21
Gestalt Journal of Australia and New Zealand, 2012, Vol 8 No 2 Pages 21-53. © 2012, GANZ
The Three Perspectives Diagnostic Model
The three Perspectives Diagnostic
Model
(How Can Diagnostics Be Used
In the Gestalt Approach And In
Psychiatry Without An Unproductive
Competition)
JAN ROUBAL
Abstract
Gestalt therapists need to conceptualize their clinical work in order to
intentionally differentiate their approach to different clients. Diagnosing is
a natural and necessary part of the therapeutic process. However, it is a
difficult task to build a coherent diagnostic system in Gestalt therapy,
because Gestalt therapists use (and often combine) different perspectives of
looking at the clinical situation. This article helps distinguish three
common points of view of the Gestalt approach: the Field Theory
Perspective, the Contextual Perspective and the Psychopathology
Perspective. Adopting these perspectives consciously allows the therapist
to take advantage of each of them and let them supplement each other to
map the complex therapeutic situation more vividly. The author uses his
psychiatric background to present the Three Perspectives Diagnostic
Model which allows an avoidance of competition between the Gestalt
approach and the medical approach.
1. Introduction
Imagine you are walking in a park and you notice a sculpture. You look at it,
sense and explore it. Then you go around it and look at it from a different place.
It is the same sculpture and yet you perceive it differently now. Then you
change place again and look at the sculpture from some other perspective. One
perspective is not enough to meet the sculpture.
This metaphor of a sculpture is used here for a clinical situation and
22
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
diagnosis. The following text wants to avoid a competition of perspectives.
The text does not deny there is an epistemological conflict between medical
and Gestalt approaches. However, it does not want the conflict to lead into an
unproductive fight: “The sculpture should be seen from this perspective!”.
Instead, the text offers the observer a tool for being more aware from which
place he is observing and what perspective other places can offer.
1.1. Psychotherapeutic Diagnosis and Case Formulation
When I meet a client in a psychotherapy situation, I experience contact with him, I
listen and watch. And different questions arise and vanish: What is happening
here? What does the therapeutic situation say about the client and about me in the
moment? What symptoms do I see? Then, often, the client also tells me about the
context of his life and I start to recognize relational patterns; I wonder if I
recognize these patterns here in the therapeutic situation, too. My questions try to
cast light on the therapeutic situation from different angles, different perspectives.
This way my awareness and understanding have more dimensions and
correspond more to the rich complexity of the situation. In this article, I want to
present my exploration of the different perspectives from which I can look at a
clinical situation. It is important not only to ask questions and form a hypothesis
but also to be aware from what point of view I am asking.
When a therapist meets a client, he1
encounters an enormous amount of
information about his client. It comes from various sides – through the
therapist‟s senses (hearing, seeing, etc.), from the therapist‟s own emotional
and bodily experiences, from the therapist´s immediate thoughts and intuitive
insights, from the therapist‟s previous personal and professional experiences
that come to mind during the meeting, from the theoretical concepts and
assumptions that a therapist has assimilated during his education. For
processing all this information a therapist needs filters and concepts that help
him organize it in a meaningful way. This is necessary for good therapy – for
contact which is healing and not re-traumatising, for identifying realistic
treatment aims and procedures, and also as the foundation for responsible
creativity on the part of the therapist.
There is a distinct effort present today in the various psychotherapeutic
approaches to elaborate a method which would enable the assessment of an
individual client and facilitate the clinical psychotherapeutic treatment he
receives using theoretical concepts. There is an effort to create
psychotherapeutic diagnostics (e.g. Bartuska et al., 2008). This, as opposed to
medical diagnostics, is not a fixed system of boxes into which clients are meant
to be put. Psychotherapeutic diagnostics is a system of clues helping the
23
TheThreePerspectivesDiagnosticModel
therapist to continuously orientate himself in the ongoing therapeutic process and
to create a useful map of a therapeutic situation. The therapist creates this map
aware of the fact that it is merely a simplification of reality and that he himself is
a part of this landscape under examination. While remaining in a relationship
with his client, the therapist watches the ongoing change of a unique therapeutic
process and consequently adjusts his description of a situation in cooperation
with his client. In this respect, psychotherapeutic diagnostics is related to another
frequently used term, which is case formulation.
Accordingly, Gestalt literature follows this trend although the Gestalt
approach is not much visible in psychotherapeutic overview publications. It is
crucial for Gestalt therapy not to fix its eyes only upon itself but to engage in
more of a mutually inspiring dialogue with other approaches. According to the
theory of Gestalt therapy, the individual is defined and grows by the processes
occurring at the contact boundary with his surroundings. Consequently, the
Gestalt approach itself is defined and developed on its borders (Roubal, 2010),
both in contact with other psychotherapeutic approaches and also with the
medical world. To further illustrate this, I recommend two new publications
where Gestalt authors can find a great deal of inspiration from other
psychotherapeutic approaches.
The book Psychotherapeutic Diagnostics (Bartuska at al., 2008) describes
the diagnostic approach of varied psychotherapeutic schools and the broader
context of assessment in psychotherapy. It is based on the following principal
questions (Pritz, 2008): How can we describe diagnostic processes in
psychotherapy? Is it possible to describe different methods of diagnostics used
by varied psychotherapeutic systems and thus set the stage for a conjoint
diagnostic practice? In the book, the Gestalt approach is represented only by a
largely theoretical chapter on diagnostics in Gestalt Theoretical Psychotherapy
(Stemberger, 2008) and by a very brief chapter on the same subject in
Integrative Gestalt Psychotherapy (Höll, 2008). Unfortunately, neither one of
the two texts offers a sufficiently comprehensive and practically applicable
conceptualisation.
The second edition of the Handbook of Psychotherapy Case Formulation
(Eells, 2007) presents case formulation as a method of organising complex
information about the client, to extrapolate the individual treatment, to observe
the changes and to transform the theory and research into clinical practice
(Eells, 2007). The book purveys an overview of case formulations in diverse
psychotherapeutic approaches that are then compared throughout the
conclusion in the search for common ground. It includes a valuable chapter
dealing with the topic of case formulation in Emotion-Focused Therapy
(Greenberg, Goldman, 2007), which is embedded within client-centered and
24
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
Gestalt therapy. The Gestalt approach is not directly represented, however2
.
I want to present here a proposal that focuses primarily on diagnostics in
Gestalt therapy. Its aim is to supplement the former as well as the newest
Gestalt literature on the topic (e.g. Mackewn, 1999; Fuhr at al., 2000; Joyce and
Sills, 2006; Francesetti and Gecele, 2009; Brownell, 2010; Dreitzel, 2010) and
thus contribute to the developing formation of the Gestalt diagnostics system.
Such a system would then accurately benefit both “inwards” and “outwards”. It
would serve Gestalt therapists as a tool in their daily practice. It would also
present a comprehensive image of the Gestalt therapy diagnostic approach to
the other psychotherapeutic schools and contribute to the search for common
ground with them.
1.2. Personal Experience with Diagnosing3
When I was still a student of medicine, preparing for my examinations in
psychiatry, I spent a great deal of time memorizing the diagnostic criteria
ICD10, describing in detail the psychopathology of patients. Later on, during
my work on the psychiatric ward I saw how easily the diagnosis may be bent
and somewhat adjusted. That was perhaps the origin of my later ongoing
suspiciousness of diagnostics. I heartily loathe the image of the
“psychopathologist” placing the client‟s soul on the autopsy desk to look for
what is wrong with it. I did not want to take part in the objectification and
pathologising of people whom I encountered in the psychiatric hospital. I did
not want to reduce living and changeable human beings to a set of petrified
psychopathological symptoms. I did not want my own I and the client‟s You
to “freeze into a thing among things” (Buber, 1996) for each other.
