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Exploring the influence of gestalt therapy training on psychiatric nursing practice: Stories from the field

Teresa Kelly and Linsey Howie School of Public Health, La Trobe University, Melbourne, Victoria, Australia

ABSTRACT: Psychiatric nurses interested in extending their interpersonal and psychotherapeutic skills sometimes undertake postgraduate training in gestalt therapy. Little is known about how this new knowledge and psychotherapeutic skill base informs their practice. This paper presents the findings of a qualitative study that aimed to explore the influence of gestalt therapy training on psychiatric nursing practice. Within a framework of narrative inquiry, four psychiatric nurses trained in gestalt therapy were invited to tell their stories of training in a gestalt approach to therapy, and recount their experiences of how it influenced their practice. In keeping with narrative analysis methods, the research findings were presented as a collection of four stories. Eight themes were derived from a thematic analysis conducted within and across the four stories. The discussion of the themes encapsulates the similarities and differences across the storied collection, providing a community and cultural context for understanding the individual stories.

KEY WORDS: gestalt therapy, holism, psychiatric nursing, psychotherapy, qualitative research.

INTRODUCTION

Cognitive behavioural therapies that are validated using standardized trials, dominate the psychotherapy discourse in contemporary mental health-care contexts (Hurley et al. 2006; Yontef & Jacobs 2007). However, standard- ized trials often do not take into account the interpersonal nature and ‘whole process of therapy’ (Yontef & Jacobs 2007, p. 354), central to the efficacy of the relational and experiential psychotherapies, contributing to these approaches being disadvantaged in the dominant scien- tific paradigm.

It is timely then to incorporate the art with the science of mental health care. In psychiatric nursing, the art lies in the humanistic, interpersonal, and therapeutic encounter, and the subtle crafts of human-to-human interconnectedness.

Gestalt therapy is a humanistic, holistic, and relational psychotherapeutic approach that aligns well with the humanistic values and interpersonal processes espoused as central to psychiatric nursing (Chambers 1998; Dziopa & Ahern 2009; Hurley et al. 2006; Moyles 2003; Peplau 1952; 1962; Welch 2005; Wright 2010).

Psychiatric nurses interested in advancing their psy- chotherapeutic agency sometimes undertake training in gestalt therapy. There has, however, been negligible research into how this training has influenced their discipline-specific practice. This qualitative study aimed to explore the influence of gestalt therapy training on the professional practice of psychiatric nurses.

To begin, an overview of gestalt therapy theory is nec- essary to provide readers new to the gestalt approach with a theoretical context to the research findings presented in this paper.

THEORETICAL OVERVIEW OF GESTALT THERAPY

Fritz Perls founded gestalt therapy during the 1940s and 1950s in collaboration with Laura Perls and Paul

Correspondence: Teresa Kelly, Northern Area Mental Health Service, c/ The Northern Hospital, 185 Cooper Street, Epping, Vic. 3076, Australia. Email: [email protected].au

Teresa Kelly, RN, MHN, PGradDip(AdvClinNursMH), MGestTher, BHIM.

Linsey Howie, PhD, MA, BA, DipOT. Accepted November 2010.

International Journal of Mental Health Nursing (2011) 20, 296–304 doi: 10.1111/j.1447-0349.2010.00729.x

© 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

Goodman (Yontef & Jacobs 2007). The origins of gestalt therapy were deeply influenced by the philosophical, cul- tural, and intellectual trends of the time (Yontef & Jacobs 2007), including existentialism, phenomenology, holism, humanism, gestalt psychology, field theory, interpersonal psychoanalysis, and Eastern philosophies (Clarkson & Mackewn 1993; Clarkson 1989; Mackewn 1997; Yontef & Jacobs 2007).

Contemporary gestalt is an experiential, relational, and process-oriented therapy. Its present-centred focus means that rather than looking to the past or imagining the future, it focuses on the ‘here and now’, thereby facilitating clarity of a person’s needs, goals, and values (Yontef & Jacobs 2007). Developing awareness and insight is a key focus in gestalt therapy (Hurley et al. 2006; Yontef & Simkin 1993). Yontef and Simkin (1993) describe awareness as ‘a form of experience that may be loosely defined as being in touch with one’s own exist- ence, with what is’ (p. 144). They describe the ‘person who is aware’ as one who ‘knows what he does, how he does it, that he has alternatives and that he chooses to be as he is’ (p. 145).

