gestalt+en+cognitieve+therapie.pdf

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GESTALT THERAPY AND COGNITIVETHERAPYCONTRASTS OR COMPLEMENTARITIES?

JAN TNNESVANGAarhus University, and Institute for

Integrative Gestalt Practice, Aarhus,

Denmark

ULLA SOMMERPrivate Practice, and Hedebocentret,

Herning, Denmark

JAMES HAMMINKPrivate Practice, Nr. Snede, Denmark

MIKAEL SONNEGestalt Training Center, Aarhus, Denmark

The article investigates the relationshipbetween crucial concepts and under-

standings in gestalt therapy and cogni-tive therapy aiming at discussing if andhow they can be mutually enrichingwhen considered as complementaryparts in a more encompassing integra-tive therapeutic approach. It is arguedthat gestalt therapy, defined as a field-theoretical approach to the study ofgestalt formation process, can comple-ment the schema-based understanding

and practice in cognitive therapy. Theclinical benefits from a complementaryview of the two approaches will be awider scope of awareness toward indi-vidual and contextual aspects of thera-peutic change processes, toward differ-ent levels of memory involved in theseprocesses, and toward the relationshipbetween basic needs, sensation andcognition in therapeutic work. Further,

a dialogue between the two approacheswill pave the way for addressing the

connection between fundamental aware-ness work in gestalt therapy and thetendency within cognitive therapytoward incorporating mindfulness asa therapeutic tool. In the conclusion ofthe article, additional complementarypoints between the two approaches areoutlined.

Keywords: integrative therapy, gestalt

formation process, field theory, mem-ory, mindfulness

Gestalt therapy and cognitive therapy are bothanchored in phenomenology and are undogmaticin their attitude toward integration of elementsfrom other therapeutic and scientific approaches,as long as such elements do not violate the phe-nomenological principles (Resnick, 1995; Rosen-berg & Mrch, 2005). In spite of this common-

ality, the approaches are different from each otherin several respects concerning their view on hu-man nature, mental health, and methodology.While cognitive therapy has become increasinglyrespected and popular in academia, among pro-fessionals, health institutions and insurance com-panies, gestalt therapy is lacking recognition inthese areas. One of the reasons for this might bethe better adaptability of cognitive therapy totraining models for applied therapeutic ap-proaches compared to experiential models. An-

other reason might be that gestalt therapy hasbeen more of an oral tradition with a compara-tively sparse production of written material and

Jan Tnnesvang, Department of Psychology, Aarhus Uni-

versity, and Institute for Integrative Gestalt Practice, Aarhus,

Denmark; Ulla Sommer, Private practice and Hedebocentret,

Herning, Denmark; James Hammink, Private practice, and

Institute for Integrative Gestalt Practice, Aarhus, Denmark;

and Mikael Sonne, Gestalt Training Center (Gestalt.dk), Aar-

hus, Denmark.

We would like to thank Sophie Madsen for fruitful assis-

tance during the manuscript preparation.

Correspondence regarding this article should be addressed

to Jan Tnnesvang, Department of Psychology, Aarhus Uni-versity, Jens Chr. Skousvej 4, 8000 Aarhus C, Denmark.

E-mail: [email protected]

Psychotherapy Theory, Research, Practice, Training 2010 American Psychological Association2010, Vol. 47, No. 4, 586 602 0033-3204/10/$12.00 DOI: 10.1037/a0021185

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an almost nonproduction of traditional research,while cognitive approaches were born with ametaphor of man as a scientist (Kelly, 1955) andsince their inception have been inhabited by re-searchers and writing practitioners. While cogni-tive therapists can celebrate this state of affairs,we find the situation unfortunate for those clientswho would benefit more from gestalt therapy, andfor the potential contributions from gestalt theoryto the scientific knowledge base in psychotherapyand psychology, which will stay in a state ofpotentiality unless the gestalt approach is broughtinto research-based dialogues with other thera-peutic and theoretical approaches.

The aim of this article is to contribute to suchdialogues by establishing a meeting point be-

tween the theoretical structures of gestalt therapyand the cognitive approaches as a baseline forinvestigating mutual areas of inspiration. The ar-ticle is part of an ongoing development of aso-called integrative gestalt practice, in whichwe investigate the potential of gestalt theory serv-ing as an integrative framework for the under-standing and practice of psychotherapy, supervi-sion, and organizational work (Tnnesvang,Hammink & Sonne, 2007; Sommer & Tnnes-vang, 2008). After a review of central theoreticalfoundations of gestalt therapy and cognitive ther-apy, the article will investigate the potentialcomplementarity between the approaches andpoint to some of the clinical implications of adialogue between them with respect to comple-mentary nodal points. Toward the end of thearticle a schematic overview of complementari-ties and comparisons between the two approachesis presented.

Basic Concepts in Gestalt

Gestalt Formation Process as the Basic Unitof Analysis in Gestalt

Gestalt therapy was defined by Perls, Heffer-line & Goodman as the science and technique offigure/background forming in the organism/environment field (1951/1994, p. 250). It is afield-theoretical approach to understand and in-vestigate how we (as organisms) create meaningthrough processes of forming and dissolving ge-stalts. It holds the view that such gestalt forma-

tion processes are initiated by organismic needsin both a physiological (hunger, thirst, shelter,touch, etc.) and a psychological (interest, curios-

ity, growth, etc.) sense. In that respect, the gestaltapproach parallels the organismic-dialectic posi-tion in Deci & Ryans (2000) self determinationtheory in which needs for relatedness, compe-tence, and autonomy are considered basic to hu-man nature. When a need presents itself (that is:when something is needed), our phenomenolog-ical field polarizes into figure and ground. Energyarises in relationship to the figure, which sharp-ens it and brings it into the foreground of ourawareness. In this way, the need, in relationshipwith the context, becomes a determinant factorin the awareness process and the following cog-nitive, emotional, and behavioral attempts to sat-isfy the need. If successful, the need is satisfiedand the gestalt dissolves.

According to Burley (2004), the central part-processes in the gestalt formation process are:

fig ur e fo rm at io n, figure sharpening, self-environment scan, resolution, assimilation, andthe undifferentiated field. These part-processeswill usually follow each other in the presentedorder. If, for example, a therapist is concentratedon working with a client while peripherally reg-istering an unfamiliar sound in the room, wewould say that the sound exists as an unclearfigure in the gestalt formation process (figure

formation). If the sound persists, it becomessharpened as a figure as more awareness is fo-cused on it (figure sharpening). The therapistbecomes distracted from the contact with theclient and interested in knowing the source of thesound and if possible stopping it. The therapistmentions the distraction to the client, looksaround the room (self-environment scan), anddiscovers that the new thermos is hissing. At themoment of this discovery the figure shifts toresolution (intending, planning, execution, veri-

fication) of the situation as the therapist adjusts

the top of the thermos and the sound stops. As-similation in the form of registering the changesin the self-environment field as the result of theresolution of the gestalt formation process willtake place, and for a brief moment the field willbe undifferentiated (equilibrium) before a new

figure forms and sharpens again, when the ther-apist returns with full attention to the client.

