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Enhancing Your Therapy with Gestalt Approaches
Gestalt Therapy continuing education psychology CEUs

Section 18
Integrating Gestalt Theory into
Dual Process Model Grief and Mourning Work

CEU Question 18 | CEU Answer Booklet | Table of Contents | Gestalt
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

Dual Process Model of Coping with Bereavement (DPM)
Stroebe and Schut (2001) described their dual process model of coping with bereavement as an integration of existing ideas rather than a completely novel framework. Stroebe and Schut (1999,2001) argued the need for a stressor-specific model of coping with bereavement because death losses invariably involve multiple and diverse Stressors rather than a single Stressor. They classified these Stressors into two types: loss oriented vs. restoration oriented. Loss-oriented Stressors are those that pertain specifically to the death-loss experience itself. Examples include the disintegration of future plans with the deceased, the ending of the physical relationship with the deceased, and the lack of social support once offered by the deceased. In contrast, restoration-oriented Stressors are those that are secondary (with regard to timing rather than intensity) to the death loss such as the addition of new household chores, decreases in financial resources, and altered communication patterns with friends and family members. Associated with each of these two types of Stressors is a specific coping orientation. Loss-oriented coping involves focusing on and processing aspects of the loss (e.g., visiting the grave, looking at photographs, emoting related to the death), while restoration-oriented coping involves focusing on the secondary Stressors that must be dealt with (e.g., financial problems) and determining how to tackle them (e.g., selling one's house). The core of DPM is the contention that the oscillation between these two types of coping processes actually is essential for adaptive coping. Through the concept of oscillation, Stroebe and Schut have managed to maintain the benefits of two of the most difficult to reconcile aspects of the mourning process: the need to move on with life and the desire to remain connected to the deceased (DeSpelder & Strickland, 2002).

DPM and counseling theories. Although the primary emphasis, here, is placed on the intriguing parallels between DPM and Gestalt theory (Perls, 1969), mental health counselors identifying with a behavioral (Wilson, 2000), person-centered (Rogers, 1980), or Jungian (Douglas, 2000) framework may find DPM concepts useful in their work with bereaved clients. With regard to behavioral and person-center approaches, recent research (Schut et al., 1997) found that widowed males assigned to a person-centered intervention showed lower distress following treatment, as did widowed females assigned to the behavioral approach; whereas men assigned to the behavioral and women to a person-centered approach exhibited little improvement. Schut et al. suggested that women naturally tend toward loss-oriented coping while men naturally tend toward restoration-focused coping and argued that individuals may benefit more when treatment challenges them to concentrate on the type of coping processes to which they are less accustomed. Because DPM has a strong non-linear emphasis, the counseling theories that emphasize holism and balance are a natural fit. For instance, the link with Jung's analytical approach is clear as he viewed the world in terms of paired opposites engaged in active struggle (Douglas). Similarly, Gestalt counseling theory suggests that individuals are self-regulating and inclined toward growth, with health being defined as the organism's awareness, recognition, and appropriate attention to needs and desires as hierarchically required (Yontef & Jacobs, 2000). Through the process of organismic self-regulation, the most pressing need / desire emerges from the background of the mind as a figure. When this figured need is addressed and attended to, it then blends into the background as the next figure in the hierarchy emerges. For healthy individuals, this process is fluid, and figures shift quite rapidly.
As both emphasize the person-environment dialectic, the gestalt approach to health and adjustment blends well with the DPM distinction between the two major types of Stressors associated with death loss: Those that can be addressed through internal processing, and those associated with the secondary losses in the environment that may be more amenable to external adjustments. Creative adjustment is the Gestalt term used to describe the process employed by individuals when they are faced with the changing demands of the environment, such as a death loss (Sabar, 2000). More specifically, creative adjustment involves a balance between internally adjusting to current conditions and externally working to change the environment, when such change is possible and appropriate (Yontef & Jacobs, 2000). Creative adjustment occurs when individuals are aware of their own organismic functioning such that they attend to the hierarchical needs / desires that emerge in new situations and make the appropriate internal and external adjustments. For bereaved individuals, "creative adjustment during mourning means adapting to 'what is,' changing oneself and reorganizing one's environment to fit the new reality of the deceased person no longer being physically present" (Sabar, p. 161). This description clearly parallels the DPM.