Gestalt therapy aims for self-knowledge, acceptance, self-responsibility, authenticity, and personal growth (Clarkson 1989; Yontef & Jacobs 2007; Yontef & Simkin 1993). The integration of fragmented parts of the self into a unique whole in the social and environmental context of a person’s life is central to the gestalt approach (Clarkson 1989; Hurley et al. 2006; Yontef & Simkin 1993). Accord- ing to Clarkson, wholeness is a cornerstone of gestalt therapy, emphasizing wholeness of the person and their experiences. In gestalt theory, the wholeness of human experience is understood through the perceptual prin- ciple of figure and ground (Clarkson 1989; Mackewn 1997). This principle, conceptualized as the cycle of expe- rience (Clarkson 1989; Joyce & Sills 2010; Mackewn 1997), provides a metaphor for understanding the aware- ness process (Joyce & Sills 2010) and extends throughout much of gestalt therapy theory and practice. Fundamen- tal theoretical perspectives in a gestalt approach include field theory, phenomenology, dialogue, and the paradoxi- cal theory of change.

Field theory Field theory provides a holistic perspective that appreci- ates the interrelationship of the person with the environ- ment (Lewin 1951; Mackewn 1997; Melnick 1997; Parlett 1991; Yontef & Simkin 1993). In gestalt therapy the ‘individual–environment entity is known as the field, where the field consists of all complex interactive phenom- ena of individuals and their environment’ (Mackewn

1997, p. 48). In this way, field theory takes into account the total situation (Lewin 1951; Parlett 1991; 2005), appreciating wholeness, complexity, and context, rather than reducing a situation to a collection of parts (Joyce & Sills 2010; Mackewn 1997; Parlett 1991; Yontef & Jacobs 2007). In gestalt, field theory provides the basis for a holistic, therapeutic approach (Joyce & Sills 2010) that encompasses the view that ‘people cannot be understood without understanding the field, or context, in which they live’ (Yontef & Jacobs 2007, p. 329).

Phenomenology Phenomenology is a method of exploring the nature of phenomena and of existence (Joyce & Sills 2010; Spinelli 2005). In a therapeutic setting, the phenomenological method has been adapted as a means of exploring the subjective meaning of a client’s experience of ‘himself and his world’ (Joyce & Sills 2010). The goal of phenomeno- logical inquiry is clarity of awareness and insight (Yontef & Jacobs 2007; Yontef & Simkin 1993). From a gestalt therapeutic perspective, the phenomenological approach involves staying as close as possible to the client’s experi- ence (Joyce & Sills 2010), with an emphasis on descrip- tively exploring and developing the client’s awareness moment to moment, rather than attempting to explain or interpret his or her behaviour (Joyce & Sills 2010; Yontef & Jacobs 2007). Therefore, the phenomenological method is as much an attitude of openness and curiosity as it is of actual techniques (Joyce & Sills 2010; Mackewn 1997).

Dialogic relationship A central focus of a gestalt approach to therapy is the relationship between the therapist and the client (Hycner & Jacobs 1995; Yontef & Jacobs 2007; Yontef & Simkin 1993). In gestalt, the therapeutic relationship is referred to as the dialogic relationship (Hycner & Jacobs 1995; Joyce & Sills 2010). It is based on an existential encounter between two people that is non-hierarchical and has an ‘emphasis on full and genuine engagement between patient and therapist’ (Hycner & Jacobs 1995, p. 52). Gestalt theory identifies the potential for change and self-development as emerging through this exis- tential encounter between the client and the therapist (Mackewn 1997).

Paradoxical theory of change The paradoxical theory of change (Bessier 1970) is another central concept in gestalt therapy (Joyce & Sills 2010; Yontef & Jacobs 2007). In this theory, Bessier

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proposed that ‘change occurs when one becomes what he is, not when he tries to become what he is not’ (Bessier 1970, p. 77). Contemporary gestalt theorists and thera- pists embrace this concept, recognizing that in therapy and in life, people change only when they fully accept and become who they are in the present moment (Joyce & Sills 2010; Mackewn 1997; Yontef & Jacobs 2007).