I have perhaps remained in psychiatric practice only thanks to finding
another way of thinking about my clients. I was eager to grasp the
psychotherapy approach, especially the Gestalt one, which looks at symptoms
as a means of creative adjustment in relationships. However, after this
enthusiastic phase (my time of “psychotherapy conversion”), disillusionment
followed. When I thought of my clients in the complex terms of the field
theory paradigm, I was not understandable to my colleagues from the
psychiatric ward so I had to return to general psychopathological terms to
communicate with them. The worst part was that I no longer believed in
psychiatric diagnostic terminology and thus I could not benefit from it. I
noticed I was losing my accurate, sharp diagnostic approach.
I looked at my clients through field theory glasses and saw their selves
as a changeable system of contacts, their symptoms interconnected with all
the other elements of the field and myself as taking part in co-creating their
25
TheThreePerspectivesDiagnosticModel
symptoms here and now. I could make good contact with my clients, but I was
not a good diagnostician. I encountered my freshly built introjects: “You
should not see the client as an object!”, “Do not focus on problems, on what is
not working!”, “You should head towards an I-You meeting!”, “Focus on the
„in between‟!” and others. I found out that when I left the objectivising and
pathologising approach of medical diagnostics behind, I started to lose a sharp
diagnostic view - the one which, from a distance, consciously grasps the fine
details of clients‟ mental functioning. Thus, I also lost the way of intentionally
and conceptually differentiating between approaches to clients with different
kinds of suffering.
I want to use my experience as a “Gestalt informed” psychiatrist. Through
this article I would like to explain my view that even a Gestalt therapist might
benefit from using the sharp and precise approach of diagnostic labelling – the
objectifying, pathologising approach, and the I-it perspective on the client. I
would also like to show how to avoid becoming restricted by such an approach
and stay open to the relational and process-oriented perspective of the Gestalt
approach.
2. Gestalt Approach and Diagnostic Assessment
2.1. Basic Assumptions and History
Gestalt diagnosis is not pointed at fixed conclusions (Brownell, 2010) but
serves as a flexible and momentary working hypothesis (Höll, 2008), which
enables the therapist to orientate himself in a clinical situation and to consider
accurate therapeutic strategies. Diagnosis is most useful when kept descriptive,
phenomenological and flexible (Joyce and Sills, 2006). In addition to this, the
Gestalt therapist co-creates and continuously corrects the diagnosis through
dialogue with the client. Gestalt therapy is based on the assumption that the
therapist who is formulating a diagnosis represents an inseparable part of the
actual web of relations and, thus, the phenomena of the interaction between the
therapist and the client are important objects of the therapist´s explorative
interest.
Every experience is random, changeable, amorphous and chaotic in the
moment of its birth (Melnick, 1998). A basic human tendency is to organise
each experience into a meaningful structure. We organise our experience of the
presence of other people in the same way – we give name to our experience, we
give it a structure. As our experience is very changeable and difficult to grasp,
we are prone to project the assessment of our experience onto the people around
us. We constantly label our surroundings: “the guy´s had a bad night”,
26
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
“you look good”, “she is a bit too carefree”. These and all other commonly
used assertions might be seen as lay diagnosis, applied to label people around
us. Diagnosing4
within psychotherapy is distinct from such everyday running
flows of labelling as the therapist employs it with the client‟s benefit in mind
and constantly reflects on the process of formulating a diagnosis.
Throughout history, Gestalt therapists either shunned diagnosis5
or they
strived to create its specific Gestalt version (Brownell, 2010). The Gestalt
approach has traditionally stood against the objectifying, pathologising and
depersonalised labelling of people (Perls et al., 1951), widely used in medicine
and early psychoanalysis. Different theoretical conclusions were emphasized,
based on the interconnection of the field phenomena and the uniqueness of the
life story of each person. However, in describing clinical cases, the Gestalt
approach was still not able to emancipate itself from the concept of medical
diagnostics. When we read, for example, descriptions of “introjectors” or
“retroflectors” (Perls et al., 1951; Polster and Polster, 1974), or of people who
somehow interrupt the contact cycle (Zinker, 1978), it is a similarly objectifying
and pathologising perspective, only using different diagnostic labels. (However,
unlike medical diagnostics, the diagnostic description in this case is not static but
reflects the process and thus signifies the possibility of change.)6
On the other hand, there has always been a need present in the Gestalt
approach to deal with typology for the sake of the therapist´s orientation and
choice of intervention (Perls et al., 1951). Gestalt therapists realize that
diagnosing cannot be avoided and so the choice, here, is either to do it
inadvertently and negligently, or thoughtfully and with full awareness (Yontef,
1993). They are aware of the risk that they would treat the diagnosis instead of
the client and their approach would become depersonalized and antitherapeutic.
On the other hand, rejecting diagnostics and differences among
people can bring about similar effects (Delisle in Gilbert, Evans, 1999).
Therefore, there are attempts to constitute a diagnostic system (e.g. Delisle,
1991; Swanson and Lichtenberg, 1998; Melnick and Nevis, 1998; Baalen, 1999;
Fuhr et al., 2000; Francesetti and Gecele, 2009; Dreitzel, 2010) which would help
therapists with orientation. These are attempts to create a classification which
would enable therapists to categorize their clinical experience in accordance with
their clients‟. Terms from both general psychopathology and the theory of Gestalt
therapy are applied for this purpose. Authors often try to combine them, which is
quite difficult as psychopathological and Gestalt terminology each originate in
different paradigms. Partial, clearly defined models from Gestalt therapy theory
are often used for diagnostics, such as the contact cycle and the styles of contact.
The contribution of this procedure lies in its clarity and articulation, which
enhances the teaching and supervision of
27
TheThreePerspectivesDiagnosticModel
the Gestalt approach, whilst also making Gestalt methods easily embraceable
for therapists of other psychotherapeutic orientations.
There is a risk, though, that models based, for example, on the contact cycle
or the contact styles might retreat from the theoretical basis of Gestalt therapy. It
seems that they might become infected by the paradigm of medical
psychopathology – they objectify and pathologise the client. There is hardly any
difference in, for example, labelling the client as “depressive” or as someone
who “is interrupting the contact cycle between the stage of mobilization of
energy and action by retroflection”. Both cases eliminate the vital contribution of
the Gestalt approach, which is openness towards encounter and reliance upon the
process. Brownell (2010) poses a question: “How do we speak about the client
without doing damage to the client?”
Gestalt therapists are aware of this risk and emphasize the relationship
context and its subjective meaning for the client in phenomena marked as
psychopathological. This is to emphasize that certain phenomena cannot be
separated or isolated from others and that it is not possible to marginalize
how the diagnosis itself is substantially influenced by the person who does
the diagnosing.
Nevertheless, the concept of a therapist‟s subjective perspective taken to the
end disables the formation of any general categories or clues. Another
disadvantage is its great complexity, which disallows simple conceptualization
and comprehensible explanation among students or supervisees, as well as other
co-operating specialists (psychiatrists, general practitioners, social workers).
