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What do Gestalt therapists do in the clinic? The expert
consensus
Madeleine Fogarty, Sunil Bhar, Stephen Theiler and Leanne O’Shea
Received 22 February 2016
Abstract: What it is that Gestalt therapists do in the clinic that is different from other
therapists? What is it, in other words, that makes Gestalt therapy Gestalt, and distinguishes
it from other psychotherapeutic modalities? This article describes the process of finding an
expert consensus about these questions as part of the process of developing a ‘fidelity scale’
for Gestalt therapy. Using a Delphi study, eight key concepts that characterise Gestalt therapy
were identified, together with the therapist behaviours that reflect those concepts.
Key words: Gestalt, fidelity scale, Delphi study, developing awareness, working relationally,
working in the here and now, phenomenological practice, working with embodiment, field
sensitive practice, contacting processes, experimental attitude.
When I (Madeleine) attended the AAGT conference in
Asilomar, California in September 2014, one of my
main goals was to persuade some of the participants
there to be involved in a study that would try to find an
answer to the following questions: What it is that
Gestalt therapists do in the clinic that is different
from other therapists? What is it, in other words, that
makes Gestalt therapy Gestalt, and distinguishes it from
other psychotherapeutic modalities? Perhaps most
dauntingly, my aim was to try to answer these questions
through a process that depended on there being a
consensus among experts in Gestalt therapy (GT).
At first, when I spoke to people at Asilomar, there was
resistance to the very notion that it was possible to
define GT in this way. Later, came warnings about the
impossibility of there ever being a consensus in a
tradition that is so rich in disagreement and differentia-
tion as GT. But more fundamentally, there were the
underlying questions: Why would you want to do this?
What would be the point of it?
As I was preparing to write this article, a client
returned to me a back issue of the British Gestalt Journal
that I had lent her several months before. Opening it up,
I found myself reading a note that Malcolm Parlett
wrote in 2007. The note provided some of the answers
to this last question. Commenting on the diversity
within the GT community, Parlett suggested that if
you were to investigate or dissect any Gestalt term,
principle, idea or method a great deal of theoretical
difference and confusion would be revealed.
Parlett was concerned that this enormous disparity
between Gestalt thinkers threatened the possibility of
securing the GT ‘brand’ in the wider therapeutic com-
munity:
I am thinking of students and trainees who have few
stable guidelines after the elementary stage and other
experienced professionals who want to grasp quickly
what Gestalt offers. If we want to take care of our
collective contact boundary with ‘interested but not
Gestalt educated others’, then surely we have to find
more consensual rubrics for describing the approach, so
we do not put off or confuse this group but rather attract
and intrigue them. One need here is to return to practice
more, to what we do, and to spelling out our under-
standing. (2007, p. 54)
Parlett’s concern, in other words, was that the wide-
ranging divergence of opinion about method and
theory within the Gestalt community was a threat to
the future of GT. Unless the Gestalt community could
agree about what GT was, then it would be difficult to
continue to attract students to the ‘brand’, or to explain
what GT is to others.
Around the same time that Parlett was calling for
greater consensus about the practice of GT, other
researchers in the GT world recognised the need to
develop an evidence base to establish that GT is an
effective form of psychotherapy (Brownell, 2014;
Burley, 2014; Barber, 2009). But before we can tell
whether or not GT works, we first need to have a
measure for determining whether or not the therapy
that a particular therapist is delivering can properly be
described as ‘Gestalt therapy’ (Perepletchikova, 2011;
Waltz et al., 1993). And in order to have such a measure,
British Gestalt Journal
2016, Vol. 25, No. 1, 32–41
#Copyright 2016 by Gestalt Publications Ltd.
What do Gestalt therapists do in the clinic? 33
we must be able to describe what Gestalt therapists do in
the clinic that can be distinguished from non-Gestalt
forms of treatment.
This then, as I explained to those I met at Asilomar,
was what I was going to try to do. The aim was to
develop a measure – a ‘fidelity scale’ – that an independ-
ent rater could use to determine how faithful therapy
being delivered by a therapist is to the methods that
characterise GT. The rationale and methodology for the
development of such a scale were extensively discussed
by Fogarty, Bhar and Theiler (2015). At the very least,
development of the scale required the identification of
the key principles and concepts of GT; and the ‘oper-
ationalisation’ of those principles and concepts in the
form of observable therapist behaviours that reflect
them.
Usually, fidelity scales are based on pre-existing
treatment manuals (Perepletchikova, 2011; Waltz et
al., 1993). However, GT has never had a manual, and
many experts argue that it would be impossible to create
one (Mann, 2010; McConville, 2014; Wollants, 2008;
Yontef and Jacobs, 2013). In the absence of a manual, an
alternative way to develop a scale is to use the Delphi
method. In the Delphi method, statements (such as a
description of a therapist behaviour) are submitted to a
panel of experts, and treated as valid if endorsed by a
consensus of 80% or more.