Figure formation processes including the stepsabove can vary in length of time stretching fromless than a second till days and even years. Under

certain circumstances there can be attempts atfigure formation that cannot be successfully com-pleted. This might be the case with each of the

Gestalt Therapy and Cognitive Therapy

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part-processes. The usual progression in the ge-stalt formation process can be blocked or turnedoff at any point in the sequence. The blockagescan either be in the service of the organism (use-ful prioritizing) or they can result in unhealthyunfinished business in the organisms self-regulation. When, for instance, a client inhibits anappropriate expression of criticism in the thera-peutic setting this might result in unhealthy un-finished business. When avoiding being criticaltoward a potential violent person on the street thesame sort of blockages might be functioning asuseful prioritizing.

Field-Theoretical Foundation

As a field-theoretical approach, gestalt therapyis inspired by Smuts holism (Perls, 1947/1969,p. 28) and Lewins field theory (Parlett, 1991). Asclarified by Staemmler (2006) there have beendiscussions as to whether or not the field shouldbe considered only in terms of the psychological

field or in terms of the field as a whole including(but not limited to) the psychological aspects.While Yontef and Jacobs (2008) propose that weonly consider the psychological field as being agenuine part of the gestalt approach, we find sucha proposal as unnecessarily limiting for an inte-grative gestalt approach. To avoid reductionismand unnecessary dichotomization between psy-chology and other scientific disciplines (for in-stance, neurobiology and sociology) we wouldargue that the gestalt conception of the fieldshould be in accordance with the Lewinian con-ceptualization of the field as a whole includingboth its psychological and nonpsychological as-pects (Lewin, 1951, pp. 172174).

Working with the whole field as the basicstance doesnt mean that the therapist must in-

clude the entire complex, and, in principle, infi-nite field when working with a client. In psycho-therapy as well as in research it is a methodicalnecessity to delimit the field focus under investi-gation (Lewin; in Perls, Hefferline, & Goodman,1951/1994, p. 277). And the way in which suchmethodical limitations of the field are realized iscontinuously up to the therapists professionalskills, aesthetic judgment and capacity to beaware of the fact that this is what is happening atthe moment.

To work with a field conception means that anunderstanding of the client must include relevantaspects of the field in which he or she is embed-

ded. It must be recognized that the field is influ-enced and experienced differently in relation tothe clients position therein (Yontef & Jacobs,2008, p. 12). And it must be recognized that theseconditions are the same for the therapist, who,therefore, cannot have a complete understandingof what is going on in an interventive process orin the life-space of the client. But the therapistcan continuously gain more understandingthrough the use of contact.

The Concept of Contact

Given that we always find ourselves within acomplex field, which we influence and are influ-enced by, contact processes become the key to

understanding how such influences take place.The gestalt concept of contact can be defined asthe exchange of information between I-ness andotherness.1 Defined this way, contact is not onlysomething that is going on between one personand another, or between a person and somethingelse in the field (a table, for instance). Contactrefers also to the exchange of information withinthe organism that makes it possible for the I toexperience a sensation in its own foot or to createan experiential relation to an emotion. At the

definitional level, the gestalt conception of con-tact does not differentiate between contact inphysical, social and psychological spheres. Thebenefit from such a definition is that it makes itpossible to work with contact in the therapeuticrelation (the social sphere) without dichotomiz-ing the exchange of information in that relationfrom the exchange of information in the clientspsychological sphere. For example, if the clientprovides the therapist with information about theweather and the therapist nods his head, there iscontact in the sense of exchange of information.This might be considered a superficial contact withno further therapeutic implications or it might be

1 Correspondingly, it is the exchange of information with

otherness that creates the possibilities for development and

creation of meaning for the individual organism. Because the

I-ness of the organism in this way is linked to otherness in the

field, it is a logical outcome of gestalt theory that the gestalt

therapist works with dialogue, contact and contact disruptions

in the therapeutic process. Gestalt theory and gestalt practice

are based on the same premises and consistently aligned to

each other, aiming at investigating gestalt formation processesas they take place in contact-relatings in the organism-

environment field.

Tnnesvang, Sommer, Hammink, and Sonne

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considered a first step in establishing a sense of trustbetween client and therapist. As in all forms ofcontact the therapist is being aware of the contactpatterns of the client. If the more superficial level ofcontact regarding the weather reflects the clientstendency to avoid contact with conflictual themes,and the therapist brings awareness to this avoid-ance, the client might experience a deepening ofcontact with the therapist (a feeling of being seen).This deepening can pave the way for the clientscontact with the origins of the avoidance pattern andits gestalt formational character (figure formation,

figure sharpening, self-environment scan, resolu-tion, assimilation). A short example will illustratethe point:

Therapist: I notice that as I am speaking there are tears in

your eyes. (By focusing awareness, the therapist invites theclient to recognize sensation. e.g., figure formation)

Client: I cant stand it. (It seems like the client gets morecontact with the feeling. e.g., figure sharpening)

T: Try looking at me and saying, I cant stand it! ( Thetherapist invites to self-environment scan and to expanding/

deepening contact with therapist.)

The client looks at the therapist; crying becomes louder anddeeper.

C (through the tears): When you said that you had to cancelour next appointment because you have to go to a funeral, I

felt as if you stabbed me in the heart. I know its crazy butthats how it felt. I was just about to run out I can see thatis what I usually do. (The clients awareness of old patternsof gestalt formation processes becomes a new figure.)

T: Even with people you love and trust? (The therapistinvites to sharpening the new figure.)

C: Yes. (The client seems to experience contact with thenew figure.)

T: What are you doing now that is different? (The therapistinvites to sharpening the figure of the new gestalt formation

process.)

C: Im still here. (The client affirms the figure sharpening.)

T: Can you look at me and say that? (The therapist invitesto stay with the new figure in contact with the therapist.)

C: The client looks at the therapist and says, I am here.(Resolution)

T: How does this feel? (The client is invited to self-contact.)

C: Scary but right. (Assimilation)

Health and Pathology in Gestalt Theory

During smooth organismic self-regulation the

gestalt formation process is brought to an end bythe fulfillment of the need(s) that underlie itsinitiation. This of course does not always happen

as easily and unproblematic as in the aforemen-tioned thermos example, or as smooth as in thedialogue above, and, in some situations, it doesnot happen at all. Thus, in some cases the out-come will be unfinished business that continu-ously will absorb energy with the unfulfilled needfunctioning as a tense readiness to seek fulfill-ment in different suitable and unsuitable situa-tions. In other cases, it may be a matter of endingan unfulfilled gestalt by recognizing that the needcannot be met (in its present form, at this point, inthis context, or never). In such cases, ending thegestalt formation-in-process will lead to an ac-ceptance of the fact that the need cannot be ful-filled. This might be linked to different degrees ofself-soothing or grieving processes extending

from the recognition of a lost childhood (whereone, e.g., has to say forever goodbye to the hopethat ones mother would be present as a securebase) to the less comprehensive grieving projectin everyday life situations; for instance, when onehas been looking forward to spending some timewith a good friend who cancels because of ill-ness. The nature and scope of such self-soothingand grieving processes are, of course, relative.For those with an unstable personality structure,it is characteristic that - what by others would beconsidered a small blow and disappointment ofeveryday life - can be experienced as a shaking offoundations (in the terms of Tillich, 1948).