Gestalt therapy then appears as a kind of fuzzy, unclear approach and easy
simplifications in the form of shortcuts can appear - such as that “everything is
happening in the field”, or that “all is constantly in process”. Obviously such
general statements are of no use in practice.
So, how to preserve clarity, comprehensibility and diagnostic accuracy
whilst remaining faithful to the original paradigm of the Gestalt approach? I
present, here, the Three Perspectives Diagnostic Model designed to provide
a clear diagnostic assessment of a clinical case that would enable
differentiated therapeutic approaches to clients with varied clinical
characteristics. I find this diagnostic model most useful in my own practice
as well as in Gestalt training and supervision, because it overcomes the
dichotomy of medical and Gestalt models.
Existing Gestalt diagnostic systems focus first on describing the content of
diagnosis – they focus on what Gestalt therapists might diagnose. The content
of diagnosis is formed by both structures (described with nouns) and processes
(described with verbs). This article supplements them by focusing on the very
process of diagnosing – on how we diagnose, at what stage of the therapeutic
Figure 1: Metaposition of the therapist
3
1
a. awareness
b. hypothesis
c. intervention
2
4
The diagnostic
considerations take place
here
28
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
process diagnosing takes place and what its regularities
are. 2.2. Metaposition
Through diagnosing we create distance in order to orientate ourselves and to
gain a greater overview of the situation. The greater is the overview, the
smaller is the contact and vice versa. Diagnostic manuals such as DSM IV or
ICD 10 represent one extreme. A diagnosing expert with a maximum
“objectivising” level of distance assesses every detail of the object under
observation and does not try to make contact with the client. Moments of full IYou
contact (Buber, 1996) in the process of therapy represent the other
extreme. At such moments, the therapist plunges into being-togetherness with
the other person to the maximum extent and does not try to orientate himself in
the situation. He does not label either the other or himself from the I-it position.
He does not diagnose, he encounters.
For psychotherapeutic work, maintaining just one of these extreme
positions is unsustainable. We either do not establish contact with the client,
or get lost in the stream of the encounter. In practice, in the course of the
psychotherapeutic process we move up and down the scale between these
polarities. We find ourselves either closer to the diagnosing pole or the pole
of encounter, depending on what is needed at the moment. It is this capacity
to move flexibly and in accordance with the actual situation from the level of
meeting the client to the level of metaposition and back that represents the
core psychotherapeutic skill.
For a better description of the therapist‟s position in the process of
diagnosing I use and adapt the model which Ernst Knijff (2000) calls
“the therapeutic dance”.
29
TheThreePerspectivesDiagnosticModel
The client and the therapist mutually respond to each other (see Arrow 1 and
2). They “act” and “re-act” back, they co-create fixed gestalts. The therapist is
trained to temporarily step out of these fixed gestalts by using his awareness.
He is aware of the patterns forming the process of the therapeutic relationship.
Thanks to his awareness he takes a position above the level of reacting and
adopts a “metaposition” (see Arrow 3). There, he is mapping his awareness
(a.), forming therapeutic hypotheses (b.), and considering possible
interventions (c.). While being in metaposition, the therapist relates to the client
through the observational I-it mode (Buber, 1969). Then he comes back and is
ready and fully present to meet the client again (see Arrow 4); he is then back
in the dialogical mode, which is open to I-You encounters (see Arrow 2). I
emphasise that this article is focused on the therapist‟s diagnostic
considerations in the “metaposition”, namely the stage of forming therapeutic
hypothesis (see b. hypothesis).
There is a continuous exchange of interactions between the client and the
therapist, both verbal and non-verbal. On the content level, it is a matter of the
mutual transfer of information; on the level of process, it is a matter of the mutual
pattern of relating. The therapist encounters the client and gains information from
different sources. One of the sources is observation of the client – how he looks,
what his bodily structure is, what expression he is putting on, what he is wearing,
how he talks etc. Further information is obtained from anamnestic data, either
given directly by the client himself or drawn from other sources (medical reports
from the client‟s general practitioner, his psychiatrist, or his relatives). We learn
about the client‟s family, the possible history of similar difficulties among his
relatives, the quality of relationships within his family, the client‟s previous and
present social situation, the character of his existing relationships, the duration
and development of his suffering, the kind of treament he has already been
subjected to etc.
However, the therapist and the client exchange more than just information.
They mutually react and, to a great extent, replay their usual patterns of
relating, or fixed gestalts. It is a necessary stage of the therapeutic process, for
which the therapist does not have to criticise himself. On the contrary, he
personally experiences how the relational field in which the client lives is
organised. All that the therapist experiences and what he does is a function of
the field and might be used as diagnostic information (Roubal, 2009). The
therapist uses his awareness – that is his own feelings, thoughts, physical
perceptions and impulses in the client‟s presence – as another source of
information. Collecting all this information is especially important in the initial
stage of therapy. This article focuses on the next step – the process of
diagnosing that structures and classifies the information.
30
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
The therapeutic situation differs from regular non-therapeutic
communication in the way that the therapist employs his ability to take up a
metaposition in favour of the client. In a metaposition the therapist steps out of
interaction with the client and observes the therapeutic situation from a distance.
There, he makes space for orientation. He classifies his observations, his
awareness – what he perceives through his senses and what he experiences
himself (predominantly the inner and outer zone of awareness according to Perls
(1969)). He considers the gained information and creates working hypotheses
(predominantly the middle zone of awareness according to Perls (1969)).
Hypotheses are different ways in which the therapist understands and assigns
meaning to the ongoing therapeutic process. Metaposition is also a place where
the therapist considers possible interventions. Intervention could be anything that
the therapist delivers on the basis of his awareness – a question, a supportive
“hmm”, a frustrating silence, an offer of experiment and so forth.
This stepping-up to the observer‟s position could take a second during a
therapeutic session, a few minutes after the session has finished when the
therapist is writing up his notes, or a longer period during supervision. While
classifying information, forming hypotheses and considering interventions,
the therapist derives benefit from not only his cognitive capacity but also his
informed and cultivated intuition7
. In the upcoming part of this text we will
focus on just one stage of the whole process, namely the stage of forming the
hypotheses, during which the diagnostic considerations of the therapist are
articulated.
3. Three Perspectives Diagnostic Model
Diagnosis must be multidimensional to fit as closely as possible the map of the
complex territory which a therapist enters when meeting a client. Forming a
multidimensional diagnosis decreases the risk of treating our own concept
instead of fully engaging with a living person; it enables us to listen to the needs
of the client with regard to the different dimensions of his life (developmental,
current relational, spiritual etc.).
When meeting a client, a therapist has a complex experience. He can form a
multidimensional diagnosis by using different points of view, flexibly changing
perspectives from which he observes his client´s process and the therapeutic
situation. He can look at the clinical situation from a Gestalt perspective or
medical perspective or some other. It is important that these perspectives are not
treated as hierarchical, as one higher or better than the other. In the following
suggested Three Perspectives Diagnostic Model, the perspectives do not
compete with each other but rather supplement each other to form together a
Focusing on the here &
now process of co-creation.
FIELDTHEORY
PERSPECTIVE
Seeingthemutual
interconnectedness
of allfield
processes.
Looking from a distance
for what does not
function healthily in an
individual.
Focusing on
the person and
symptoms of
disorders.
PSYCHOPATHOLOGY
PERSPECTIVE
CLINICAL
SITUATION
Focusing on the roles of
persons and functions of
symptoms in a broader
context.
Observing the system as
a functional unit.