When reading GT’s rich, vast and diverse body of
literature, it is sometimes difficult to imagine that there
could be a consensus about anything within GT, and
certainly difficult to imagine that experts in GT could
agree about the clinical behaviours that characterise
Gestalt therapists and that distinguish them from
therapists trained in other modalities. Despite these
difficulties, in the absence of a manual, the Delphi
method seemed to offer a viable and parsimonious
path to the development of a fidelity scale for GT.
Whether the Delphi method would work depended
on whether there was enough consensus in the GT
community about what it is to be a Gestalt therapist.
Whether, in other words, a panel of GT experts would
agree with Dave Mann that although ‘no two Gestalt
therapists will be the same . . . both will be recognisable
as Gestalt therapists’ (2010, preface, p. xi).
The Delphi method
The Delphi method is an established method for con-
sensus building that poses a series of questionnaires to
collect data from a panel of experts about real-world
practices (Linstone and Turoff, 1975). The Delphi
method involves a group of experts making private,
independent ratings of agreement on a series of state-
ments. Experts are also invited to comment on the
statements and there are opportunities to offer amend-
ments and modifications in every phase of the Delphi
process. Once ratings are received and collated, a sum-
mary is fed back to the panel members, who then
complete a second round of rating and feedback
(Hart et al., 2009). The Delphi method has been
widely used in Information Technology and in the
field of education to determine prototypical practices
for new technologies and practices (Carley et al., 2006;
Clayton, 1997). More recently it has been adopted by
the health sector in establishing benchmark practices
for identifying and treating various disorders (de Vil-
liers et al., 2005; Falzon et al., 2014; Hart et al., 2009).
In contrast to other data gathering and analysis
techniques, the Delphi invites participants to engage
in a process of multiple iterations, in which feedback
and analysis from the first questionnaire is integrated
into subsequent questionnaires until a consensus of
80% agreement is reached on each item. Consequently,
in the Delphi process participants may have the oppor-
tunity to augment or modify their initial position in
relation to the analysis and feedback provided by other
panel members and communicated by the researcher
who facilitates the Delphi process.
The flexibility of the Delphi method and the fact that
it provided an opportunity for a wide range of views to
be expressed and collated seemed the most appropriate
method to develop a consensus about GT and how it
might be operationalised in clinical practice.
Participants in the Delphi study
The process of gathering participants for the study
began at the AAGT conference in Asilomar, California
in 2014. At that meeting, over fifty members of the
AAGT were presented with the proposal for the Delphi
and invited to participate, or otherwise to suggest
participants who may be able to contribute to the
study. Despite initial resistance to the notion of a
fidelity scale, and many cautions about the difficulties
of creating such a consensus in the GT tradition that is
so rich in disagreement and differentiation, participants
began to warm to the idea, and to understand the
importance of such a scale in the face of the demands
for evidence-based practice (EBP) in institutional train-
ing and the wider health systems (Burley, 2014; Brow-
nell, 2008, 2014; Frew, 2013; Gold and Zahm, 2008;
O’Leary, 2013).
The opportunity to meet face to face with so many
GT practitioners at the beginning of the process was
foundational for this study, as it provided a basis for the
lived experience of GT and grounded the cyberspace
technology of the project in that experience. Experts for
the Delphi had to have either been a GT trainer; edited a
GT journal; published books or refereed-journal articles
on GT; or been a director of a GT centre. The Asilomar
34 Madeleine Fogarty, Sunil Bhar, Stephen Theiler and Leanne O’Shea
conference was inevitably North American-centric.
However, Asilomar was only the starting point for the
invitation of potential participants. After Asilomar, I
approached people who were familiar with other
regions where Gestalt was practised – such as Eastern
and Western Europe and Latin America – to suggest
people in those regions who met the selection criteria.
The people invited to participate were intended to
provide a reasonable representation of contemporary
experts in GT theory and practice. Is the representation
perfect? Of course not. One obvious limitation of the
Delphi is that the study was conducted in English. Given
that limitation, it is no surprise that although the list of
participants includes experts from many countries,
cultures and language, more than half the participants
are English speakers. However, parts of the research
project have already been translated into German,
Russian and Spanish; and in the long run, it will not
only be interesting to see whether the study can be
validated in the English-speaking world, but whether it
can be validated in other languages and cultures as well.
Drafting the survey
Preparing the survey items for the Delphi was a daunt-
ing task. A veritable library of resources has been
written about GT theory and practice. However, finding
commonalities amongst this vast body of literature
became easier as the project progressed.