Just as a gestalt formation process can be dis-solved in different ways, the appearance of needscan have different degrees of legitimacy (Bur-ley, 2004). Some needs might be the result of afaulty perception of a bodily state or a faultyinterpretation of, for instance, body sensations inthe stomach region as hunger when in fact theyare an expression of thirst or possibly nervous-ness. As a consequence, the continued figure for-

mation process will rest on a false premise andresult in an impaired organismic self-regulation.It will not lead to the health and well-being thatusually results from the flow of healthy organis-mic self-regulation.

In a gestalt framework mental unbalances anddisturbances are seen as expressions of organis-mic self-regulatory processes that have been mis-trained or misformed such as the example in theprevious paragraph. As a result, the processesthrough which figures are formed and dissolved

are either diffused or blocked or rigid, creatingunsuitable and poor functional fits between theindividuals administration of needs and the de-


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mands of the surroundings. When organismicself-regulation takes place without too manyprocess lumps, the result will be that the mostvital and central need in the situation becomesfigure (cf. the description of the first stages in theprocess of gestalt formation). This requires theindividual organism to know and acknowledgewhat it senses, feels, thinks, and does here andnow. It further requires that it adapts the fulfill-ment of these needs to the concrete context (in-terpersonal, material, and cultural) wherein it issituated. In order for such creative adjustmentsto happen, the individuals ego-boundaries mustbe properly permeable. They must, on the onehand, make it possible to be in contact with andsay yes to that which facilitates creative adjust-

ment and, on the other hand, make it possible toreject that which is psychologically or physicallyinvading and disabling (Perls et al., 1951/1994, p.230; Yontef & Jacobs, 2008, p. 20).

Ego-boundaries can be off-balance in manyways, and to a greater or lesser extent. For someclients with a personality disorder, we will findexcessive permeability amounting almost to dis-solution when a potentially nourishing contactwith another activates fear of merging into and/orbeing destroyed by the other. At the same time,

an intense anxiety of being left to ones ownimmature (mistrained or misformed) self-regulation and self-support can be activated whenthese persons get nearer a potential ego-boundaryand recognize their separation. Recognizing thelife-situations at the contact boundary for suchpersons gives us a clue about the painful existen-tial extremities that basic contact disorders areabout.

Gestalt Diagnosis

Traditionally, gestalt theoreticians and thera-pists have had a strained attitude toward diagno-sis. Many have completely disassociated them-selves from the use of it. However, with the boostof evidence-based therapy during the last de-cades, gestalt therapists have come to recognizethat the nonchalant strategy of rejecting diagnosisis a residual from the past. It is therefore suitablethat Burley (2005) developed the contours of adiagnostic strategy, which on the one hand is

anchored in basic gestalt principles and on theother hand seems to promise a match of thesymptom descriptions in ICD-10 and the DSM

system with the gestalt formation processes be-neath the symptoms.

The central assumption in gestalt process diag-nosis is that the type of disturbed self-regulationis a manifestation of specific dysfunctions in thegestalt formation process (Burley, 2004, 2005).Where there is a problem in the gestalt formationprocess, and whatthat problem is in each of thesesteps (figure formation, figure sharpening, self-environment scan, resolution, assimilation re-spectively) will determine the differences be-tween specific psychopathologies at a processlevel. Thus, psychopathologies in which figureformation is inhibited from the start are differentfrom psychopathologies in which figures areformed, but not held clear long enough to secure

the realization of the need of which it is anexpression. And psychopathologies in which anovertly strong figure is formed are different frompathologies in which figure formation holds asplit between two phenomenological worlds thatare mutually exclusive. The situation concerningsplitting is, for instance, characteristic of border-line disorders where ground as well as figure issplit in two mutually excluding phenomenologi-cal modes that coexist through the whole gestaltformation process. When one of these phenome-

nological modes is activated (and dominates) theclients figure formation process has a positivevalence and s/he might idealize the therapist,while when the other mode dominates, the figureformation process has a negative valence and s/hemight devaluate the therapist. Due to the splitbetween the two modes the client will not recog-nize the inconsistency in the two processes lead-ing to the oscillating attitudes. The situation inwhich we find inhibited figure formation, is char-acteristic of depression where no figure of inter-

est is formedfollowed or determined by feel-ings of helplessness or hopelessness. When nofigure is formed there will be no need-basedaction (resolution) and satisfaction (assimilation).In obsessivecompulsive disorders there will bea clear figure formation, but at the moment (in thegestalt formation process) when self-environmentscanning takes place, the clear figure is captured(and replaced) by other figures in the environ-ment; the result being that the primary need (theoriginal figure) remains unsatisfied and therefore,

there is no resolution or assimilation of that need.(For further elaboration and examples, see Bur-ley, 2005).


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Uncovering Character Structure

Within a gestalt framework, psychological dis-turbances are considered to be expressions ofdysfunctional gestalt formation processes. As

mentioned, the different types of disturbance arethe result of where in the gestalt formation pro-cess the organism has a tendency to interrupt, aswell as to the typical style or way in which itinterrupts itself. With reference to Burley andFreier (2004) we can say that the implicit ten-dency to perform particular gestalt formationsexpresses the character structure of the individ-ual, which will manifest itself in a uniform wayregardless of the individuals participation in dif-fering contexts. It will appear in therapeutic sit-

uations with a typical phenomeno-logic patternwhich will repeat itself in divergent life situationsmore or less pronounced. Although different lifesituations call for different experiences, behav-iors, and manifestations of identity, the way inwhich the individual forms and dissolves gestaltsas process and process interruptions will typi-cally be the same across contexts. For example byrepeating a pattern of mistrust in otherwise trust-worthy relationships or by seeking the same en-forced mirroring responses in all sorts of differentrelationships. Correspondingly, it is the character

structure, expressed in the patterns of the individ-uals gestalt formation processes that are the ba-sic goal of the transforming therapeutic work(Burley & Freier, 2004; Yontef & Jacobs, 2008).The pivotal point in gestalt therapeutic work is tobring awareness to how gestalt formation pro-cesses typically unfold (as the patterns making upthe character structure) in relation to differentexperiential content and contexts.

Awareness as Means and End in theTherapeutic Work

Awareness refers to the attentiveness that wecan have toward what is going on and when ithappens. It is a sort of knowing as one is doing.More strictly, awareness can be defined as con-tact with difference and movement at a boundary.Framed this way, the meaning of awareness isclose to the meaning of core consciousness asdefined by Damasio (1999), as a sense of beingan organism in which something happens due to

its relation to an object. To be aware (as a pro-cess) is related to that which the awareness isabout (sensations, feelings, thoughts, acts, etc.).

In relation to the transformational work on gestaltformation processes, awareness is the means bywhich the individual comes to know (the prob-lems in) the steps of the process through which

figures are formed and sharpened, followed byself-environment scanning, resolution, and as-similation. At the same time, awareness is an endin the sense that by becoming aware of whathappens and when it happens, smooth organismicself-regulation most likely will occur.