METHODS

Aim The aim of this qualitative research study was to explore the influence of gestalt therapy training on psychiatric nurses’ practice.

Participants The participants were four psychiatric nurses trained in gestalt therapy. The small sample size was consistent with qualitative research where the richness of the data and their capacity to encompass the dimensions of the topic of inquiry was more important than the number of partici- pants (Rice & Ezzy 2001; Whitehead & Annells 2007). Snowball sampling (Patton 2002; Whitehead & Annells 2007) was employed to recruit six potential participants: two men and four women. Both men chose not to partici- pate in the study. The researchers did not consider sex balance to be important to the research topic (Kelly & Howie 2007).

At the time of the study, the four participants were working as registered psychiatric nurses in Victoria, Aus- tralia. Their practice settings included adolescent mental health; a specialist mental health service; education and professional development; and private practice (Kelly & Howie 2007).

Ethical considerations The study was approved by the La Trobe University Faculty of Health Sciences Ethics Committee. All partici- pants provided informed consent. To assure confidential- ity, a pseudonym was applied to each participant at the data collection phase, and any potentially identifying data evident in the transcripts were omitted or changed early in the data analysis process (Kelly & Howie 2007).

Data collection Qualitative data were collected through semistructured, individual narrative interviews. The narrative interview techniques were employed with the specific intent of eliciting narrative responses from the research partici- pant (Kelly & Howie 2007; Rice & Ezzy 2001; Riessman

1993). Each narrative interview was audiotaped and transcribed.

Data analysis A narrative analysis type of narrative inquiry was employed in this qualitative study (see Emden 1998a,b; Polkinghorne 1995). In this type of narrative inquiry, data analysis involves reduction, synthesis, and recon- figuration of the data to produce stories as the research outcome (Kelly & Howie 2007; Polkinghorne 1995). The product of the narrative analysis employed in this study was a collection of four stories. Because the researchers were interested in exploring the stories of the partici- pants as individuals and as members of a community of gestalt-trained psychiatric nurses, they conducted a the- matic analysis across the storied database. This involved the systematic, rigorous, and careful examination of the plots and subplots common to all stories to identify common elements and experiences across the stories, and the synthesis of these to inform eight emerging themes (Kelly & Howie 2007). This process encom- passed the emplotment reasoning of Polkinghorne (1995), while utilizing procedures described by Emden (1998b) for examining plots, subplots, and themes across all four core stories.

RESULTS AND DISCUSSION

The comprehensive across-story analysis conducted across the storied collection identified eight themes: ‘growing professionally in fertile ground’, ‘resonating with the gestalt potential’, ‘emerging gestalt potential in psy- chiatric nursing settings’, ‘gestalt learning: the self in process’, ‘bringing gestalt into psychiatric nursing prac- tice’, ‘expressing the multidimensional influence of gestalt therapy on advanced psychiatric nursing practice’, ‘inte- grating and assimilating gestalt’, and ‘making sense’.

Mapping the themes to the gestalt experience cycle Faithful to the narrative methodology underpinning this study, the themes were located within a temporal frame- work that encompassed the participants’ experiences of their personal and professional transitions (Polsters 1987). In this way, the themes are part of a collective ‘temporal gestalt’ (Polkinghorne 1995, p. 18) or whole, reflecting the storied experience of all the participants.

Conceptualizing the themes as a ‘temporal gestalt’ was useful in this study, as it incorporated the understand- ings inherent in narrative analysis, while lending itself to being understood within a gestalt therapy theoretical

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framework’. In gestalt theory, a temporal gestalt can be understood as the cycle of gestalt formation and destruc- tion: the temporal process of experience evolving through stages (Clarkson 1989).