Eight key concepts emerged repeatedly: increasing
awareness, working relationally, working in the here
and now, phenomenological practice, working with
embodiment, field sensitive practice, working with
contacting processes, and experimental attitude. Never-
theless, dividing GT into eight discrete concepts felt
slightly artificial, because any given moment in a clinical
session is likely to include several of these concepts
operating simultaneously. Descriptions of the concepts
were based on an extensive literature review
1
as well as
regular consultation with my supervisors and col-
leagues; but they also had to be brief, inclusive, pithy
and comprehensive.
Describing observable behaviours was even more
challenging, as behaviours characteristic of one concept
(e.g. phenomenological practice) might just as easily be
exemplary of another concept (e.g. working in the here
and now).
In this study, the first round of the Delphi was used to
develop and refine descriptions of the key concepts and
associated therapist behaviours. The refined therapist
behaviours were then submitted to the participants in
the second round of the Delphi. Therapist behaviours
that are endorsed by a consensus of participants in the
second round will form the basis of a draft Gestalt
Therapy Fidelity Scale (GTFS).
Sending the survey
In the first round, prospective panel members were sent
a link to an online survey in which they were presented
with descriptions of the eight key GT concepts and
associated therapist behaviours. They were asked to rate
on a five-point scale whether they agreed with the
proposed title and concept description of the eight
key concepts of GT in clinical practice. Participants
were invited to provide feedback on the name of the
concept, whether they thought it was foundational for
GT clinical practice, and whether there were any mod-
ifications or omissions that needed to be addressed.
Participants were also given descriptions of therapist
behaviours and asked whether they agreed that each of
these behaviours reflected one of the key GT concepts.
Finally, participants were given the opportunity to
make their own suggestions as to how best to oper-
ationalise the key GT concepts.
The moment before the first ‘send’ button was
pressed was like jumping out of an aeroplane (albeit
with a parachute and instructor). A leap into the
unknown: were people going to respond? Would they
be offended by the brevity and condensation of GT into
such discrete items? Would they recognise the beha-
viours as distinctively Gestalt? Were the differences and
conflicts within GT about to surface beyond any hope of
consensus?
Beyond expectation, the participation from the inter-
national Gestalt community was overwhelmingly co-
operative. Over sixty experts from around the globe
participated, and I feel deeply grateful for their con-
sidered feedback and willingness to stay engaged in the
consensus building process. Participants included:
2
Europe:Austria – Nancy Amendt-Lyon; Belorussia –
Elena Iasaja; Czech Republic – Anton Polak, Jan Roubal;
Denmark – Hanne Hostrup; France – Vincent Beja,
Gonzague Masquelier, Jean-Marie Robine; Germany –
Willi Butollo, Rosemarie Wulf; Italy – Gianni France-
setti, Margherita Spagnuolo Lobb; Russia – Maria
Lekareva, Illia Mstibovskyi, Rezeda Popova; Sweden –
Sea
´n Gaffney, Ia Martensson Astvik; United Kingdom –
Sally Denham-Vaughan, Toni Gilligan, Phil Joyce, Dave
Mann, Malcolm Parlett, Peter Philippson, Christine
Stevens.
Middle East: Israel – Nurith Levi.
Asia: Japan – Norioshi Okada.
Latin America:Argentina – Myriam Sas de Guiter;
Chile – Pablo Herrara Salinas; Mexico – Heather
Keyes, Myriam Munoz Polit.
North America:Canada – Leslie Greenberg; United
States – Lena Axelsson, Dan Bloom, Phil Brownell,
Victor Daniels, Mark Fairfield, Bud Feder, Iris Fodor,
Ruella Frank, Eva Gold, Elinor Greenberg, Mary-Ann
Kraus, Lynne Jacobs, Jay Levin, Mark McConville, Joe
What do Gestalt therapists do in the clinic? 35
Melnick, Ken Meyer, Erving Polster, Bob Resnick, Alan
Schwartz, Ansel Woldt, Steve Zahm.
Oceania:Australia – Susanna Goodrich, Noel Haarbur-
ger, Tony Jackson, Judy Leung, Alan Meara, Brian
O’Neill, Phoebe Riches, Richie Robertson, Claire Tau-
bert, Greer White; New Zealand – Anne McLean.
These participants responded with such clarity and
willingness that the iterative process of the Delphi was
surprisingly short. In the first round of the Delphi,
participants were presented with descriptions of eight
key concepts and thirty-five associated therapist beha-
viours. In light of the feedback received, several thera-
pist behaviours were eliminated, and many more were
redrafted. The twenty-five remaining and redrafted
therapist behaviours were used to create a mock-up of
a draft GTFS.
The first mock-up was taken to a seminar with Bob
and Rita Resnick at the Relational Centre in Sydney in
early November 2015. Live work and videos were
compared with items in the mock-up of the draft
GTFS. The work presented by the Resnicks aligned
with the mock-up, but further analysis was required.