CONTEXTUAL
PERSPECTIVE
31
TheThreePerspectivesDiagnosticModel
multidimensional diagnosis. It is most important that the therapist recognizes
the perspective from which he is diagnosing at a given moment. If he were to
confuse the different perspectives, it would make it impossible for him to
benefit from each of them.
The following model describes the three perspectives most frequently used
by Gestalt therapists (see Figure 2). A therapist might start from any of them, but
he must be aware from which perspective he is observing and which perspective
he is not employing. He changes flexibly between them and gradually uses the
viewpoints of the three diagnostic perspectives. He works with the diagnostic
description of a case partly alone after the session has ended, while he is
recording it in writing, partly during supervision, and also directly in the course
of the session (while in metaposition). He also has the option to sensitively and
safely bring in his diagnostic reflections during the conversation with the client
and they thus can enlarge the awareness of the present situation together.
Therapist and client can then explore, test and transform the diagnosis
continuously. This type of diagnosing is of a dialogical nature.
Figure 2: Three Perspectives Diagnostic Model
32
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
The picture shows the three possible diagnostic perspectives frequently adopted
by Gestalt practitioners. During the process of formulating a diagnosis, a
therapist is aware from which position he is actually looking at the client and at
the therapeutic situation. The model is cyclic; a therapist fluidly changes the
perspectives to obtain a complex, multidimensional diagnostic picture.
3.1. Psychopathology Perspective
Is it possible for a Gestalt therapist to see his client as, for example, depressive,
obsessive or borderline? I think it is, if the therapist keeps the psychopathology
diagnosis as a hypothesis and knows he is looking at the therapeutic situation
from just one of several possible perspectives. The Psychopathology
Perspective results from a clinical situation: the therapist observes the client and
forms hypotheses about him from the I-it perspective. We may say that he takes
up the Newtonian paradigm, which is rooted in the assumption of objective8
observation of the phenomenon; he treats the client as a classical medical
practitioner. He relates his observations to his formerly gained knowledge and
so creates the Psychopathology Perspective.
Psychopathology perspective: focus on what is not working healthily
The therapist is asking: What symptoms do I observe?9
The therapist is looking at the client as at an object; he is critically and
comprehensively looking for what is not working in a healthy way
with the client.
The therapist is applying his knowledge of general medical
psychopathology and theoretical models of the Gestalt approach
(and possibly of other psychotherapeutic systems).
The therapist is attempting to diagnose the symptoms in the most
accurate way possible.
The therapist does not worry that he “should” be focused on the
relationship, the process of creative adjustment, the field theory
perspective or the co-creation of symptoms at the present moment.
He puts these Gestalt introjects away, brackets them for the moment.
The Psychopathology Perspective of diagnosis describes the dysfunctional
characteristics of the client using both general psychopathological and Gestalt
terminology. The therapist discriminates and labels the client´s difficulties,
33
TheThreePerspectivesDiagnosticModel
forming hypotheses on how they appeared and how they are maintained
onward. The therapist observes the client as an object on the I-it level of a
relationship. As he does so, he accepts the initial perspective of the client
himself, who also usually observes himself as if he were observing an object at
the beginning of the therapy and relates to others on the “it-it” level (Gilbert
and Evans, 1999). The present therapeutic relationship becomes the subject of
diagnosing and therapy (Francesetti and Gecele, 2009).
From this perspective, the therapist may take the liberty of using rather
“improper” thinking and terminology, from the Gestalt point of view. He
consciously pathologises the client, he “objectifies” his diagnostic position. The
therapist asks himself questions related to medical classification systems: “What
symptoms do I observe? Do I note psychotic, depressive, anxious or other
symptoms in the client? Do I see any displays of personality disorder?” The
therapist can also make use of metaphors or partial Gestalt models (contact
styles, contact cycle, functions of the self, polarities, fixed Gestalts and so forth).
Some possible questions the therapist poses are: “What contact styles is the
client using and how is he applying them to prevent fluent contact and the
accomplishment of his needs? How is the contact cycle deformed? At what
stage does the client interrupt the cycle? Which stages does he skip?” The
therapist also focuses on the client‟s history and poses questions such as: “What
developmental needs have not been satisfied? What trauma has the client
suffered? What relationship deficiency has he brought from his childhood and
how does it affect his self-concept?” A Gestalt therapist might use the diagnostic
systems of other psychotherapeutic approaches here (such as psychodynamic,
cognitively behavioural or transactionally analytic (Bartuska et al., 2008)), if
they help him in creating a clear picture of the client´s situation.
The Psychopathology Perspective is focused on the disorders and
dysfunctional strategies of the client. The advantage of such an approach is that
the therapist obtains a clear and distinct image of the client‟s suffering.
(Therefore, it is greatly advantageous at the intake-interview or while mapping a
critical situation.) At the same time, the therapist has the possibility ofvalidating
his thoughts with the client, to diagnose in a dialogical way. He might pose
questions such as: “What troubles you the most?”, “What diagnosis or labels did
you get in the past and what is your opinion of them?”, “What do you think –
why are you having these troubles? How do you understand the situation?”
3.1.1. The Psychopathology Perspective: Diagnostic Case example
To illustrate the Three Perspective Diagnostic Model, I present an abbreviated
case study from my practice.10
In order to develop this part of a complex
3 4
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
diagnosis (constructed from the Psychopathology Perspective) I gather
information from the anamnestic interview with the client, from observation and
from my own awareness, and look at it from the Psychopathology Perspective.
Martin (49 years of age) enters therapy because of panic/anxiety attacks
that have appeared during the last 8 months irregularly, about once a week
and with no apparent cause. He lives in a small town with his wife. His two
sons (24 and 21 years of age) are away from home in full-time education
and he sees them very little. He is an office worker. He suffers from chronic
backache and is slightly overweight; otherwise, he is perfectly healthy. He
has never been treated for psychological conditions and apart from the
panic attacks suffers from no other mental disease. He states that his
present relationships are in good order except for the fact that he and his
wife are going through a minor crisis due to her short romantic involvement
with another man. Martin has no siblings, his mother died of cancer when
he was 12 years old, his father, a regular soldier, died a year ago. Martin
has been advised to enter therapy by his general practitioner and would
rather try this than take pills.
Martin speaks quietly with his look mostly pinned to the floor. After each
of my questions he always takes time to think for a while, then looks up and
answers precisely and with attention to every detail. While he is discreetly
fixing the wrinkled carpet with his feet, I notice his shiny polished shoes.
What is my awareness in his presence? At first he arouses my interest
and I quickly take up the role of an expert, which he is expecting. I notice that
I am concentrating on the problem (as Martin does himself) and that I am
not seeing Martin as a person with many dimensions whom I might
encounter now. His answers are always so precise and comprehensive that
they satisfy me yet also discourage me from further conversation with him. It
becomes gradually more and more difficult to maintain concentration and in
the meantime, while Martin is thinking about his next answer, I escape into
my own thoughts. The conversation runs on the rational, problem-solving
level. To questions such as: `How do you feel?”, Martin answers: `I think, it
is because of...”.
From the Psychopathological Perspective I create various working
hypotheses and infer possible interventions from them:
Medical hypotheses: I observe Martin‟s obviously anxious state, I hear
about his panic attacks and chronic backache, I notice the obsessive
compulsive personality traits.