In the literature, while some gestalt theorists have rep- resented the process of experience as a circle (Clarkson 1989; Joyce & Sills 2010; Sills et al. 1996), others have represented it as an open-ended wave (Gaffney 2009; Mackewn 1997; Zinker 1977). Inspired by Clarkson (1989) and Joyce and Sills (2010), we refer to the process of experience as the ‘gestalt experience cycle’, and repre- sent it diagrammatically as a circle for the purpose of emphasizing the temporal, cyclical, and whole nature of experience (Clarkson 1989; Sills et al. 1996). Figure 1 dia- grammatically maps the eight themes identified in this study to the gestalt experience cycle.

In the gestalt experience cycle, a ‘dominant figure emerges from a background, claims attention and fades into the background again as a new compelling figure emerges’ (Clarkson 1989, p. 27). For example, a woman browsing in a bookshop gazes upon a book. As she reads

its dust cover, the other books fade into the background. Then another book catches her eye and it becomes figural, and so on.

Cycles of experience can be microscopic, such as the process of breathing in and out. They can also be macro- scopic and take many years, such as studying for a degree, raising a child, or a person’s lifetime (Clarkson 1989; Mackewn 1997). Smaller cycles can occur within larger cycles. They are like stories within stories.

This study was concerned with the macroscopic expe- rience cycle relevant to the participants’ experiences of the influence gestalt therapy training on their psychiatric nursing practice. In this way, the cycle encompasses the participants’ journeys into and through gestalt training and their experiences of how the training influenced their practice and their professional lives as psychiatric nurses.

The following discussion of the eight themes encapsu- lates the similarities and differences across the storied collection, and provides a community and cultural context for understanding the individual stories.

FIG. 1: Mapping the themes to the gestalt experience cycle (adapted from Clarkson 1989).

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Growing professionally in fertile ground This theme relates to the ‘the fertile void’ (Perls 1969, p. 57): a period of rest and calmness that occurs between the completion of one gestalt and the emergence of a new one. It is described as a space rich with limitless possibili- ties (Clarkson 1989; Joyce & Sills 2010; Mackewn 1997; Sills et al. 1996).

‘Growing professionally in fertile ground’ describes the background features of the participants’ lives prior to the commencement of their gestalt therapy journey. This theme provides the context for the imminent emer- gence of their interest in gestalt therapy. Common to the background or ‘ground’ of all the participants was their unique features, their professional environments, and their energetic involvement in professional develop- ment pursuits.

Mary’s ground was one of creativity. Even before she began gestalt training, she was working creatively with people who had long-term mental illness. Cathy’s ground included an enduring desire to ‘practice holistically’. Sally’s ground was one of change and professional chal- lenge, and Peta’s was very much structured around her professional experience and expertise. The professional environments of all four participants, although varied with regard to the type, nature, and even location in time, were all rich in terms of experience and possibilities.

Resonating with the gestalt potential This theme relates to the sensation phase of the gestalt experience cycle. It is when raw sensory information begins to register for the individual, but is ‘before these possibilities come fully into meaningful awareness’ (Clarkson 1989, p. 32). It is here that the participants’ interest in gestalt therapy began to emerge as a new figure from a previously undifferentiated ground.

‘Resonating with the gestalt potential’ is about the par- ticipants sensitizing and attuning themselves to the field and the context of their current environment. Across the stories, this theme encompasses a kaleidoscope of influ- encing factors that oscillate in the fields of the participants as individuals. In this theme, the field is alive with stir- rings, influences, and possibilities. It captures what it was about the participants’ professional and personal contexts that contributed to and heightened their interest in gestalt therapy, and its potential scope in relation to their psychi- atric nursing practice. An unmistakable openness to influ- ences and practice possibilities outside of the more traditional ‘medical model’ psychiatric nursing role was common across the participants’ stories. Each participant was in professional contact with colleagues skilled in psy- chotherapeutic modalities or group work, and had some

exposure to exploring practice possibilities lateral to more medically-orientated psychiatric nursing practice.

Emerging gestalt potential in psychiatric nursing settings This theme relates to the awareness phase of the gestalt experience cycle. In this phase, the new figure that started to form in the earlier phase begins to impinge on an individual’s awareness and becomes the point of interest for the individual (Clarkson 1989). In ‘emerging potential in psychiatric nursing settings’, the emerging interest in gestalt training sharpened for the participants. The par- ticipants became more attuned to their field, as they began to see the potential application of their gestalt therapy knowledge and skills to their psychiatric nursing practice within their respective practice settings.