Videos of live work by Gordon Wheeler (APA Series 1 –
Systems of Psychotherapy), Erv Polster (work with the
unmotivated client), Fritz and Laura Perls, recent work
by Serge Ginger, Gonzague Masquelier, and work
available on YouTube were analysed. Videos of live
work with Lynne Jacobs and Gary Yontef were obtained
by consent from supervisees and colleagues to extend
further the analysis of the draft GTFS. Finally, the
process of analysing the mock-up of the draft GTFS
against videos of live work from other therapeutic
modalities led to further refinement of the scale.
From the outset of this project it was recognised that
dividing GT into differing concepts was challenging
because of the fact that GT is a holistic approach that
cannot easily be delineated into a list of techniques or
skills. Similarly, dividing therapist behaviours into dis-
crete items fails to take account of the fact that in every
clinical moment several therapist behaviours may be
operating at once. Conversely, no single session of GT
will necessarily require each of the therapist behaviours
that define GT. Nonetheless, the mock-up of the draft
GTFS sought to identify the core therapist behaviours
that characterise most sessions of clinical GT.
In the second round of the Delphi, the panel (includ-
ing several experts who had not participated in the first
round) were presented with this refined list of twenty-
five therapist behaviours, and asked whether in their
view each of these behaviours reflected one of the eight
key GT concepts. While I have not yet completed my
analysis of the results of the second round of the Delphi,
at the time of writing it appears that there will be
enough consensus about the therapist behaviours for
there to be a viable GTFS.
What follows is a description of each concept,
redrafted in light of the feedback given by the partici-
pants in the first round of the Delphi, together with
some discussion of that feedback. I have also included
the twenty-five therapist behaviours that were sub-
mitted to the second-round panel.
Developing awareness
Description of the concept
The aim of GT is to develop awareness and promote
awareness of awareness. This does not mean simply
developing insight or introspection, but exploring
experience as physical and emotional beings making
sense of our world and our relationship to others and
the environment. The therapist supports awareness for
the client and his life world and the process by which
awareness is developed. In this way awareness can be
seen to increase self-regulation. Awareness includes
sensory and bodily experience as well as cognitive and
emotional awareness. GT identifies three zones of
awareness: inner (feeling states), outer (contact func-
tions: behaviour, speech and actions), and middle
(thoughts, judgments, ideas). Each of these zones of
awareness and their relationship to each other and the
wider field is developed through the major concepts
that will be explicated below:
1. Working relationally
2. Working in the here and now
3. Phenomenological practice
4. Working with embodiment
5. Field sensitive practice
6. Working with contacting processes
7. Experimental attitude
Given that the aim of developing awareness is central to
all GT concepts, no specific therapist behaviours were
identified for this concept.
Feedback
There were three comments about this concept that
were not fully integrated into the descriptions repro-
duced in this article (as they were not representative of
most views) but remain important to mention. The first
comment related to a perennial theme within GT
theory: whether the central concept is contact or aware-
ness. The second comment related to the ‘zones of
awareness’ that some felt were outmoded in contem-
porary GT. The third comment related to the objection
that awareness can be perceived as awareness for its own
sake (e.g. egotism, self-commenting) rather than devel-
oping awareness towards a therapy of action spontane-
ity and growth (which are clearly the objectives of GT).
Fortunately, the comments really only applied to the
36 Madeleine Fogarty, Sunil Bhar, Stephen Theiler and Leanne O’Shea
descriptions of the key concepts, rather than the asso-
ciated therapist behaviours.
Working relationally
Description of the concept
Relational perspectives have become central to con-
temporary GT practice. A relational approach is
grounded in a contextualist framework in which
human experience is shaped by context. Hence the
concept of working relationally is not only focused on
the therapeutic alliance, but underscores the meaning-
making paradigm for GT. A contextualist framework is
paradigmatic in working with the nuances of emotional
process, therapist–client interaction, and enduring rela-
tional themes.
The therapeutic alliance draws on the concepts of
‘inclusion’, ‘confirmation’ and ‘presence’. ‘Inclusion’
requires the therapist to do more than empathically
listen and attune to her clients. The therapist leans into
the client’s experience such that she connects with the
client’s existence as if it were a sensation within her own
body. This is not a merging with the client, but a
sensitivity that enables a visceral encounter between
therapist and client. Inclusion integrates the therapist’s
awareness of her responses to the client with a deeply
attuned appreciation of the ‘otherness’ of the client’s
experience.
‘Confirmation’ involves a profound acceptance of the
immediate existence and potential of the client. The
therapist does not control the therapeutic encounter.
There is no therapist goal or agenda (except that of
increasing the client’s awareness). This does not mean
that the therapist mirrors or agrees with everything that
the client brings to the session. The therapist is com-
mitted to the dialogue and this includes genuine
moments of dissonance, which are made transparent.
The therapist is part of the relational field. This entails
commitment to change, not only for the client, but also
for the therapist.
