Common mental disorders in Gestalt therapy treatment: a multiple case study comparing patients with moderate and low integrated personality structures

Abstract

Introduction: Empowerment is central to self-development and growth in Gestalt therapy. The self evolves through interactions with others, forming self- and object-relations, and ego-functions. Underlying structural functions build the ability to regulate, differentiate, and integrate experiences, leading to self-, and emotion-regulation. Our study examined the self-development of seven clients with prevalent mental health issues and structural challenges, all of whom underwent 30 sessions of Gestalt therapy in a real-world individual therapy context.

Methods: Using a multiple case study approach, we contrasted two client groups: those with moderately integrated and those with low-integrated personality structures, as defined by the operationalised psychodynamic diagnostic manual. Our exploration centered on specific factors of empowerment, therapy processes, and interventions. The study's mixed-method design encompassed quantitative outcome measures (empowerment, wellbeing, psychosocial health, and severity of personality functioning), therapy diaries from both clients and therapists, and semi-structured client interviews about empowering factors in therapy.

Results: Both groups showed positive therapy outcomes on wellbeing, psychosocial health, and empowerment. Specific empowerment-related factors included promoting experiences, relationships, and self-efficacy in the low-integrated group. Support of self-regulation was reported to be essential for successful outcomes in the moderately integrated group. While the therapy processes proceeded similarly in both groups, we observed a strong focus on body awareness-oriented interventions and promotion of verbalisation in the low-integrated group and a relationship-oriented emphasis in the moderately integrated group. Emotional experience linked to positive experience was limited in the low-integrated group, suggesting an impairment of emotional processing, including bodily felt feelings. No change was reported in the level of personality functioning after 30 sessions in both groups.

Discussion: These results underscore the need for tailored therapeutic approaches based on the client's level of personality integration. Future research should probe the long-term effects of therapy and delve deeper into shifts in personality functioning, especially concerning emotional and bodily experiences. In practical terms, therapists should prioritize linking bodily sensations with emotions for clients with low-integrated personalities. For those with moderate integration, the emphasis should be on fostering exploration, awareness, and bolstering self-regulation.

Keywords: Gestalt therapy; common mental health disorders; mixed-methods case study; operationalized psychodynamic diagnostic; outcome; process; psychotherapy.

Figure 1

Overview of the study design. The graph depicts data collection in Gestalt therapy treatment using a parallel research design: quantitative data (white boxes) from outcome measures and qualitative data (light gray boxes) from therapy diaries. The therapist also self-reported on the Gestalt therapy fidelity scale (GTFS) after each session. Sequentially, post-treatment, semi-structured interviews were conducted. Thick lines represent directed content analysis, and dotted lines represent conventional content analysis. Integration of quantitative and qualitative data occurred during the comparison of MI and LI groups.

Figure 2

Coding system for qualitative data. The graph displays the coding system of qualitative data sources (psychotherapist's therapy diary, clients' therapy diaries, and interviews) on the level of categories and subcategories (branches). Descriptions of codes are summarized in Supplementary Table S3.

Figure 3

Treatment outcome measures. Overview of pre-post effect sizes from outcome measures after 15 and 30 sessions. Black bars indicate the “moderately integrated” (MI) group and white bars indicate the “low integrated” (LI) group. Solid bars indicate effect sizes after 15 sessions, and dotted bars indicate effect sizes after 30 sessions of psychotherapy compared to baseline measures.

Figure 4

Narrative process coding system (NPCS). The figure shows narrative process coding sequences, relationship focus, and interventions documented over 30 therapy sessions in the moderately integrated (MI) and low-integrated (LI) groups.

Figure 5

Emotional expressions co-occur with topics. On the left side, emotional expressions are listed that occur together with different topics (on the right side) displayed in a Sankey graph for the moderately integrated (MI) and low-integrated (LI) groups.