Gestalt theoretical hypotheses: After initial contact on the cliche level is
35
TheThreePerspectivesDiagnosticModel
established, the overall interaction becomes gradually more and more disturbed
and both ofus find ourselves in a state ofisolation. The contact cycle of Martin‟s
experience is markedly set back at the stage of energy mobilization; action is
delayed and is not aimed at establishing contact (but at the fulfillment of a task).
Martin‟s typical contact style is egotism; the chronic backache implies
somatised retroflection. The rational processing of a situation predominates for
Martin; when it comes to focusing on emotion, he avoids it.
There are some guidelines for therapeutic attitude that arise from the
Psychopathology Perspective of diagnosis:
- Martin enters psychotherapy to “try it”. It is necessary to take into account
his cautious attitude and clearly anxious state. That is why it is advisable to
accept his perspective to begin with – to focus on the problem, the symptom, to
stay within the frame of rational thinking. It might be helpful to offer him a
lecture on panic attacks and possibilities of coping (e.g. controlled breathing).
- The therapist might only very carefully and slowly examine the
relationship and experiential areas of Martin´s life (emotion, body) as
this approach is new and threatening to him.
- It would be good to give him time and space for his inner elaboration
(egotism). And gradually also offer him a means of getting out of it through
contact facilitated by the authentic interest in his person.
- The therapist can notice the moments when Martin is gathering
energy and go to meet him in such situations.
3.2. The Contextual Perspective
The Psychopathology Perspective described above arises from the medical
model, which encompasses concepts such as objectivity and disorder. From
this perspective, the clinician describes the static structure. Thanks to this
perspective, the diagnosing psychotherapist obtains information on the
gravity and character of the client´s disorder which determines the basic
setting of the therapy.
However, the therapist is not stuck in this point of view and can also use
other perspectives of diagnosing. Here, I would like to stress the difference
between two other perspectives often used by Gestalt therapists: the Field
Theory Perspective and the Systemic or Contextual Perspective. I would like
to focus now on the second perspective, which I prefer to call a contextual
one, because the word systemic has many different connotations in other
psychotherapeutic approaches, e.g. in family and systemic therapy.
There are two ways to extend the therapist‟s view of his client when moving
from the Psychopathology Perspective to the Contextual Perspective of
36
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
diagnosing. Firstly, the therapist does not focus solely on the client as an
isolated person, but sees him as a part of a manifold system of relations11
.
Secondly, he does not understand the client‟s suffering as a dysfunctional
disorder but as a means of survival. From an etiopathogenetic attitude leading to
the treatment of dysfunctional disorders, the therapist transits to a salutogenetic
attitude that reinforces health and the potential for self-healing. From the
Contextual Perspective the therapist sees the client as a member of a system and
observes the roles he takes within the system; he explores the function of the
client‟s phenomenology (seen as symptoms from the Psychopathology
Perspective) in a wider context.
It might seem redundant to talk about the Contextual Perspective when we
have a field theory. However, it is important to distinguish between these two
to gain benefit from both of them. From the Contextual Perspective we look at
the therapeutic situation and see individuals that have certain roles within a
system. It could be a client‟s family system or a system constituted by the
client-therapist pair. From the individualistic point of view of the
Psychopathology Perspective we observe the individual personal structure and
the causality of functioning of the client – what has caused or contributed to the
appearance of symptoms (etiogenesis) and how the symptoms have developed
(pathogenesis). Now, from the Contextual Perspective we adopt a systemic
point of view that deals with circular causality. The symptoms appear within
systems of the client‟s relationships with other people and they also feed back
into, and thereby influence these systems.
The Field Theory Perspective seems similar but there is a significant
difference, which is, however, not easy to describe. When we look from the
Field Theory Perspective we do not see individuals but rather events happening
in “the between”; we do not see causality (even the circular kind) but rather the
interconnectedness of all mutual influences (including the diagnosing therapist)
and the permanent process of co-creation. From the Contextual Perspective a
client, a therapist and “symptoms” play a role in the system and from the Field
Theory Perspective they are functions of the field. The contextual (or systemic)
point of view defines objects as existing independently outside the field and the
context is added to the object later. By contrast, field theory assumes there cannot
be anything that is not “of the field” (Yontef, 1993). This difference will be
described later in the text. Both the contextual/systemic and field theory
approaches provide useful means for not treating complex phenomena in
isolation but rather in their context, situations, and environments (Parlett, 1991).
The Gestalt therapist can gain useful insights using both of them if he
distinguishes between them and adopts them consciously.
37
TheThreePerspectivesDiagnosticModel
The contextual perspective: focus on roles within a system of relations
The therapist asks: What is the role of the client‟s phenomenology
(seen as a “symptom” form the Psychopathology Perspective)?
The therapist inquires about the function symptoms had performed in
the client‟s personal history. How had they served him? What have they
protected him from? What needs have they satisfied?
The therapist also examines the purpose they serve in the client‟s present
relationships (including the therapeutic one). What are the “secondary
benefits” and limitations the symptoms bring?
The therapist applies a systemic Contextual Perspective and focuses
on the dynamics of the roles and ways of relating within the system to
which the client belongs.
The Contextual Perspective of diagnosis describes how the client has
functioned and is functioning in various systems (the original and present
family, job etc.). It maps out the role the client‟s phenomenology (seen as
“symptoms” from the Psychopathology Perspective) has played in his
relationships. Throughout life a person learns that certain roles he takes
within a system of important persons are acceptable or appreciated while
others are refused or ignored. A person thus repeats the roles which proved
useful and result in the satisfaction of personal needs. These repeating roles
are then adopted, creating each person‟s unique being in the world and the
particular way in which each person relates to his surroundings.
These ways of relating have served the client well and played their part in
his life. However, as he is now seeking help in therapy we might assume he is
stagnating in these roles and ways of relating and is unable to react to changing
surroundings, to act alternatively. The original adaptation and functional way
of relating has turned into a rigid form that the client automatically applies in
situations that require a different approach. This leaves his needs unsatisfied.
Diagnoses made from the Contextual Perspective are descriptions of such rigid
roles and ways of relating.
The therapist does not focus only on where these roles and ways of relating
have restrained the client and what they have deprived him of. He also explores
how they have served the client and how they have enabled him to survive nonsupportive
environmental conditions. The Contextual Perspective of diagnosis
focuses on the client´s inner and outer sources of support. The therapist
understands the symptoms as the best possible way of coping the
38
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
client has had at his disposal so far. The therapist is searching for the role
of a particular symptom, inquiring about what maintains it and whether
the client has any other possible roles at his disposal.
The therapist and the client co-operate as they co-create the diagnostic
description from the Contextual Perspective together. The therapist may ask
the client: “How has your suffering, or this particular role or way of relating
you described helped you in your life? What is its origin? What is its present
contribution? At what price?”
3.2.1. Contextual Perspective: Diagnostic Case Example
Let‟s come back to Martin. Taking the Contextual Perspective, I broaden
my view and think of Martin‟s phenomenology (described from the
Psychopathological Perspective as “symptoms”) as a part of the client´s
relationship systems and as a kind of survival mechanism.
From the Contextual Perspective of diagnosis I form “systemic and
relational“ working hypotheses: Martin´s contact style (his restriction of the
mobilization of energy and his egotistic rational elaboration) probably
helped him to sustain himself throughout a childhood without siblings, cope
with his mother’s early death, and share one household with just his soldier
father from then on. It is possible that this way of relating also serves him
well in his office job position, where he is quite successful. It seems, though,
that this way of relating restricts him and causes him trouble as well. His
wife´s experience in their relationship might be close to my own experience
in his presence – she is losing interest and escaping. His sons are becoming
estranged. His body is responding with backache. From this perspective his
panic attacks appear to be an alarming signal urging him to change. It
seems that Martin is passing through a crossroads, which might be related to
his father’s death (a year ago) and Martin´s upcoming 50th birthday.