The balance between this gently focused inclusion
and commitment to the co-created space of the therapy
session requires ‘presence’. ‘Presence’ is evident in a
grounded and assured quality in the therapist. Equally,
‘presence’ entails a willingness to be uncertain, to work
with ‘creative indifference’ and to offer support to the
client’s expressive capacity. This lends an intrinsic
ethical quality to the clinical encounter in which
shared meaning-making between the client and thera-
pist is developed through an open exchange about how
the therapist and client are affected by each other.
Shame and other disruption affective states can also
be triggered within the therapeutic relationship for a
range of reasons including when the therapist is attend-
ing to one aspect of the client’s situation, without
maintaining attention for another co-existent (but
possibly un-named) aspect of his situation. These
ruptures are evident in the withdrawal of the client
from the process. It is important for the therapist to
attend to ruptures in the therapeutic relationship
through offering support and investigating the contri-
bution that the therapist might make in co-creating a
shame experience in therapy.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist follows the client attentively, tracking
the awareness process and the client’s experience, not
following a predetermined agenda.
.The therapist responds non-judgmentally to the
client, creating the conditions that allow for the
most effective client expression.
.The therapist demonstrates a willingness to be uncer-
tain and to work with creative indifference.
.The therapist draws on her relationship with the
client as the ground for challenge and growth.
.The therapist seeks to identify and repair any rup-
tures in the relationship.
Feedback
Several themes emerged in the feedback on this concept.
Firstly, a relational stance is central to most humanistic
approaches. However, what is specific in GT is the way
the therapist recognises that she is a part of the client’s
field and can be often – as the Other of the situation –
his figure of interest. Thus, in GT we often work with/
on the clinical relationship. Secondly, many partici-
pants wanted the term ‘dialogic inclusion’ to be used
instead of ‘working relationally’. But as the question of
Buber’s centrality to GT remains debated, it was
decided to retain the term relational, whilst leaning
into Buber’s notions of presence, confirmation and
inclusion. Thirdly, there was some opposition to a
‘Rogerian’ flavour in the original description and the
GT stance of differentiation and challenge, and this led
to some revisions in the description of the concept, as
reproduced above. Finally, there was much discussion
about the proposition that the therapist does not set an
agenda. While most agreed with this as a basis for GT,
there was deliberation about the role of the therapist in
co-creating the therapeutic space. Most agreed that
some kind of interpretation from the therapist is
always informing the contact with the client, but
some were wary of a top-down approach. In the
therapist behaviours submitted to the second round
of the Delphi study, a balance was struck between this
inevitable tension and recognition that the importance
of field sensitivity would inflect the specific situation in
each unique therapeutic encounter.
What do Gestalt therapists do in the clinic? 37
Working in the here and now
Description of the concept
Immediate experience is the essential material for heal-
ing and growth in GT. Laura Perls observed that the
actual experience of any situation does not need to be
explained or interpreted: it can be directly contacted,
felt and described in the here and now. This is because
the act of remembering the past or anticipating the
future occurs in the present. Therefore, in the clinical
encounter, references to the past or future are brought
back to the present: focusing on what and how the client
perceives his situation now. As Gestalt therapists, we
concentrate on ‘what is’ rather than ‘what was’ or ‘what
will be’, not because we wish to ignore a person’s history
or his future intentions. For example, in the case of
sexual abuse the focus is primarily on how the abuse is
being communicated now.
The therapist and client work together on the imme-
diacy of a situation: exploring the many dimensions of
the present behaviour or affect. This is particularly the
case when the behaviour or affect is habitual or causes
suffering. Exploration of moment-to-moment aware-
ness of the present situation can assist in understanding
the choices inherent in the broader context of the client’s
life space. The past may be considered relevant to this
exploration, when the immediate situation is thematic
of habitual or past experiences. However, the emphasis is
always on the immediate encounter, such that if a client
wishes to relate an event from the past the therapist
would enquire about how it feels to tell that story now.
Working in the present supports the client to ‘stay
with’ his situation rather than shift or change it. This
concept is reflected in the paradoxical theory of change
that maintains that the focus of the therapy is not to
change, but to embrace as fully as possible all aspects of
an experience, by increasing awareness of that experi-
ence. The aim is not to change, but paradoxically to stay
the same, and to engage more fully in that experience.
Once full acceptance is reached, then change follows
that process of acceptance.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist enquires about the client’s immediate
presentation.
.The therapist supports the client to stay with what is
happening in the encounter between them, by
enquiring and seeking to extend awareness about
immediate sensation, affect, cognitions and somatic
presentations.
.The therapist supports the client to accept and
deepen his awareness of his presenting issue rather
than trying to change it.
Feedback
Many participants preferred the term ‘immediacy’ to
‘the here and now’. Others also objected to the decon-
textualised implications of ‘the here and now’, though
this was mitigated by the operationalisation of field
sensitive practice.