Gestalt learning: the self in process ‘Gestalt learning: the self in process’ encompasses the self-learning, personal growth, and self-awareness inher- ent in gestalt therapy training and the impact of this on the participants’ professional lives. Throughout this theme, the participants were more fully engaging in the awareness phase of the gestalt experience cycle through deepening their awareness of their own personal process. This theme encompasses the concept of the ‘self as chang- ing process and self as enduring identity . . .’ (Mackewn 1997, p. 76), in that the participants developed personal insights, awareness, and understandings, and integrated these into their personal and professional lives. Peta’s reflections on her choice of career provided an exquisite example of the integration of such self insights:

Someone commented that one of my functions in my gestalt training group was to make the group feel safe. This was interesting feedback, given my choice of career, which is about containing people and making people feel safe. It hadn’t occurred to me that I would do that in another setting.

The participants also told of the challenge inherent in the personal growth and self-awareness aspects of gestalt training. Mary’s metaphor of gestalt training being like a washing machine captures the challenge inherent in the personal growth process:

The influence of gestalt therapy training on my life and . . . my work as a psychiatric nurse is like a washing machine. It’s washed me clean. I feel spun dry and ready. Being spun about in a washing machine is a ‘bloody awful’ thing. It’s also very cleansing, if you can hack it. . . . (Kelly & Howie 2007, p. 142)

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Cathy’s story captures the rawness of her experience and the paradox of this challenge becoming a source of valuable learning:

The first year . . . was very experiential and involved intense personal work. It was quite traumatic for me. The process of increased self-awareness had quite a destabi- lizing effect on me . . . Yet at the same time, this experi- ence was quite useful. It helped me to become aware of my ‘own stuff’ so that I could hold it and be more able to work therapeutically with my clients. As I progressed in my gestalt training, I developed confidence and ability to just be with my clients in their distress and discomfort.

Bringing gestalt into psychiatric nursing practice This theme relates to the mobilization and action phases of the experience cycle. In the mobilization phase, the emerging figure becomes sharper and generates energy (Clarkson 1989). The person begins to respond to the sharpening figure, makes sense of it, and prepares to act (Sills et al. 1996). In the action phase, the person experi- ments with different courses of action, as they progress towards achieving their goal (Sills et al. 1996).

‘Bringing gestalt into psychiatric nursing practice’ is descriptive of how the participants began to connect with gestalt theory and apply it actively to their psychiatric nursing practice. The participants experimented with bringing aspects of gestalt to their psychiatric nursing practice, making flexible adaptations to gestalt interven- tions to ensure the appropriateness of the intervention to the specific needs of their clients (see Yontef & Jacobs 2007). The influence of the participants’ gestalt training became progressively evident, as it began to inform their individual and group interventions with clients. Collec- tively, the participants’ stories were replete with many practical examples of how they applied their gestalt knowledge and skills to their psychiatric nursing practice during their training years. Mary recalled a rich and poi- gnant story of her application of her gestalt learning to her work with a man with long-term mental illness:

One of my clients . . . was psychotically depressed and frequently attempted suicide . . . Following a gestalt training session on projection, I was working with this man in my office. My hat trunk was open. He picked up a hat and put it on his head and I put one on my head. We began playing characters. These hats helped us talk about his mental illness and his thoughts about suicide . . . This story speaks to me about the power of the creativity of gestalt. I tried to go with where my client was; with his energy. Paradoxically, we got back to his illness, which is what did need to be talked about. It was through

projective work that this client and I engaged and then moved on to deeper and more meaningful work. (Kelly & Howie 2007, p. 142)

Cathy’s description of the influence of her gestalt train- ing on her work as psychiatric nurse–therapist captures the development of a much more ‘dialogic’ and relational therapeutic style:

Prior to gestalt training, I had shied away from thinking about my impact on the client, my relationship with them, and what happens between the client and me. During my training, I started to think about my relationship with my client. I also began to take more responsibility for the impact I had on my client. I moved from being focused on the content of my client’s story to encouraging them to think about what we were actually doing together in the therapy sessions.