It is, tangentially, in close relation to the estab-lishing of process awareness that we find the ratio-nale behind conceiving gestalt therapy as a how-therapy, in which the therapeutic activity primarilyfocuses on the how instead of the why or the

what (Perls et al., 1951/1994, p. 232). It is thevery process (how, what is happening, happens) thatis the focus of attention. The purpose is to providethe client with the opportunity to capture and expe-rience with awareness the gestalt formation pro-cesses as they are taking place here and now in thecontact between the client and the therapist. Thepoint is that the contact between therapist andclient nurtures the clients capacity to be in con-tact with, to sense, know, and accept the changingfigures that appear from moment to moment

(Yontef & Jacobs, 2008, p. 35). And to the extentthat the client increases his or her awareness ofthese changing figures, the organismic self-regulation will improve, thus loosening the rigid-ity of the character.

Exploration and Techniques in Gestalt Therapy

The prototypical methods and strategies in ge-stalt therapy will explore direct experience incontact-relations through phenomenological ex-

perimentation (Yontef & Jacobs, 2008, p. 36;Naranjo, 2000, p. 50). Phenomenological exper-imentation implies focused attention to the gestaltformation process and can unfold in any creativeexperimental way that the skilled therapist mightchoose (Zinker, 1978). The two-chair dialoguehas been one of the techniques used for that, andsince it has been repeatedly used, it has oftenbeen mistaken for being equivalent to gestalttherapy, which it is not. Gestalt therapy is not aset of techniques but a basic explorative stancetoward working with facilitation of organismicself-regulation through contact-full dialogue, and


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by means of creating awareness of gestalt forma-tion processesas they happen.2

Cognitive Understanding of Pathology

and HealthThe cognitive model explains psychological

disturbances and disorders as dysfunctionalthinking at different levels. The most superficiallevel is the situational level of automatic thinkingand the most fundamental level is the level ofschemas (also termed core beliefs) considered aspersonality structure (Beck, Freeman & Davis,2004, p. 27).3 Schemas are organizing principlesor meaning structures, whichwhen activatedestablish a perceptual and experiential filter in the

individuals relation to the environment. Accord-ing to Young, Klosko & Weishaar (2003, p. 54)schemas originate in the dyadic interaction be-tween caretaker and child and have affinity withBowlbys working models. They develop fromearly (preverbal) childhood through adolescence,and though they become rather stable when theyhave been established, they will continuously beelaborated and adjusted throughout life. The cru-cial difference between psychological distur-bance and health is the rigidity versus flexibilitythat characterizes different schemas as well as therelative ease and strength with which they areactivated. In personality disorders we generallyfind that the most central schemas are prepotent(repress other schemas into the background) andhypervalent (low threshold of activation) (Becket al., 2004, p. 28). Further, there will be rigiditywith a tendency to not let information and expe-riences that diverge from the activated schemamake an impression; consequently, there will beno modification or adjustment of the activatedschema. In accordance with Piaget we can say

that the adjustments will primarily be assimila-tive and not accommodative.

Maintenance of Schemas

Once schemas have been established, the indi-vidual will typically try to confirm and maintainthem, also in the face of disconfirming data in theenvironment. It happens partly through cognitivedistortions, and partly through the behavioral pat-terns that are developed to cope with schemas.

Young et al. (2003) presents three such copingstrategies: (a) compensation; (b) surrender; (c)avoidance. Each of these strategies can manifest

themselves as behavioral patterns or as mental(thought) patterns. Thus, in relation to a schemasuch as distrustwhich is often activated in ther-apy with neglected youngsters, and which inYoungs model belongs to the domain of discon-nection and rejectionthe following strategiesmay be used: (a) an overcompensating copingstyle in which one acts according to a mental andbehavioral logic of using or hurting others beforegetting hurt oneself. Next: (b) a coping style ofsurrender in which one, for example, repeatedlyattaches oneself to friends who abuse and takeadvantage, sexually, economically, or in otherways. And finally: (c) the coping style of avoid-ance by which ones distrust makes one avoidinvolvement and intimacy with others, including

the therapist whom one also tries to keep at adistance in different ways. The paradox in thesestrategies is that all three of them are self-perpetuating because others typically respond tothem in ways that confirm their beliefs that socialcontact with others is compromising.

2 Correspondingly, the gestalt experiment serves to bring

into the present contextual aspects including the conditions of

experiencing, the social milieu and the habitual self-

regulations of the client, to support awareness of the gestalt

formation process in the here and now (Sonne, 1998). Even ifthe therapist can see the behavior and convictions of the client

as limiting and inappropriate, the client may not be able to see

or understand this. A fundamental aspect of such a problem

might be the clients way of thinking about the problem. The

experiment is designed to give the client a possibility in a new

setting to experience the problemincluding the organism/

environment fieldwith the purpose of heightening aware-

ness of the gestalt formation process involved, the result being

heightened awareness of self-regulations (involving cogni-

tive, behavioral and somatic aspects) and awareness of new

possibilities, which might seem more satisfying and less lim-

iting than the old ones. The purpose of the experiment is, so

to speak, to unfold the phenomenology of the client, not with

the explicit purpose of changing anything, but, through aware-

ness of what is, to give way to the clients own choice of

change. In principle, the therapist and client together design

the experiment. The purpose of the experiment is to explore

whether the once-appropriate self-regulations and convictions

of the client are still appropriate.3 We choose to ignore the concept of modus, which is

proposed to be at a deeper level than schemas by referring to

a state in which more schemas are activated at the same time

(Beck, 1996; Rosenberg & Mrch, 2005). The concept of

modus is used somewhat differently by, for instance, Beck

and Young. We leave out the discussion of how modus shouldbe understood and will use schemas as referring to the most

basic level (together with modus).


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Youngs model consists of 18 early establishedmaladaptive schemas that can be grouped intofive broad categories termed schema domains.These domains are related to the assumption thatfive basic and universal emotional needs (whennot being met sufficiently in childhood) providethe background for the development of maladap-tive schemas in varying degrees. The more mal-adaptive these schemas influencing and guidingthe person are, the more severe the disturbanceand disorder will be. According to Young et al.,we can outline the basic needs and their relateddomains as the following:

1. Secure attachment related to the schemadomain of disconnection and rejection.

Examples of specific schemas containedare mistrust, defectiveness, and emotionaldeprivation.

2. Competence, autonomy and experience ofidentity related to the schema domain ofimpaired competence and autonomy withspecific schemas as for instance, vulnera-bility to harm, enmeshment/undevelopedself and failure.

3. Freedom to express needs and feelings re-lated to the schema domain of other-directedness. Examples of schemas con-tained are self-sacrifice and subjugation.

4. Spontaneity and play related to the schemadomain of inhibition and overvigilance,where emotional inhibition and unrelent-ing standards are examples of specificschemas.

5. Realistic limits and self-control related tothe schema domain of impaired limits. Ex-amples of schemas under this domain are

entitlement/grandiosity and insufficientself-control.