Phenomenological practice
Description of the concept
Phenomenological practice is more than simply vali-
dating the client’s subjective experience. It involves
exploring the life world situations that the client
brings to each session. This requires attunement to
‘the id of the situation’ through enquiry and support
for descriptive language that captures the embodied and
sensate aspects of experience. This process may be
guided by the method of moving from the general to
the particular and avoiding abstraction. By using this
method, the therapist and client are able to grow into
the situation that they are exploring together and to
observe which elements settle into the foreground
against the background of the total situation. The
main point is to stay as close as possible to the client’s
experience and to stay with and deepen ‘what is’ for the
client.
This experiential focus takes place in the context of
three major precepts of phenomenological investiga-
tion: bracket, describe, observe. The first precept is the
rule of epoche, which entails bracketing the question of
truth or falsehood of any interpretations of reality. The
second precept is the rule of description, which dis-
courages interpretations and promotes experience–
close detailing of the immediate and concrete aspects
of a situation. The third precept is the rule of equalisa-
tion. This rule requires the therapist to treat all observed
data as equally important without assigning value or
structuring a hierarchy.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist supports the client to describe and
deepen and become more present to his experience.
.The therapist articulates the different perspectives/
experience of the therapist and client.
.The therapist encourages the client to widen his
choices rather than establishing a program for
change.
.The therapist shares (where appropriate) her own
experiences that relate to the client’s experience.
Feedback
Feedback on this concept revolved around the question
of observation, which was too removed from the inter-
38 Madeleine Fogarty, Sunil Bhar, Stephen Theiler and Leanne O’Shea
connectedness of the encounter between therapist and
client for some. By extension, there was also challenge to
the notion of equalisation: as the therapy progresses,
not all phenomena are treated equally, and fixed gestalts
or the co-created contact style between therapist and
client appropriately receive greater attention. In con-
temporary phenomenology there is greater acceptance
of subjective ‘prejudices’ that shape and inform percep-
tion. Rather than seek to reduce these, there is accept-
ance that we are each always already situated.
Working with embodiment
Description of the concept
Attention to the body is a major focus for GT. From its
inception, GT has been informed by Wilhelm Reich’s
insight that past emotional experiences are carried in
habitual bodily tensions. Some therapists might pay
attention to the body through introducing somatic
experiments. But even without introducing the possi-
bility to exaggerate a somatic habit, or trying a different
way of holding the body, GT increases awareness of the
way in which the physicality of the client is engaged in
relating to the therapist and his wider environment.
This approach is both mutual and shame sensitive. The
therapist develops awareness of her own body process
during the session, and this co-creates an embodied
field, which is supportive to the bodily life experience of
the client. Shame can often desensitise the body, and
encouraging rapid release of physical expression can be
overwhelming. So it is important to grade an embodied
approach to therapeutic work. Observation of breath
(without trying to change breathing patterns) is an
example of the GT approach to embodiment.
Therapists may seek to increase a client’s awareness of
a particular movement or gesture through an invitation
to exaggerate, or pay attention to that gesture. Thera-
pists may invite a client to put words to a pain in the
body. Connecting embodiment with thought and feel-
ings is essential, as GT does not explore and increase
somatic awareness for its own sake.
Touch is not required in working with embodiment,
though it can be used to communicate empathy, or to
offer support.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist makes observations and enquires
about the client’s embodiment (including breath-
ing).
.The therapist invites the client to identify sensations,
feelings, emotions, thoughts or images that emerge as
a consequence of attending to somatic experiences.
.The therapist invites the client to engage with his
body through experiment.
Feedback
Feedback on this concept pointed to a tendency to
neglect the relational aspect of embodiment in the
clinical alliance. The therapist calibrates her own pre-
sence and embodiment to support and/or resonate with
the client’s kinaesthetic experience. Therapists heighten
the awareness and ability of clients both to sense their
own embodied process and resonate with others. For
example, the therapist might say ‘I have a sinking feeling
in my body as you say that. I wonder what it’s like
for you?’
Field sensitive practice
Description of the concept
Field theory is considered to be the scientific basis of
GT and is fundamental to GT philosophy and
method. Field theory is a way of analysing causal
relations, such that any event or experience is the
result of many factors in which every emerging figure
of interest emerges from the ground of a person’s life
space. Figure and ground are not seen as separate
entities but as embedded elements of the person’s
organism/environmental field.
Field approaches focus on observing, describing, and
explicating the exact structure of whatever is being
studied in terms of its organisation, contemporaneity,
uniqueness, possible relevance and changing process.
There are three important aspects of ‘field’ in GT. First,
the experiential field, where the client’s perceptions and
immediate subjective experience are explored at the
level of self-awareness. Second, the relational field
between the client and the therapist. Third is the
wider field including social, historical, cultural context
(or life space) in which the client is situated.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist investigates the ground (or context)
from which the client’s presenting figure emerges.