Peta’s story of a ‘relationship group’ provides a descrip- tion of her application of gestalt theory and practice to her group work as a psychiatric nurse in adolescent mental health. Peta identified her interventions in this group as being primarily sensitive to the needs of the young people yet very much informed by her gestalt learning:

One of the groups was about pre-existing relationships. In this group, we sat in a circle, pretending to be around a campfire, and told stories of our family and of our ances- tors. I encouraged each participant to respond to the young person who told the story: ‘What was it like for you when you heard that?’ In this way, I was able to gently support these emotionally and socially-disabled young people to support each other. This helped the sense of cohesion and altruism in the group. My intervention was framed by what I learnt in my gestalt training. It was about supporting the young people in sharing an emo- tional response and being in relationship. It was about connection.

Expressing the multidimensional influence of gestalt therapy on advanced psychiatric nursing practice This theme relates to the contact phase of the gestalt experience cycle. In this phase, there is energy, excite- ment, interest, and engagement (Clarkson 1989; Sills et al. 1996). Expression in this sense is compatible with achieving full contact with the figure of interest of the gestalt experience cycle (Clarkson 1989; Mackewn 1997; Wheeler 1991).

The theme provides a clear description of the partici- pants’ full engagement with gestalt theory and practice and how it relates to their multifaceted, advanced psychi- atric nursing roles. Specifically, this theme identifies the dialogic, phenomenological, and field theoretical

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influences in the professional practice areas of nursing professional development, management, nursing educa- tion, clinical supervision, and individual and group therapy.

Cathy articulated her ‘interest in the experiential aspects of gestalt’. Her description of working in the moment with clients provides an example of the evolving and mature gestalt influence on her psychotherapeutic work with clients following her training years:

I work with the individual clients in the group to capture some confidence or self-esteem and encourage them to fully experience what it feels like to experience confi- dence or self-esteem in the moment that it happens. Not just talking: actually being in there doing it, and talking about it too.

Sally’s story about sharing her gestalt knowledge and skills with her work team provides a snapshot of the vibrancy, energy, excitement, and expression that is ‘final contact’ (See Clarkson 1989, pp. 33–34). Her story dem- onstrates her full engagement with bringing her gestalt knowledge into her psychiatric nursing practice and to her work team:

What stands out for me is the interest and curiosity about gestalt among the staff. They wanted to run groups with me and to learn about gestalt . . . Together, we explored lots of questions: ‘How might a situation be understood from a gestalt point of view?’ ‘What might be a gestalt understanding of the person’s experience?’ . . . We explored a person’s field, rather than just thinking about their history and genogram.

Sally identified that, as a manager, gestalt helped her to ‘be more attentive to the different skills within the staff group’ and to ‘think differently about management issues’. Sally’s example of dealing with ‘scapegoating’ in a work team provides a description of how gestalt influenced her work as a manager:

I think about what purpose scapegoating might serve in the team . . . what’s happening in the context of the field? I consider what might be happening for that individual with those people around them, and what’s leading to things being the way they are. Gestalt has given me a broader way of looking at situations. It has also given me more scope and more ways of dealing with things.

Integrating and assimilating gestalt This theme relates to the phase of the gestalt experience cycle that involves ‘satisfaction and gestalt completion’ (Clarkson 1989, p. 35). This phase occurs on the comple- tion of a life experience and reaching a point of reflecting on its meaningfulness in relation to one’s past and present

life. ‘Integrating and assimilating gestalt’ encompasses how gestalt became integrated and assimilated into the participants’ psychiatric nursing practice and professional ways of being subsequent to their gestalt training years. The influence of gestalt therapy is evident in the partici- pants’ more reflective and confident professional styles that are mindful of the importance of relationship and the impact of phenomenological and field theoretical influ- ences across their spectrum of practice. Mary reflected:

I hardly think about myself as a gestalt psychiatric nurse, but I am. It’s integral to who I am. I’m very phenomeno- logical and really curious. I am interested in how nurses and patients view their world . . . My understanding of field theory and my living of it helps me see what’s going on. I’m incredibly observant. I’m mindful of the big picture and the interrelated parts. Relationship is impor- tant. How I meet you and show myself to you is the crux. It can mean that we get done

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