There are some guidelines for the adoption of the appropriate therapeutic
attitude that arise from the Contextual Perspective of diagnosis:
- To be on the safe side, it is important to stick with the level of rational
elaboration at first as it is natural for Martin. Gradually and slowly I can also
offer him a new point of view on his current problems.
- It would be suitable, here, to examine his personal history (primarily the
relationship with his father) as well as map the important stages and critical
points of his life . This might shed new light on Martin‟s present anxious
troubles and provide them with fresh meaning.
39
TheThreePerspectivesDiagnosticModel
- Another strategy might focus on his communication style. The therapist
and Martin together may map how Martin managed periods of solitude, what
helped him.
- They may explore how this experience has influenced his present
relationships. What are his sources of coping and what is the price he
pays for his safe, conservative way of life?
3.3. The Field Theory Perspective
It is not easy to define the Field Theory Perspective because the language we
must use for the description is meant to fix subjects and structure. But we want
to describe “the between” process. So, for example, Martin Buber had to use a
strange expression “I-Thou basic word” (Buber, 1996) because we have no
words for the ongoing process happening in between the elements of the field
(and including the elements). Moreover, there are different understandings of
field theory in Gestalt literature (Staemmler, 2006) and the concept of field
theory is sometimes mixed up with the systemic point of view; the differences
between the concepts of “being of the field” and “being in the field” are often
overlooked (Yontef, 1993).
The advantage of the presented Three Perspectives Diagnostic Model is
that when we explicitly distinguish the Psychopathology and Contextual
Perspectives we can dare to take the very radical position of the Field Theory
Perspective. We can adopt the field theory outlook, in which concepts like
holism, organismic self-regulation and present-centredness are all woven
together (Parlett, 1991). A clinical situation can then be seen as a constant flow
of mutual interconectedness, where everything that appears is a function of the
field. There is no client and no therapist as isolated persons, no clearly bounded
system; there is no history or inner and outer world, there is no causality. Every
memory of a client, every so called “counter-transferential” experience of a
therapist, every diagnosis that comes to a therapist‟s mind – all these are
functions of the field. And so are all the other events, even the bird flying
outside the window of the therapy room or the illness of the therapist‟s
daughter that occupies his mind for a moment. All the events co-create the
ongoing flow of the process. The mental structures and limitations we use are
strategies to give the potentially overwhelming world experience some
meaning so that we do not become mad.
The Psychopathology Perspective and the Contextual Perspective as
described above are common to several psychotherapeutic approaches. The
Psychopathology Perspective is very profoundly elaborated, for example, in
Cognitive Behavioral Therapy, and the Contextual Perspective in systemic
40
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
and family therapeutic approaches. We Gestalt therapists can find a great deal of
inspiration there. However, the Field Theory Perspective is traditionally
cultivated within the Gestalt approach and represents something unique which
the Gestalt therapy approach can offer as an inspiration to others. Gestalt therapy
theory has explored and developed this concept more than most of the other
psychotherapeutic approaches (the Process Oriented Psychotherapy of Arnold
Mindell is very developed in this sense too).
How can we use this perspective to supplement the other two abovementioned
perspectives in the process of diagnosing? From the
Psychopathology Perspective the therapist knowingly and on purpose observes
the client as a static, “physical” object. Then, he can move from a medical
model to a contextual one, from assessment to understanding. Taking the
Contextual Perspective, the therapist allows the client to “come to life” in the
therapist‟s imagination. He does not observe the client as a fixed lifeless thing
(Psychopathology Perspective) but is discovering the client‟s functioning
(Contextual Perspective), as if transiting from physics to biology.
Nevertheless, the therapist continues to be a clear-cut, separate observer while
the client continues to be an object.
From the Field Theory Perspective the therapist observes the co-creation of
the situation here and now. He moves from the psychodynamic model, where
he assessed the intrapsychic and interpersonal dynamics, to the field theory
model. He realizes he is not an independent observer but a part of the actual cocreation
of the field.
What was seen as the client‟s symptoms from the Psychopathological
Perspective or roles from the Contextual Perspective is now understood as cocreated
by both the client and the therapist. The therapist observes how he is
co-creating the field phenomena together with the client. He transfers his
attention from “another time and another place” (Yontef, 1993) to “here and
now”. He is watching how the client‟s usual ways of organizing the field meet
the therapist‟s ones. And he explores the way the actual field is organised. The
therapist observes how he organises himself in the presence of the client; he
traces his own here and now responses to his client.
From the Field Theory Perspective every person organises himself here and
now on the contact boundary with his environment by the process of creative
adjustment. A person is not seen as a thing or subject and his uniqueness is not
built from the inside. (Although we may knowingly reduce him to an observable
“thing” (the Psychopathology Perspective) or a subject taking a role (the
Contextual Perspective), if such reductions are functional.) A person can be seen
as the ever changing process within relationships. The process of organising
oneself, the “selfing” (Parlett, 1991), has certain regularities that are
41
TheThreePerspectivesDiagnosticModel
specific for each individual. These regularities of the field organisation create
individual uniqueness enacted on the contact boundary with the environment at
every present moment as well as continuously throughout life (Roubal, 2007).
The client‟s regularities of field organisation meet the therapist‟s regularities of
field organisation. The actual field organises itself as a kind of dance that arises
from the interaction of the two “original choreographies” (Jacobs, 2008) where
also some unique “new steps” might appear.
The Field Theory Perspective of diagnosis has a direct impact on the
therapeutic attitude. Thanks to diagnostic assessment made from this
perspective, the therapist is able to step out of a fixed pattern; he is able not to
react to the client, but, rather, knowingly to choose a different way (or allow a
new one to appear): to open up a space for a change of the stereotypical
process of field organisation. The Field Theory Perspective of diagnosis also
inherently offers the unique healing potential of a therapeutic relationship. The
therapist proceeds from a focus on the present relationship to a state of being
together within the present relationship. He does not perceive the client as an
object (as he did when taking the Psychopathology Perspective and Contextual
Perspective) but takes a part in the meeting of two human beings that define
each other by mutual contact. The therapist is not limited to the I-it level as he
opens himself up to the potential of an existential encounter with the client on
the I-You level.
Taking this Field Theory Perspective of diagnosis, the therapist also
takes notice of the spiritual extent of the encounter with the client. He
wonders what it means to himself to have this particular client entering
therapy at this particular time. What does it reveal about the therapist
himself? What kind of challenge does it pose?
The field theory perspective: focus on co-creation of creative adjustment
here and now
The therapist asks: “How do we co-create the present phenomena of the
shared field (seen as “symptoms” from the Psychopathology Perspective)
together with the client here and now?”
The therapist explores his own contribution to the clinical situation
in which these phenomena appear here and now in the therapy.
The therapist also focuses on the kind of potential present in the
therapeutic relationship.
The therapist asks in what way this particular client is unique for him
personally. In what way is the therapist himself unique for this particular
42
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
client? What meaning does this encounter have in their lives?