.The therapist supports the client to identify how his
perception of his environment and prior relation-
ships and needs organise current experience.
.The therapist supports the client to identify the
uniqueness of his experience.
Feedback
Feedback on this concept was less varied than other
concepts. On the whole, most seemed satisfied with the
original description though some attempt was made to
integrate a more holistic and interconnected approach
to the field, including the systemic idea that one
experience or behaviour cannot be isolated from the
rest of the elements of the field. The therapist beha-
What do Gestalt therapists do in the clinic? 39
viours reflecting this concept attempt to include the
clinical practice in which the therapist recognises herself
as ‘a function of a field’, as defined by the current field
with the client, and uses her awareness as information
about the current field formation.
Working with contacting processes
Description of the concept
In GT, awareness can be increased by focusing on styles
of contact. The contact cycle is one of the key concepts
in GT’s understanding of how the organism reaches
towards the environment and engages in the (full or
partial) satisfaction or frustration of needs and attend-
ant meaning-making. As the client moves towards
another (or towards a satisfaction of a need by reaching
out towards the environment) there are certain char-
acteristics of this movement that the Gestalt therapist is
trained to identify as contact processes. Initially only
four stages of contact were described: fore-contact,
contact, final contact, and post-contact. These terms
were later developed into a heuristic tool: the cycle of
contact/awareness/experience. This cycle describes the
‘ideal’ interactive process of contact and withdrawal of
organism and environment as involving sensation,
awareness, mobilisation of energy, action, contact,
satisfaction (assimilation), and withdrawal.
This cycle can be useful in tracking the experience of
figure formation and identifying relational patterns
where a client may become habitually stuck. Early GT
thinkers suggested that psychological disturbances
resulted from interruptions to this cycle, which when
completed satisfactorily is regarded as ‘healthy’ self-
regulation. Seven major styles of interruption to contact
were identified: desensitisation, deflection, egotism
(self spectatorship), introjection (swallowing rules or
norms without consideration), retroflection (turning
an impulse back on the self), projection (disowning
qualities of the self and attributing them to others), and
confluence. More recent GT thinkers revised this
notion of interruptions as individualistic and inconsist-
ent with field theory and refigured the contact cycle as
styles of moderation to the flow of contact that might be
adopted in any given organism/environment. Whether
a contact style is useful or dysfunctional will depend
upon the context in which it occurs. The seven inter-
ruptions to contact were refigured on a paired con-
tinuum:
.desensitisation – hypersensitivity
.deflection – staying with
.egotism - spontaneity
.introjection – questioning/rejecting
.retroflection – expressivity
.projection – owning
.confluence – differentiation
Through this continuum, every creative adjustment
to the environment is considered a form of self-regula-
tion at the contact boundary. Observations about con-
tact style are not based on the content that a client
brings to the session, but on the way in which he brings
it (or not), including the way he brings (or does not
bring) himself to the therapist. The contact style
emerges from the relationship between the therapist
and the client. It is not a one-person event.
This formulation of patterns of contact and creative
adjustments has been further elaborated by European
and North American writers. They suggest that the
Gestalt therapist develops the ability to sense how the
client’s intentions for contact move and shift so as to
perceive the sense of an absence at the contact boundary
of the therapeutic encounter. This involves cooperation
between client and therapist to facilitate a new synthesis
of awareness and create new meaning by focusing on
experiential information that was previously not yet
figural.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist works with the client’s interactional
patterns as they emerge between client and therapist.
.The therapist and the client identify the figure
together.
.The therapist co-creates a space in which the client
and therapist explore how they are impacting each
other.
.The therapist identifies experiential processes that
have not yet been named or overted and explores the
impact of this on her awareness.
Feedback
This was the concept that attracted the most varied and
passionate feedback from participants. At one stage I
suggested to one of my supervisors (Leanne O’Shea)
that the feedback was so engaging that a conference on
the topic of contact in GT would be very lively (and
potentially lethal, she added!). The main objections
arose from the intra-psychic, individualistic paradigm
that underscored the models of contact that were
developed post-Perls, Hefferline and Goodman
(1951). It was difficult to retain the theoretical import-
ance of these models whilst also retaining the more
contemporaneous and relational GT approach in which
the contact style is emergent from the dyad, not from
the client. Many participants emphasised the import-
ance of recognising that contact always occurs in an
organism/environment relationship.
40 Madeleine Fogarty, Sunil Bhar, Stephen Theiler and Leanne O’Shea
Experimental attitude
Description of the concept
Awareness can also be explored through working with
an experimental attitude. Experiments are introduced
from material that emerges in the therapeutic encoun-
ter. Experiments are co-created by the client and thera-
pist and are graded for risk and challenge in a way that
supports the client’s capacity to engage with and deepen
into his awareness. The therapist supports an experi-
ence where the client tries out new behaviour, poten-
tially leading to new meaning-making and deeper
awareness. The therapist is sensitive to the potential
that an experiment may be shaming or rupturing of the
relationship. The therapist works with the client to
integrate material that emerges from the experiment.