Besides the described coping and behavioralstrategies, cognitive distortions are a crucial partof maintaining already established schemas.Some of the most common distortions are: (a)selective abstractions in which parts of reality areignored while others are accentuated; (b) over-generalization when events in a specific situationbecome general assumptions; (c) dichotomous

thinking with changing polarities of, for instance,good-evil, hate-love, self-determination-subjugation; (d) personalization in which events

in the environment are ascribed to oneself; (e)arbitrary conclusions in which causal explana-tions are randomly and inconsistently distributed;and finally (f) catastrophic thinking related toanxiety.

Therapeutic Goal and Treatment Principles

In line with the conceptualization of psycho-pathology as dysfunctional cognitions, the goal ofcognitive therapy is the adjustment of the clientsway of thinking and interpreting. In other words,if the dysfunctional beliefs can be modified in amore functional and self-supporting direction, itwill result in less suffering and reduction ofsymptoms (Beck et al., 2004, p. 4). Even though

cognitive therapists as Young et al. (2003) andBeck (2005) are also concerned with behavioraloriented coping strategies, they consider thesepathology-maintaining strategies to be dictatedby schemas, and so the therapeutic aim will stillbe a modification or healing of the clients sche-mas. While modification or healing of schemas isto be expected, it should be noted that this is notthe same as a more fundamental restructuring,which is rarely realistic. As a change at a lessschema-modifying level, reinterpretation can be astrategy toward establishing more suitable waysof living with the already existing schemas. In thetreatment of, for instance, a histrionic person, thiscould be manifested in supporting the person infinding relevant scenarios and contexts in whichit may be possible to realize a desire of being atthe center of others attention.

Regarding the therapeutic work with modifica-tion of schemas, Young et al. (2003) describesfour general change strategies. These are:

1. The therapeutic relation with particular

focus on the empathic confrontation andthe so-called limited parenting directedtoward those of the clients needs thathave been thwarted.

2. Cognitive strategies using standard cogni-tive methods. For instance, Socratic ques-tioning and guided discovery to create in-sight in the content of thinking, and in theattributional processes and biases that re-inforce nonadaptive belief systems and be-haviors.

3. Experience-oriented Strategies borrowedpartly from gestalt therapy.


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4. Behavioral strategies with the aim of in-terrupting the behavior that maintains andsustains the existing schemas.

Collaborative EmpiricismIn cognitive therapy the therapeutic relation-

ship is understood according to the principle ofcollaborative empiricism forming the basic mind-set for using specific cognitive methods and gen-eral strategies. Collaborative empiricism refers toa joint investigation of how the client interpretsand acts in the world, which consequences thismay have for the client, and how the client iden-tifies and obtains transformational goals (Holm,2001; Padesky, 1993). The mental and behavioral

patterns and the symptoms that are the objects ofthe therapy are considered as data, which likeother data can be submitted to a closer explora-tion and be tested for their validity. Implicit in theattitude of collaborative empiricism is an aim thatthe client will learn to evaluate thoughts, behav-iors, moods, and life circumstances more gener-ally aside from the specific problems that broughtthe client to therapy (Padesky, 1993). Further, thecollaborative attitude also implies that the cogni-tive therapist seeks to communicate the cognitiveframework to the clientin a condensed andsimplified form (of course), adjusted to the indi-vidual clients level of understanding.

Case Conceptualization

Related to the collaboration between client andtherapist in cognitive therapy, the individual caseconceptualization is important in at least twoways. Partly as a joint working tool for the ther-apist and client, and partly as a support to thetherapists planning of the treatment: in the pre-

liminary stages as well as in its function as aguideline for the therapeutic sessions and as ahorizon for the therapy in its entirety (Beck,2005). As a common denominator in all the vari-ants of case conceptualizations (see, for instance,Young et al., 2003, p. 66; Beck, 2005, chap. 2;Mrch, 2005, p. 209), case conceptualization pro-vides an individual-specific version of the generalcognitive model of psychological difficulties. Inthe cognitive case formulation, the clients cur-rent difficulties and symptoms are illuminated

through childhood and life experience as remem-bered by the client and through identification ofexactly this clients central schemas and assump-

tions, as they have been constructed from priorexperience together with the strategies that havebeen developed in order to cope with them. Inthat respect, a clear individual-specific version ofthe general model appears that can shed lightupon the predisposing as well as the maintainingcognitive systems. The method is commonly re-garded as an essential tool in the treatment ofpersonality disorders where it also serves a func-tion in predicting cooperation difficulties in thetherapeutic relationship.

Pedagogical Elements

Together with strategies for developing theclients insights into his or her problems, peda-

gogical elements also play a significant role incognitive therapy. The two most central elementsin that respect are psycho-education, aimed atgiving the client knowledge of his or her mentalcondition; and social skills training, dealing withthe development and training of the communica-tive skills and problem solving strategies of theclient, so that s/he can learn better and moreeffective methods for communication and prob-lem solving, including more suitable ways ofcoping with symptoms.

Points of Convergence and ComplementaritiesBetween Gestalt and Cognitive Therapy

In gestalt therapy and cognitive therapy wefind different terminologies, different views onwhat constitutes individual variability and health,and different views on therapeutic methodology.Basically we can say that cognitive therapists,working in modes of collaborative empiricism,are aiming at modifying thoughts and behavior inorder to make these more adaptive and self-

supporting. Gestalt therapists are aiming at cre-ating, expanding, and focusing awareness on thegestalt formation process as it happens here andnow in a therapeutic contact modus betweenI-ness and otherness. This is due to the fact thatawareness of this process must precede any pos-sible basic change. Considered this way, we candifferentiate between a modifying cognitive meth-odology and a facilitating gestalt therapeuticmethodology (Kellogg, 2004).

In our view these differences are usually con-

sidered more incompatible than necessary giventhat both positions have a common understandingof the significance of memory in psychological


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dysfunction; that the current dysfunction is theresult of patterns formed through a childs adap-tation and creative adjustment to conditions in theyears of growing up. In the gestalt approach suchpatterns are understood in terms of typical figureformation tendencies, and in the cognitive ap-proach they are understood as typical tendenciesin schema activation. In both positions, memoryis considered central to both the establishing ofthese typical tendencies and to their persistencein the face of changing circumstances. Within thecognitive position, inertia against change is seenas determined by the persistence of schemas,once they have come into existence and beenrelated to the maintaining system, with behav-ioral strategies, interpersonal contexts, and cop-

ing patterns having a strong self-perpetuating ef-fect. In the gestalt position the inertia againstchange is anchored in frozen organismic self-regulation (rigid character structure patterns) cre-ating contact disturbances in gestalt formationprocesses. The schematic processing systems inthe cognitive approach and the character structurepatterns in gestalt are both determined by mem-ory. But the aspect of memory that becomes themost central differs in the two approaches withthe cognitive approach paying most attention tosemantic memory, and the gestalt approach pay-ing particular attention to procedural memory.Our point, then, is that precisely because theyfocus on different aspects of the memory system,we are given a key for opening a dialogic door-way between the positions, by which we can gaina better understanding of the relation betweenprocess and content in psychological dysfunctionand the treatment thereof. We shall, therefore,start our considerations of the complementaritiesbetween the two approaches by looking at this.

