this book reveal that Gestalt therapy has special significance among the therapeutic modalities in the domains of interpersonal relationships, particularly couple relationships and social relationships with family members, friends and at the workplace. Further data demonstrate this very good effect and indicate Gestalt therapy clients’ ability to establish contact and sustain attachments, to improve their ability to resolve conflicts and solve interpersonal problems are promoted. On the one hand these effects are based on the special importance of the emotion-focused and experiential approach of Gestalt therapy. However, at the same time the data are also evidence of the efficacy of Gestalt therapy in working on strict standards, dogmas and principles and appraisals of the self, others and relationships. In these domains of therapeutic change the modes of working in Gestalt therapy could also contribute to an enrichment for other forms of therapy. It would therefore seem necessary and promising to conduct further research into contact work and dialogical processes in Gestalt therapy and the methods used for therapeutic work with interruptions to contact. Further research could also lead to new insights into the action mechanisms of experiential work with emotions, and in particular how they lead to reductions in mental suffering and symptoms and to changes in interpersonal problems and personality disorders. The findings of this meta-analysis confirm that Gestalt therapy, a holistic approach, is equally able to reduce symptoms as the behavioral therapies, which have hitherto been more symptom-oriented.

Gestalt therapy was developed in the tradition of the humanistic therapies. No differences in efficacy have been demonstrated between the group of humanistic therapies as a whole and cognitive behavior therapy. At the current state of the art, research shows that, among the humanistic therapies, emotion-focused, process and experiential therapies are particularly effective. This applies to a group of therapeutic modalities, including Gestalt therapy and forms of therapy that are based on Gestalt therapy.

In many clinical text books today one still finds the opinion that both humanistic therapies, client-centered therapy in particular, are less effective than the established therapies and that their applications tend to be restricted to personal awareness work. In particular, based on the older meta-analyses, the opinion is still often expressed that the humanistic therapies are less effective than the modern methods of behavior therapy. The results of the meta- and re-analyses presented in this book demonstrate that this false appraisal of the humanistic therapies, including Gestalt therapy, is due to a number of biasing factors. The results of the older meta-analyses, in particular, are biased by the allegiances of the research teams. This became evident in the analyses conducted by Elliott (2001) and Elliott et al. (2004). If the therapeutic modality is included in the analysis, no differences between the humanistic therapies and cognitive-behavioral therapy are detectable. On the basis of the tests carried out by Elliott all sub-groups of the humanistic therapies investigated are equally as effective as cognitive-behavior therapy. Thus Elliott confirms the same result for the comparison between the humanistic therapies and cognitive-behavior therapy that Luborsky et al. (1999, 2002, 2003) found for various comparisons between psychodynamic, pharmacological and behavior therapies.

Future research programs should take into account this author bias described by Elliott and Luborsky, particularly by co-operating together in research teams containing balanced proportions of representatives from different schools of therapy. In addition, studies comparing different forms of therapy should be given preference over the traditional control group designs, with the proviso that the research teams are balanced in terms of allegiance.

Gestalt therapists have strongly neglected the scientific evaluation of their work for too long, pointing to the uniqueness of each therapeutic process. Happily, the empirical investigation has gained substantial momentum in the last few decades. The new studies, in particular, are characterized by increasing scientific quality. While the methodological shortcomings of older studies sometimes concealed the size of the effects, more recent studies have documented the effectiveness of Gestalt therapy in the treatment of various mental disorders, including very severe ones, and its long-term effect,

Research on therapeutic process has produced some interesting results on the mechanism of action of Gestalt therapy and also some productive impulses for practice. One of the emphases of current research, in which a link is being sought between different aspects of therapeutic process and therapeutic outcome, would seem particularly promising.

One task of future research programs, which ideally should document both the process and outcome of therapies, will be to establish which special features and strengths characterize each individual therapy. Further studies comparing the humanistic therapies with psychodynamic modalities would be desirable. There has, in particular, been no research comparing long-term psychoanalytic therapy with other forms of therapy.