The result of the experiment produces a fresh figure of
clarity for the client (a new awareness arises).
Experiments include:
.An invitation to exaggerate, minimise, repeat or
reverse a bodily gesture or behaviour.
.Empty chair work: either with an aspect of self, or
with a person with whom the client is relating.
.Working with unfinished situations from the past by
focusing on the internal structure of the therapeutic
alliance.
.Guided visualisation.
.Staying at the impasse.
.Directing awareness to breath or bodily movement
or sensations.
.Creating a safe emergency.
.Introduction of art materials, movement, music or
imagery.
Participants in the second round of the Delphi were
asked whether the following therapist behaviours reflect
this concept:
.The therapist uses material that emerges in the
therapeutic encounter as the basis for introducing
experiments to develop the client’s awareness.
.The therapist grades the experiment by eliciting
feedback from the client regarding the degree of
challenge and support that the client perceives.
.The therapist supports the client to integrate learning
and awareness that emerges from an experiment.
Feedback
Most participants agreed that an experimental attitude
is an essential and differential element of GT. This is
only the case where the experimental attitude is a
process rather than a method or technique (as some
modalities have taken up the empty chair as a technique
and decontextualised it from the relational foundations
of GT). Thus, the whole of GT is experimenting –
experimenting with contacting, presence, self-disclo-
sure, embodiment, challenge, support, where the
Gestalt therapist holds an experiential stance and
works with clients to develop experiments.
Validation of the scale
Preliminary analysis of the responses to the second
round of the Delphi study suggests that it is likely to
result in a working document containing descriptions
of therapist behaviours that the expert panel agree
characterise the specificity of GT in clinical practice.
The analysis will be completed in time for the EAGT/
AAGT conference in Taormina, Sicily, and may be the
subject of a postscript to this article in a subsequent
issue of the BGJ.
Once the analysis of the results of the Delphi study
has been completed, the next stage in the development
of the GTFS will involve the validation and reliability of
the scale. This stage involves raters being trained in the
use of the draft GTFS, rating recodings of sessions from
two groups. The first group will be videos of clinical
work by therapists trained in (and purporting to prac-
tise) GT. The second group will be videos of clinical
work by therapists not trained in (and not purporting
to practise) GT. The hypothesis to be validated is
simple: those trained in (and purporting to practise)
GT should rate higher on the GTFS than those not
trained in (and not purporting to practise) GT. Once
the scale is validated it can be used for clinical trials
(including post hoc analysis) and for training purposes.
This has been a wonderful project to be engaged in. I
have deeply appreciated the warmth and encour-
agement from the Gestalt community and have some-
times welcomed the many challenges along the way.
Research can often be a lonely path, but this project has
offered connection, and most importantly a means
towards consensus that our community needs in
order to thrive.
Notes
1. The full reference list for the Delphi study is too long for print
publication, but it can be accessed via the BGJ website (www.bri-
tishgestaltjournal.com), or be obtained by contacting the first-
named author.
2. There were three further participants who elected to not be
named.
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Madeleine Fogarty, MA, Dip Ed, Adv Dip Gestalt Therapy, Grad Dip Psych (Hons), lives (with her
large and beautiful family) in Melbourne, Australia where she has been working as a psychotherapist
and supervisor in private practice for the last seventeen years. Madeleine is currently undertaking her
PhD in Psychology at Swinburne University of Technology on the development of a fidelity scale for
Gestalt. Madeleine is a clinical member of GANZ, PACFA and a scientific board member for research
at the EAGT.
Address for correspondence: mfogarty@swin.edu.au or madeleine@madeleinefogarty.com
Sunil Bhar, PhD, is an Associate Professor at Swinburne University of Technology, and a supervisor of
this project. Sunil is Chair of the Department of Psychological Sciences, and convenes the Clinical
Psychology Programs at the university. Sunil has maintained a clinical practice for the last twenty
years, and has integrated his clinical experience into his teaching and research.
Address for correspondence: SBHAR@swin.edu.au
Stephen Theiler, PhD, is an Associate Professor in the Department of Psychological Sciences,
Swinburne University of Technology, and a supervisor of this project. Stephen is Deputy Director
of Swinburne Psychology Clinic and a member of the Australian Psychological Society and is a
counselling and clinical psychologist.
Address for correspondence: stheiler@swin.edu.au
Leanne O’Shea, MSc, DPsych is a Faculty member of Gestalt Therapy Australia, and a supervisor of
this project. She maintains a private practice in Melbourne and teaches Gestalt therapy both locally
and internationally.
Address for correspondence: leanne.oshea@gmail.com