Procedural Memory and Semantic Memory

As famously elaborated by Tulving, we canassume the existence of three different memory-systems: procedural, semantic, and episodic(Tulving, 1983). All three systems make possiblethe utilization of acquired and retained knowl-edge, but they differ in the ways in which differ-ent kinds of knowledge are acquired or used. Asstated by Tulving:

Procedural memory [. . .] is concerned with how things are

donewith the acquisition, retention, and utilization of per-ceptual, cognitive, and motor skills. Semantic memory [. . .]has to do with the symbolically representable knowledge that

organisms possess about the world. Episodic memory medi-ates the remembering of personally experienced events.(Tulving, 1985, pp. 2)

According to Tulving, the three systems are hi-erarchically ordered with procedural memory as themost fundamental and inclusive category entailingsemantic memory as a subcategory, which thenagain entails episodic memory as a subcategory.Each form of memory is also characterized by adifferent kind of consciousness. While episodicmemory is related to autonoetic consciousness (self-knowing), semantic memory is related to noeticconsciousness (knowing), and procedural memoryis related to anoetic consciousness (nonknowing),bound to current situations.

Procedural memory then, is nondeclarative,

bodily anchored, and implicit in the activities thatare unfolded. When we ride a bike, tie our shoes orwhen a combination for a lock simply lies in ourfingers, we use procedural memory as an automat-ically activated pattern of movements. If the com-bination for the lock is demanded from us, wemight not be able to figure it out without doing themovement pattern once again. Unlike episodic andsemantic memory, procedural memory is self-contained in the sense that it does not include anyreference to nonpresent extraorganismic stimuli andstates of the world. It is a memory for doing thingswithout reflected thoughts and use of language. It islearned through attunement between the organismand the situations that it happens to be in and relateto: procedural memory happens at the momentwhen it happens.

While procedural memory can be understood asa memory for how to handle situational activities(broadly speaking), episodic memory is a figuralmemory for the episodes we participate in. Suchepisodes become part of autobiographical memoryand the life-narratives we tell about ourselves as

building blocks of our identity (McAdams & Pals,2006). Episodic memory develops through accre-tion with a specific self-reference: It was I who wasin that specific situation at that given time in mylife. This auto-noetic consciousness in episodicmemory does not belong to semantic memory. It iswith semantic memory that we extract and gener-alize information and knowledge about the worldon the basis of situations with a certain resem-blance. Semantic memory develops and changesthrough restructuring processes, in which we form

internal representations (beliefs or schemas) thatcan be processed and manipulated at a purely men-tal level and at a distance from direct contact to


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specific situational happenings and without behav-ioral response. When a cognitive therapist uses So-cratic questioning and guided discovery to explorethe background for and the actual functionality of abelief, the exploration will most typically be at asemantic level with glimpses of episodes to validateor invalidate the assumptions and spoken words. Ifprocedural memory is to be activated, it will typi-cally afford some kind of bodily action or concretesensation, which cannot be manipulated solely at amental level but has to be lived out more directly.

Forms of Memory in Gestalt Therapy andCognitive Therapy

According to Burley and Freier (2004), it is pri-

marily at the procedural level that we find the ten-dencies for psychological dysfunctionalities to per-sistently repeat themselves, and so the procedurallevel should be of primary concern in the therapeu-tic process, if we want therapy to promote long-term change. At the same time they argue, that thisis precisely what gestalt therapy is aiming at.Though there might have been a tendency for thoselooking from the outside to consider gestalt therapyas a cathartic approach working with relieving sit-uations out of episodic memory in the here andnow, this is not what defines the approach. Asmentioned earlier, the defining element of the ge-stalt approach is to bring awareness to the gestaltformation process in order to provide the organismwith the possibility of greater choice (more appro-priate self-regulation) and thereby freeing it fromtypical patterns dictated by procedural memory.This process may include mental processing at thesemantic level but it is not always necessary or evendesirable. If awareness is not consistently directedtoward the procedural level, the individual will keepon doing what s/he is doing, regardless of how

unsuitable this might be in a specific life situation;that is, if the behavior is anchored at the procedurallevel. An individual may often be capable of rec-ognizing (at a semantic level) the unsuitable aspectof a particular behavior pattern. For instance, aftersome time in therapy one might see that ones corebelief of oneself as being unlovable says moreabout the family one grew up in than it says aboutoneself. Nonetheless, one continues to live the pro-cedural pattern as if it was true. This proceduralpattern will then be activated every time one finds

oneself in situations with affinity to ones formerrelationship with ones parents, with the conse-quence that one (independent of ones semantic

knowledge) makes efforts to be lovable in the eyesof others and oneself. Procedural patterns win oversemantic knowledge.

In Burley and Freiers (2004) view, cognitivetherapy and gestalt therapy differ from each other intheir different estimations of memory: cognitivetherapy pays primary attention to semantic mem-ory, while gestalt therapy is methodologically fo-cused on procedural memory. While we fully agreewith the latter part of the postulate, we do not fullyagree with the former part. Even though there is asense of truth in the claim that cognitive therapytypically is more semantically orientated, it is alsotrue that procedural level aspects are implied in thebehavioral experimental orientation included in thecognitive methodology. Cognitivebehavioral ex-

periments are primarily created (a) to test the valid-ity of thoughts as constructions of world, self, andothers; (b) to create new/modified living rules andschemas; and (c) to practice new behavior. We do,however, agree with Burley & Freier that the factthat the explanatory models in the cognitive ap-proach are primarily anchored at the semantic levelwill tend to steer the typical practice of cognitivetherapy in a specific direction for considering whichmicro processes that are stimulated for investiga-tion, and how their influences should be conceived.4

Thus, we would agree that some of the centralinstructions of traditional cognitive therapy make itless likely that certain micro processes are priori-tized and granted the necessary time to create suf-ficient awareness on them to promote change at theprocedural level. When, however, Teasdale et al.(2002) recently differentiated between metacogni-tive knowledge and metacognitive insight, theyseemed to attune the cognitive approach to suchprocesses, and thereby also brought it closer to theawareness work at a procedural level in gestalttherapy. The point is that metacognitive knowledge

deals with semantics by referring to beliefs aboutcognitive phenomena stored in memory as propo-sitional facts in much the same way as other facts(p. 286), while metacognitive insight refers to the

4 With the same sort of attention Williams illustrates (from

a cognitive frame of reference) the inertia in procedural mem-

ory changes when related to the effect of trauma. He reminds

us that in therapy we should be attentive towards not only

what they remember but the way in which they remember it;

not only their conscious recollection, but their behavioral

memories that have survived long after the initial event thatprecipitated them; not only their retrospective memory but

their prospective memory (Williams, 1996, p. 111).


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way mental phenomena are experienced as theyarise, which points directly to what gestalt therapistswould call awareness of the gestalt formation pro-cess. Interestingly, Teasdale et al. (2002), indepen-dently use the term metacognitive awareness, whenthey talk about metacognitive insight as actuallyexperiencing thoughts as thoughts . . . in the mo-ment they occur (p. 286).