Gestalt therapists should participate more in the scientific discussion. Research results also offer an opportunity to improve understanding between the schools of therapy in the interests of improving treatment for our patients. The findings presented in this meta-analysis could represent a first step towards a re-appraisal of the alternatives to the established therapeutic modalities developed within the humanistic therapies.

Whereas the accumulated experience of „classical“ Gestalt therapy existed only in the form of implicit knowledge gained through experience, the images of what happens in therapy that have been obtained in therapeutic process research have now given us new insights. With these we can improve therapeutic modalities in an empirically supported manner and refine them. In particular, the importance of work with feelings, on which Gestalt therapy has focused especially since its inception, have been re-formulated on the basis of psychotherapy research and results from research on infant development, emotion and the brain. One might ask where the experience- and process-oriented humanistic therapies can be located within the landscape of different therapies. The founders of process-experiential therapy, which was developed on the basis of Gestalt and client-centered therapy, see themselves in the field of tension between the psychodynamic and behavioral approaches, between object relations theory and models of behavior modification.

Empirically supported new developments such as process-experiential therapy, in which implicit knowledge gained from experience are brought together, are in fact an extract of the accumulated experience that Gestalt therapists have gathered over the last 60 years on active work with the disturbed emotional processes that occur in many different kinds of mental disorders. In this book I have tried to present this implicit knowledge in a systematic fashion and to render it accessible, thereby not restricting myself to presenting the results of controlled clinical studies in the narrower sense. In line with this objective this volume also contains a systematic documentation of case reports which I consider to be empirical work developed at the therapeutic base. Of course, the only way in which this work of a large number of authors could be acknowledged here has been by citing it. However, the reader will find the sources on many subjects relevant to therapeutic practice systematized on the basis of keywords. I also hope to have made a contribution to future research, but also, and above all, to the exchange of knowledge accumulated by experience.

A further domain of therapeutic experience, therapeutic work with dreams, which prominent Gestalt therapists such as Miriam and Erving Polster consider to be of exceptional importance in Gestalt therapy, is only just beginning to be researched in any detail. Freud described work with dreams as the „royal road“ of psychotherapy and behavior therapists have now also begun to become interested in the encoded messages contained in dreams, metaphors, body images and bodily expression. Fritz Perls was of the opinion that the patient can recapture lost parts of the self by actively identifying during a therapy session with dream elements in which these parts of the self are hidden. The patient can directly experience in the identification that these parts, which he symbolizes as foreign, belong to him. The activation of direct, processual experiencing within the therapy session, particularly of parts of the self in the background, is a major component of Gestalt therapy.

Other subjects which could also be interesting for a discourse the transcends the boundaries of the therapeutic schools have also had to be excluded from this review. In the discussion of the theoretical approaches of Gestalt therapy I have limited myself to the fundamental and original developments and a few more recent ones. I have only been able to briefly mention the newer further developments of Gestalt therapy to a dialogical approach. I have also not included attempts to translate field theory into the terms of self-organization theory. However, the various developments of the theory of impulses, affects and emotions provide interesting starting points for a discussion of the different schools of therapy. Important aspects of the classical Gestalt therapy view of emotions have their roots in theoretical developments in the psychoanalytic tradition. But there are also overlaps with models developed within the behavioral/interactional directions. More recent concepts such as that of the emotion scheme, which has grown out Piaget’s psychology, show parallels with newer models developed in the behavioral tradition, including for instance Grawe’s concept of the motivational scheme (Grawe, 1998).

In the historical part of this book I have traced the development of Gestalt therapy initially from stringent influences from the experimental efforts within psychoanalysis, in particular the development of active interventions and work with bodily expression, at the beginning of the last century until a historical break took place. Since the nineteen fifties Gestalt therapists have worked intensively on further developing experiential interventions. The further developments of the theory and practice of Gestalt therapy represent a condensation and synthesis of a wealth of experience which is only today beginning to be made available in a bundled form. The importance that this wealth of experience, which for the most part only exists in the form of implicit knowledge accumulated through experience, will have for the future of psychotherapy cannot yet be estimated. However, the mechanisms of action and efficacy have been demonstrated in the studies reported in this review.
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