The Field Theory Perspective of diagnosis maps the patterns of field
formation here and now. The therapist concentrates on the existing process in
the therapeutic relationship. What kind of contact do the client and therapist
have? How does the contact proceed? What are its regularities? What patterns
of field organisation appear in the client-therapist relationship? Which patterns
from the client‟s and therapist‟s personal histories come to life here? How do
they interact and what new possible ways of field organisation might appear?
The therapist employs the phenomenological method (Yontef, 1993) while
putting his presumptions “in brackets” and observing the obvious. His
observations are tested through questions posed to the client: “What do you
feel now? What is happening? What are you aware of at the moment?”. The
therapist is aware of his own contribution to the process of organisation of the
field here and now. His own awareness is a substantial part of the Field Theory
Perspective of diagnosing.
3.3.1. Co-created Gestalt
From the Field Theory Perspective of diagnosing, the therapist applies a
paradigm radically different not only from the medical approach, but also
from the systemic approach. The observable phenomena (“symptoms” and
their “roles” in the context) are now seen without evaluation as creative
adjustment, as functions of the field. Also the therapist‟s own awareness and
interpretations are understood as functions of the field; they do not have an
“objective” quality, but rather arise from the shared situation and contribute
to the ongoing process.
The therapist is diagnosing a relationship. The client‟s anxiety, borderline
behaviour, retroflection, or disturbance of the contact cycle are seen and accepted
as phenomena of the field which are co-created here and now together within the
therapeutic relationship and to which the client and therapist contribute with their
own share. Client and therapist are both part of the process of relating in which
these phenomena emerge. Therefore, the therapist includes himselfin the
phenomenological observation. This is a necessary part ofGestalt diagnosing.
The therapist uses himself as a tool, his awareness providing him with
information on the way in which the actual field he shares with the client
organises itself. All that the therapist experiences, thinks and does is a function of
the field. He, himself, is a function of the field. The therapist asks: “How do the
client´s phenomena affect me? How do I contribute to them?”
43
TheThreePerspectivesDiagnosticModel
The therapist is aware that the way he is just now is determined by the
relationship. The therapist knows that he rearranges and reorganises himself
through the relationship with the other person in order to make sense of the
experience here and now. The client also reshapes and reorganises himself in
the relationship with the therapist. They define each other. Each of them is the
ever changing process that meaningfully organizes itself the moment they come
into contact. Each of them is a function of the actual field. The therapist might
wonder: “Who did I become when meeting this client? And what kind of person
is he with me?”; “In what kind of story are we taking part together?”; “What
metaphor might I choose to describe our relationship? Might we be, for
example, like a pair of fairy tale creatures or animals? What are the risks and
potentials of such a relationship?”.
The therapist sees not only the client (as from the Psychopathology
Perspective) and his pattern of relating (as from the Contextual Perspective). He
also looks at himself and so he completes the complexity of the therapeutic
situation. He is able to perceive the whole “shape“ of the usual ways of relational
field organisation that the client brings with him into the therapy and which are
revived once more in the therapeutic situation with the therapist as an active cocreator.
And the therapist is aware of his own usual ways of relational field
organisation that emerge when meeting this particular client. When the therapist
notices these usual ways and also new creative potentials, he is diagnosing from
the Field Theory Perspective.
The usual process of relational field organisation that the client is well
familiar with and that has actually brought him into therapy is inevitably
repeated in the therapeutic situation. The therapist experiences a relationship
with him similar to that experienced by people from the client‟s
surroundings. This is not a mistake though. On the contrary, it is crucial that
the therapist allows himself to be seduced and pulled into his client‟s usual
process of field organisation so that he can taste this kind of field process
from within, in his own skin. The therapist co-creates the client‟s diagnosis.
There is a danger, though, that the therapist slips into one of the extreme
positions. He might assess the situation either through projective thinking: “the
client is the diagnosis and none of it is my business”, or through retroflective
thinking: “I am the diagnosis and the way the therapy is proceeding is my
fault”. There are always both of these poles present: “When I am labelling the
client, I am always talking about myself at the same time. When I am talking
about myself, there is always a message present about the client with whom I
am co-creating the field”. It is the therapist‟s task to observe with curiosity his
own awareness within the field he shares with his client. Then he can use
himself as a diagnostic tool.
44
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
The capacity to take up a metaposition enables the therapist to accept and
eventually step out of the usual ways of field organisation, a diagnosis. The
therapist realizes his part in the co-creation of the situation‚ he gains orientation
which allows him to creatively reorganise himself in a new way. He can then
begin to organise himself differently, which alters the whole field. Thus he also
opens up a space in which to change his client‟s diagnosis. The therapeutic
relationship brings to life the usual ways of field organisation – the diagnosis. At
the same time the unique encounter of two individual beings embraces the
potential of hope for liberation from the diagnosis.
3.3.2. The Non-Expert Approach
When the therapist is diagnosing from the Field Theory Perspective, he steps
out of the expert position. He is aware of his own habitual and safe ways of
field organisation, his fixed gestalts, his diagnosis. He is aware that the
diagnosis he imputed to the client from the Psychopathology Perspective and
Contextual Perspective points, to a great extent, back to him. How could he
diagnose the particular characteristics of the client if he was not well familiar
with them himself? The diagnosis serves both as glasses and a mirror. It is
necessary that the therapist is aware of his own diagnosis to the greatest extent
possible while diagnosing the client. The more the therapist fears the discovery
of certain traits in himself (e.g. borderline patterns) the more vehemently he will
seek to diagnose them in his clients. It is the same as when a half-deaf person
shouts loudly because he automatically presumes the other must also suffer
from impaired hearing.
When diagnosing the client, the therapist inevitably diagnoses the
relationship with him as well. At the same time, he always diagnoses himself.
When I say that my client suffers from a “borderline personality disorder” I
am, in reality, saying a great deal about our relationship and myself. The
psychotherapist does not give up his ability to phenomenologically observe
and orientate himself. He is simply aware that, as the observer, he is a part of
the observed and that he finds himself in a recursive loop of the diagnosis
(Fuhr et al., 2000). In place of the objectifying diagnostic criteria, he puts the
following questions: “When I observe the traits of a borderline personality
disorder in my client, how do I then feel myself? How do I contribute to this
phenomenon? What can I learn from all this about my relationship with the
client? And what can I learn about my own process?”
45
TheThreePerspectivesDiagnosticModel
3.3.3. Diagnosing Within A Relationship
Through diagnosing, the therapist creates distance from the therapeutic situation
in order to gain orientation, simultaneously stepping back from contact with the
client. However, it is impossible for the therapist to step out of the relationship
with the client; he must diagnose within the frame of their relationship.
The diagnosis made from the Psychopathology and Contextual
Perspectives does not appear somewhere outside the therapeutic relationship.
By choosing and labelling one particular aspect of his relationship with the
client, the therapist reduces a substantial amount of meaning and potential that
the field of relation bears. The therapist diagnoses within the frame of a
relationship. When I diagnose the client with “the traits of a borderline
personality disorder”, even if I do not say it aloud but just to myself, I am thus
changing our relationship. While diagnosing, the therapist always actively
transforms the therapeutic relationship.
Let me use a metaphor to illustrate this. I remember how I was chasing small
chickens as a little boy in the country. They used to run away in a tight, yellow and
squeaking flock. Once I picked one up and the rest of them scattered in all
directions. I could get a thorough look at the one I was holding in my palm.