Experiential Processes Versus AttributionalProcesses

From a gestalt perspective, the tight structuringadvocated in traditional cognitive therapy of theindividual sessions and the therapy in generalwith explicit formulations of goals (preferably

agreed upon and operationalized early on) will beseen as a restriction on the possibility of investi-gating the procedural patterns in gestalt forma-tions as they evolve and are experienced by theclient in the present, lived moment. Also, from agestalt perspective, the cognitive focus on cogni-tion will seem to be restricting the scope ofinvestigation by excluding sensation and aware-ness of need-based gestalt formation processes ina broader sense. According to Fodor, the cogni-tive stance means that highlighting the momentof experience is often lost in the talking aboutbeliefs (1996, p. 33). It is characteristic of thecognitive-Socratic investigation of thinking (i.e.,what goes through your mind right now? what doyou tell yourself?) that it invites the client tomake attributions and assumptions about the now,which is lived and experienced. In gestalt therapysuch assumptions are preferably suspended,5

while in a sensory, present, almost meditativeattitude the therapeutic work is oriented towardsharpening and focusing awareness of the gestaltformation process in order to strengthen the or-

ganismic self-regulation. In that respect it is in-teresting that Naranjo (2000, p. 24) compares the(gestalt) therapists frequently used support andencouragement of the client to be aware of thestream of consciousness with a verbalized inter-personal meditation.

On the other hand, in relation to the cognitiveclassic what are you telling yourself rightnow?, there is, in principle, nothing that pre-vents the therapist from being silent and lettingthe now-moment unfold in its dynamic experien-

tial structure if that is what is considered mostconducive in the present situation. Neither is itforbidden to ask the client what s/he senses (in

her/his body). What s/he attends to right now? Orto tell her/him that I (the therapist) notice thather/his shoulders are rising a little bit, and that Iwould encourage her/him to lift them even more.The aim is to investigate whether by focusingawareness on a present, though unaware (proce-dural) behavior, and through conscious exagger-ation of the behavior, there could be a facilitationof the therapeutic process by creating moreawareness at precisely the procedural level.

Though there is, again, in principle, nothingwrong with such interventions and mirroring in acognitive framework, they are not the most ob-vious interventions in cognitive therapy. Withreference to their therapeutic guidelines cognitivetherapists will presumably tend to look at such

interventions as less productive errands on theirway. They might seem to be too much of adiversion from the cognitive case conceptualiza-tion, the negotiated goals for the therapy, and theexplicitly formulated agenda items for an indi-vidual session.

In this respect gestalt methodology can obvi-ously contribute to creating more room for theexperiential and sensational moments in cogni-tive practice. On the other hand, the conceptualapparatus of cognitive therapy can contribute tobeing more specific in formulating the cognitiveaspects of the gestalt formation process than hastraditionally been done in gestalt. As also pointedout by Burley (2004), gestalt formation processesare not just about sensations and experiences butcontain meaning ascriptions and interpretations ata fundamental level. In cognitive terminology,such ascriptions and interpretational elementsare called thinking, and according to Fodor(1996) it is a mistake to consider them asdichotomous with sensation. To counterpara-phrase one of Perls famous quotes, there is no

point in loosing our heads when we turn to oursenses. It will be more profitable to use ourheads in sensitive ways and to avoid bringingourselves in a delimiting position in whichwork with awareness is restricted to sensationand experience.

5 To be sure this does not mean that gestalt therapists do not

work with thinking or interpretations. The concept of introjec-

tion in gestalt therapy is, for instance, rather consistent with

the cognitive terminology of dysfunctional and irrational be-

liefs. Likewise, gestalt therapists are usually interested inseparating sensations from fantasies and ideas (that is, think-

ing).


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The question then is: Are psycho-functionalities -that in the cognitive approach are explained with theactivation of schemas and underlying assumptions -roughly the same as those which, in the gestaltapproach, are explained with reference to gestaltformation processes? Kellogg (2004) thinks so, andwhen we define gestalts as dynamic knowledgestructures that organize experience, Fodor wouldagree (1996, p. 34), and so would weat leastgenerally as an invitation to continue looking at theapproaches as complementarities rather than con-tradictions.

Mentality of the Individual Versus FieldOrientation

One of the fruits of a complementary positionis an increased attention toward aspects that theapproaches in themselves would not be attendingto with the same strength. Concerning the relationbetween schemas and contexts in cognitive ther-apy, the field orientation of gestalt would, forinstance, more consistently than the cognitivedescriptions of triggering situations investigatethe contextual circumstances under which spe-cific schemas are activated. In cognitive therapy,triggering situations are explicitly investigated inthe initial phases of therapy as part of collectingdata in order to obtain a systematic analysis of theclients difficulties in everyday life and to formu-late hypotheses about the central rules and sche-mas that are underlying the different problemsituations of the client. But when the clarificationof the clients maintaining system through a cog-nitive case conceptualization has been madeand due to the fact that cognitive therapiststhrough situational analyses often manage tomake the clients maintaining thought and behav-ioral patterns appear very vivid and clearit

seems as if no further clarification of the field isnecessary to understand the clients phenomenol-ogy and actions. While there might be someadvantages to such focused strategies, the poten-tial disadvantage isof coursethe risk of treat-ing the clients beliefs (and maybe his or herdisorder in general) as being uninfluenced by thevarious contexts in which he or she lives (Fodor,1996). With a field orientation as a basic stance,the therapist will - all things being equal - bemore inclined to dwell on which contextual cir-

cumstances support or provoke the activation of aparticular thought/schema and will, therefore, geta more thorough understanding of the field-

determined how of the individuals schema-activation.

The Meaning of the Therapeutic Relationship

in TherapyIn the cognitive literature, discussions of the

therapeutic relationship are often concerned withhow the collaboration between therapist and cli-ent can be maintained or reestablished after in-terruptions in order to reinstate the use of stan-dard cognitive (restructuring) methods (Burns &Auerbach, 1996; Beck, 2005). The general atti-tude seems to be that for a therapy to be success-ful it must be done within an atmosphere ofwarmth, genuineness, and empathy. Presumably,

because this is considered obvious, discussions ofthe therapeutic relationship and contact are typi-cally lacking or at least not prioritized in thecognitive literature. Instead, discussions of thesubject are concerned with the technical direc-tions for maintaining the collaborative relation-ship and adjusting the standard methods (for thespecific symptom disorders) so that they mightbecome suitable for working with personality-disturbed clients (Beck et al., 2004; Beck, 2005).The number of problem identifications and meth-odological suggestions for solutions, created inthat respect, are definitely inspirational material.Still, they concern the technical aspects of ther-apy and not the therapist/client contact and rela-tionship as such.

From the observer of the field, a question couldbe that if certain techniques alone are what makethe difference in therapy, then why not just re-place the psychotherapeutic context with a mix-ture of self-help books and computer programsprovided that the computer technique becomessufficiently sophisticated (Naranjo, 2000, p. 3).