Another strong connection between DPM and Gestalt theory is the attention given by both to dualism and oscillation. According to Gestalt theory, life is marked by polarities (Yontef & Jacobs, 2000), and each figure stands against an opposite ground. For healthy functioning, both poles of each dichotomy must be allowed to become figures, and the constantly shifting balance between the poles is critical to the process of creative adjustment. As connected with the DPM, bereaved individuals have a dichotomy with regard to loss- and restoration-oriented coping, and both poles must be allowed to rise as figures and be addressed as hierarchically required by the organismic functioning of the individual. After a loss, bereaved individuals need to self-regulate both the pace and intensity of their grief, following a comfortable rhythm of avoidance of and attention to the pain so that they become neither overwhelmed nor numb (Sabar, 2000). Based on her clinical work with the bereaved, Clark (1982) took this notion of rhythm even further and defined times within the mourning process as either periods of connecting or separating. The similarity between her descriptions of these periods and the loss and restoration orientations of DPM is striking. More specifically, Clark explained that during connecting times, "people were involved in their life activities, making plans, doing everyday tasks, exploring and experimenting" (p. 59). In contrast, when in a time of separating, peoples attention centered on the impact of their loss. Thus, in a wave-like rhythm, "therapy flows back and forth during transition times between awareness of separating and awareness of connecting, between times of 'living' and times of 'dying'" (p. 61).

Just as Stroebe and Schut (1999,2001) described complicated grief as a disturbance in the oscillation, Gestalt theory suggests that neurotic regulation occurs when some aspects of one's mental background are not allowed to become figures, that is, when the polarities are not fluid, but rather become hardened dichotomies (Yontef & JacoDs, 2000). The recommendation for mental health counselors with regard to both approaches is to foster the acknowledgement and expression of both dimensions, loss and restoration, thereby encouraging clients toward balance.
- Servaty-Seib, Heather L.; Connections Between Counseling Theories and Current Theories of Grief and Mourning; Journal of Mental Health Counseling, Apr2004, Vol. 26 Issue 2
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #4
The preceding section contained information about integrating Gestalt techniques into grief and mourning work.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
What is the definition of the Gestalt term "creative adjustment"? Record the letter of the correct answer the CEU Answer Booklet.