Aside from our guess that probably not manypsychotherapists would think of this as a realisticpossibility, two objections arise based on whatHougaard (2004, p. 622) calls the anthropologicaldilemma of psychotherapy. The first objectionwill adduce that experiences of contact and theprocess between people in the therapeutic roomwith all its ramified implications of lived pres-ence between client and therapist are actuallyhealing in and of itself. Thus, the contact (as anexchange of information between I-ness and oth-

erness) in the therapeutic relationship becomes anend in itself and not only a means. The secondobjection will adduce that no matter how sophis-


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ticated and effective our techniques, it still takestwo to tango; that is, an interpersonal space andprocesses therein are what make the techniqueswork. Thus, the relational contact becomes a nec-essary means for the healing potential in thetechniques to work. While the prototypical cog-nitive stance will be in accordance with the latterunderstanding, the gestalt approach will basicallymatch the view that contact has a definitive func-tion in the therapeutic work with change pro-cesses.

Conclusion

By virtue of a common phenomenologicalstance, a compatible understanding of psycholog-

ical dysfunctionality as related to memory, and areasonably common attitude toward the client inthe therapeutic room, gestalt therapy and cogni-tive therapy are so sufficiently alike that it seemsreasonable to consider the relationship betweenthe approaches in integrative terms (not just tech-nically or from an eclectic stance, but also theo-retically). Precisely because they are also suffi-ciently different in several respects, they have thepotential of being complementary in clinicalpractice. Although we have argued that the ge-stalt formation process and the processes con-cerning development and maintenance of sche-mas in essence are to be considered as synonymsdescribing the same phenomena, the two ap-proaches are at the same time focusing the pro-cesses differently. While cognitive therapists aremostly concerned about what the machinerydoes, and how it can be modified, gestalt thera-pists are mostly concerned about how the ma-chinery works, and how the working processescan be facilitated. Precisely this attention regard-ing different aspects of the same process phe-

nomena makes a mutual dialogue between theapproaches on their complementarities a worth-while endeavor - a dialogue in which neither ofthe positions should be reduced to a derivation ofthe other.

Among the themes that we have been workingwith in the article, we can sum up the followingcharacteristics of the positions in the hope thatthey may stimulate a continuing dialogue amongadvocates of gestalt and cognitive therapy regard-ing the complementarities between the ap-

proaches (Table 1).To avoid a misreading of the content in thetable, it should be kept in mind that it is summing

up prototypic (and principal) differences betweenthe two approaches. We expect both gestalt ther-apists and cognitive therapists to have their per-sonally anchored strategies which in the diversityof the therapeutic meeting will to some extentcompensate for those aspects of reality that arenot so well described in their preferred theoreticaland practical references. By sharpening the linesbetween the perspectives, the aspects of the hu-man condition that each approach are particularlyattentive to, become clearer.

To those who are concerned about the evi-dence of effectiveness of gestalt therapy in com-parison with the effectiveness of cognitive andcognitive behavioral therapy, there are someoutcome studies that compare the effect of the

approaches showing that gestalt therapy is atleast as promising as the more evidence-investigated cognitive approaches.6 For in-stance, Beutler et al. (1991) found that gestalttherapy outperformed cognitive therapy intreating depressed persons. Johnson and Smith(1997) found that in the treatment of a phobia,the gestalt technique of the empty chair andcognitive desensitization seemed to workequally well in contrast to the no treatmentgroup, and that the gestalt group in contrast to

the desensitization group indicated a variety ofbenefits beyond the focus of therapy. Watson(2006) compared 40 clients classified with ei-ther good or poor outcome in either cognitivebehavior therapy or manualized gestalt therapy,and showed that good responders of either ther-apeutic approach exhibited superior levels ofemotional processing and that clients receivinggestalt therapy ended up being superior to cog-nitive behavior clients in emotional processing.And, finally, to mention the classic study of

emotionally focused couples therapy by John-son and Greenberg (1985), it was shown thatcognitive behavior therapy and gestalt ap-proaches in a general comparison turned out tobe equivalent, and that there is a benefit togestalt therapy that does not appear in cogni-tive therapies, namely that those who receivegestalt therapy continue to improve after the

end of therapy rather than to simply hold the

6 We appreciate the discussion with Todd Burley and the

references provided by him on this subject during our meetingin the Aarhus Research Group in Gestalt (ARGG) on Novem-

ber 3, 2009.


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progress that they have made. The last resultmight be precisely a result of gestalt therapyworking at the procedural level. In general,there seems to be no reason for concern regard-ing the scientific and practical soundness ofeither of the two approaches we have discussedin this article. Following Beutlers (2009)warning against oversimplification of psycho-therapy through methodological one-sidedness,our article of faith (p. 306) will be, that mean-

ingful disagreements between researchers andpractitioners with advanced capacities for per-spective taking is the main road toward a futureintegrative psychotherapy that has transcendedsectarianism and included the most valuableparts of our existing knowledge of what reallymatters.

A Closing Remark About Some Remarkabilities

In combination with the earlier mentionedattention toward metacognitive awareness as

formulated by Teasdale et al. (2002), it is quiteinteresting that meditation and mindfulnesshave appeared in - what has been called - athird wave or a second revolution within cog-nitive therapy (Wllestad, 2007; Holden,2008). The aim of the meditative techniques ispartly to cultivate an open and accepting atti-tude toward ones experiences without meetingthem with judgment or steering them in anyparticular direction and partly to cultivate theability to reconcile oneself with reality as it is,

without wanting to change it (Neff, 2003). Thisattitude is astonishingly similar to the assump-tion in gestalt therapy about paradoxical

change: change happens when we become whatwe are, without trying to change who we are(Beisser, 1970). Further, there is a remarkablystrong resemblance between the gestalt as-sumption about the paradox of change and thedialectical view of the relationship betweenaccept and change as it is seen in dialecticalbehavior therapy, in which we find an explicitadaptation of Zen-philosophy (Swales &Heard, 2007; Kver & Nilsonne, 2004) (whichhas been part of gestalt since the early years).The client is supposed to both accept who s/heis and undergo change. Through developmentof self-acceptancewhich to a large extent istransmitted through the therapists acceptanceand validation of the clients here and now

existencethe client becomes capable of self-transformation in the next now moment(Swales & Heard, 2007, p. 187). Gestalt ther-apists and some cognitive therapists now seemto agree that change is to be understood in thisparadoxical sense. That when we have basi-cally become reconciled to ourselves and toreality as it is, then we have often alreadychanged quite a lot.

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TABLE 1. Characteristics of Gestalt and Cognitive Therapy

Cognitive therapy Gestalt therapy

Individual orientation Field orientationSchema-activation Gestalt formation process

Types of schemas Gestalt process diagnosisCognition Experience and sensationExplicit goals and tight

structure as guidingprinciple and focus

Awareness on here-and-nowas guiding principle andfocus

The therapist as expert ontruth, including thepedagogical element

The therapist as expert oncontact-processes,including the therapeuticlicense to be creative

Modifying modus workingwith collaborativeempiricism

Facilitating modus workingwith phenomenologicalexperimentation


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