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Table of Contents

Enhancing psychotherapy process with common factors feedback: A randomized, clinical trial.
In this study, we developed and tested a common factors feedback (CFF) system. The CFF system was designed to provide ongoing feedback to clients and therapists about client ratings of three common factors: (a) outcome expectations, (b) empathy, and (c) the therapeutic alliance. We evaluated the CFF system using randomized, clinical trial (RCT) methodology. Participants: Clients were 79 undergraduates who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments. These clients were randomized to either: (a) treatment as usual (TAU) or (b) treatment as usual plus the CFF system (TAU + CFF). Both conditions entailed 5 weekly sessions of evidence-based therapy delivered by doctoral students in clinical psychology. Clients completed measures of common factors (i.e., outcome expectations, empathy, therapeutic alliance) and outcome at each session. Clients and therapists in TAU + CFF received feedback on client ratings of common factors at the beginning of Sessions 2 through 5. When surveyed, clients and therapists indicated that that they were satisfied with the CFF system and found it useful. Multilevel modeling revealed that TAU + CFF clients reported larger gains in perceived empathy and alliance over the course of treatment compared with TAU clients. No between-groups effects were found for outcome expectations or treatment outcome. These results imply that our CFF system was well received and has the potential to improve therapy process for clients with depressive symptoms. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Can reflecting on personal values online increase positive beliefs about counseling?
This research developed and tested an online values-affirmation exercise to attenuate threat and enhance positive beliefs about counseling among individuals struggling with mental health concerns. There is evidence that reflecting on personal values (values-affirmation) is an effective approach to eliciting self-affirmation—a psychological process that temporarily bolsters self-worth in order to forestall maladaptive, self-protective responses to counseling information. The present study utilized a randomized 2-group between-subjects design to test the effectiveness of a values-affirmation exercise with an online sample (N = 186) of adults who reported struggling with a mental health concern. It was predicted that values-affirmation would reduce threat related to reading mental health information and increase positive beliefs about counseling. Results indicated that those in the values-affirmation condition reported fewer negative emotions such as feeling upset, irritable, hostile, and scared after reading mental health information, indicating that the information was perceived as less threatening. There was also evidence that engaging in values-affirmation was associated with greater anticipated growth in counseling and greater intent to seek counseling, reflecting greater positive beliefs about counseling. Overall, the results suggest that reflecting on personal values may have the potential to enhance the positive effects of online psychoeducation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Depression symptoms moderate the association between emotion and communal behavior.
Depression is associated with emotion regulation deficits which manifest as elevated negative affect and greater continuation of negative affect over time. The present study examined a possible emotion regulatory deficit, whether depression symptoms attenuate the association between communal (i.e., agreeable, quarrelsome) behavior and affect. A community sample reported on depression and anxiety symptoms before recording their affect and behavior following naturally occurring interpersonal interactions over 21 days. Participants’ behaviors were measured using items selected to represent the Interpersonal Circumplex Model of behavior. Results indicated an association between affect and communal behavior, which was stronger for negative than positive affect. Depression symptoms moderated this association; elevated depression symptoms were associated with decreased association of affect and interpersonal behavior. Comorbid anxiety symptoms did not moderate this association. Results suggest that elevated depression symptoms are associated with a diminished ability to adapt communal behavior to emotion cues. Given prior evidence of elevated overall quarrelsome behavior among individuals with elevated depression symptoms, this may demonstrate an interpersonal mechanism by which emotion regulation deficits impact the generation of interpersonal problems. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Thwarted belongingness, perceived burdensomeness, and depression among asian americans: A longitudinal study of interpersonal shame as a mediator and perfectionistic family discrepancy as a moderator.
This short-term longitudinal study applied Joiner’s (2005) Interpersonal-Psychological Theory of Suicide to Asian Americans’ experiences with depression. Interpersonal shame (i.e., the experience of inadequacy arising from interpersonal concerns) was hypothesized to mediate the effects of (a) thwarted belongingness and (b) perceived burdensomeness on future depression. Furthermore, the positive associations between (a) thwarted belongingness and (b) perceived burdensomeness on future depression were hypothesized to vary depending on students’ experiences with perfectionistic family discrepancy (PFD; their perceived gap between their actual performance and what their parents expect of them). A total of 605 Asian Americans attending predominantly White, Midwestern universities completed 3 online surveys. Conditional process modeling via Hayes’s (2013) PROCESS was used to analyze the data. Results demonstrated that (a) thwarted belongingness and (b) perceived burdensomeness contributed to higher interpersonal shame, which influenced students’ future depression. Furthermore, the effect of thwarted belongingness on future depression was significantly positive for those with PFD levels greater than the 12th percentile, after taking into account students’ initial level of depression. The effect of perceived burdensomeness on future depression was not significant for those with PFD levels greater than the 3.5th percentile. This study identified that students with perfectionistic family discrepancy may be at higher risk for depression while experiencing thwarted belongingness. Overall, findings supported using Joiner’s (2005) theory to understand Asian American students’ risk for future depression. Future studies may gather data across Asian American students’ years in college. Counselors can apply these findings to increase students’ awareness about possible risk factors for depression. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Distress disclosure and psychological functioning among Taiwanese nationals and European Americans: The moderating roles of mindfulness and nationality.
Research using Western samples shows that talking about unpleasant emotions—distress disclosure—is associated with fewer psychological symptoms and higher well-being. These benefits of distress disclosure may or may not be observed in East Asia where emotional control is valued. Instead, mindfulness may be more relevant to emotion regulation in East Asia (e.g., Taiwan). In the present study, cultural context (Taiwanese nationals vs. European Americans) and mindfulness were examined as moderators of the relation between distress disclosure and both depression symptoms and life satisfaction. A sample of 256 Taiwanese college students and a sample of 209 European American college students completed self-report measures in their native language. Moderated multiple regression analyses revealed significant interaction effects of mindfulness and distress disclosure on both depression symptoms and life satisfaction for Taiwanese participants but not for European Americans. Specifically, distress disclosure was negatively associated with depression symptoms and positively associated with life satisfaction for Taiwanese low in mindfulness but not for Taiwanese high in mindfulness. For European Americans, distress disclosure was not associated with depression symptoms but was associated with higher life satisfaction, regardless of one’s level of mindfulness. These findings suggest that the potential benefits of disclosing distress are a function of one’s cultural context as well as, for those from Taiwan, one’s mindfulness. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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