However, I disturbed the coherence of the flock, of the whole. By choosing one
part, I inevitably actively influenced the whole. There is much of the same when
diagnosing. When the therapist examines one aspect of the client‟s presence in
detail, he simultaneously actively transforms the situation at the risk of frightening
away the other possible dimensions of the therapeutic relationship. Diagnosing is
already an active formation of the contact with the client.
3.3.4. The Existential And Spiritual Dimension
Stepping out of the expert position enables the client and the therapist to meet as
two equal and fully-valued human beings. It facilitates the dialogic encounter,
which is not aimed at a certain goal but is the “meeting without aiming” (Yontef,
2006). The existential offer of the therapist towards the client is: “Accept your
experience” (Greenberg, 1996). Such a challenge may be truly answered only if
the therapist, through his own attitude, also conveys the other part of the
message: “...just as I do accept my own existence”.
When we speak of the existential encounter in the therapeutic
relationship we often quote the dialogic concept of existence of Martin
Buber and his description of the horizontal human encounter on the I-Thou
level. Buber also naturally speaks of the “eternal You” where “the prolonged
lines of relations intersect” (Buber, 1996).
46
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
A person exists only in relationships with other persons and so also in a
relationship with the essence of our common existence, where “prolonged
lines” of these relationships also “intersect”. It is the basic source of existence
which transcends us and connects us with other human beings.
The effort to define oneself as a personality (even through attempts to
define the personalities of others and their pathology) is just a more or less
successful attempt to escape anxiety. The nature of this anxiety is existential
and it arises from the idea that we are not a thing but a process on the contact
boundary: that we do not exist, but are happening; that we are not the water in
the stream, but the flowing of the water.
From the Field Theory Perspective of diagnosis the therapist therefore
also contemplates the existential dimension of a relationship. He embraces the
experience stemming from the encounter of I-You and the spiritual extent of a
relationship. The relational field presents for him a basis for both his and his
client‟s spiritual growth; both of them may evolve a worldcentric, global and
non-dual awareness as a higher level of spiritual development (Williams,
2006). The therapist encountering the client may ask questions such as:
“What does the encounter with this particular person mean for my life? And
what does meeting with me mean for him? What is the meaning of the fact
that we are meeting at this time and in this place? How does our encounter
contribute (due to “the butterfly effect”) to changing the world?”
From the Field Theory Perspective the therapist diagnoses the present
processes happening here and now on the contact boundary.12
The therapist
comprehends psychopathology as the pathology of a relationship, as the
“suffering of the „between‟”(Francesetti and Gecele, 2009). He describes the
usual ways and patterns organising the field of the therapeutic relationship and
also the possible new creative way by which the field is pregnant. Also from
this perspective, the therapist creates the diagnostic hypothesis dialogically in
cooperation with the client. He may ask the client: “Do you recognize the
relational issues that trouble you in your life, also here in the therapy, in our
relationship? How do you think I contribute to it? What do I do to make it
happen again? How do we both together co-create it? And what would you
need from me? What would you need to happen in our relationship?”
3.3.5. Field Theory Perspective: Diagnostic Case Example
From the Field Theory Perspective of diagnosis I focus on the process of cocreation
of the shared situation. I wonder at how we, Martin and I, cooperate
in forming the pattern of relating here and now in our relationship. How do I
myself contribute to it? And what is the meaning of our encounter?
47
TheThreePerspectivesDiagnosticModel
I create hypotheses on the process of field organisation here and now in
the therapeutic situation. We define each other in a way that can be
described like this: “Martin has a minor problem, otherwise he is perfectly
fine. I am the expert for his minor trouble. I pose questions and he
accurately answers each one after a short moment of reflection. We are
thinking, our focus is on “an error that needs to be fixed”. We look at the
problem and we avoid direct eye contact that might be understanding,
sympathetic and full of empathy.” This last point is what he has probably
been missing in his personal development, what he has been seeking in his
relationships. But at the same time he acts in such a way that he does not
recognise it. This usual process of field organisation recurs here and now
in our present relationship.
There are some guidelines for adopting the correct therapeutic attitude
that arise from the Field Theoretical Perspective of diagnosis:
- I shall notice the moments when I am avoiding contact myself,
when I am focused on the problem and do not see Martin as a person I
am meeting at the present moment.
- I shall more carefully distinguish when these moments of avoiding
intensive contact provide Martin with feelings of safety and support and
when such contact is simply comfortable for me (which would signify
my own fixed gestalt).
- I shall also focus on capturing moments when Martin arouses my interest
as a person, when I am experiencing emotions with him. I might gradually use
these moments to establish more personal contact – either through sharing my
experience or through authentic interest in his own.
- This is related to another possible path to follow – to see Martin as a
person that has now entered my life. I can ask myself: What can I learn from
him? In what way do my relationships resemble his? He is ten years older than I
and might now be passing through the exact lifetime crisis that yet awaits me in
a way. I shall not expose these thoughts to Martin. Nevertheless, they mean a
distinct change in my perspective.
- Posing these questions makes Martin a very interesting, inspiring person
for me. And through this change in my attitude I transform the stereotyped
organisation of the field of relations. When Martin gets to arouse my interest as
a unique person I may also relate to him otherwise. I stop focusing solely on the
problem he has brought into therapy. Thus, I stop pushing him to change, which
might open up a space for change (see the paradoxical theory of change
(Beisser, 1970)). He may begin to step out of his cosy prison of fixed gestalts, to
leave the “diagnosis” behind, and within our relationship he might also try
48
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
to organise himself in other ways.
4. Conclusion
Diagnosing helps the therapist to gain orientation and consciously differentiate
between therapeutic styles of working with different clients. It is necessary that
Gestalt therapists should not stagnate, solely focusing on observation of the
present interactions, but that they should also be capable of forming operational
hypotheses, to set both short-term and long-term treatment projects (Mackewn,
1999). It is important to cultivate the capacity of Gestalt therapists to connect
practice with theory, to create Gestalt case formulations. The Three Perspectives
Diagnostic Model introduced here might contribute to this. It might guide the
therapist through the complex process of Gestalt diagnosing. It would help him
identify the perspective of diagnosing he is employing at the moment – seeing
either clinical symptoms (Psychopathological Perspective) or roles within a
relational system (Contextual Perspective) or the process of the co-creation of the
field organisation here and now (Field Theory Perspective). Each perspective has
its benefits as well as its limits and they complement each other.
Using this Three Perspective Model, the therapist can decide which
perspective to choose. When it is useful, the therapist can allow himself to
consciously look at the therapeutic situation from the position of the medical
model (and he does not need to compete with it). And then, when it is useful, he
can allow this particular perspective to step aside in favour of the other
perspectives, the contextual or field theory one. It would be a waste of energy if
we Gestalt therapists let these models compete with each other (even if only in
our heads) and remain caught up in the paradigm of good versus bad. Instead, it
is possible to take advantage of the potential provided by their different focuses
and let them dynamically complement each other. One becomes prominent at a
certain moment and the other perspectives step into the background, then they
can change their position according to the process.
Whenever we diagnose we are fixing the particular way the field of the
therapeutic situation has organised itself. Doing this, we do not follow the flow
of the process of the actual meeting. By diagnosing we gain distance and lose
contact. But if we burdened ourselves with the demand that we should flow
with the process all the time, we would paradoxically limit our therapeutic
flexibility. Full contact in the therapeutic relationship can happen if we allow
ourselves also to withdraw, look from a distance, diagnose. An encounter is
enabled by distance. We cannot avoid diagnosing. All we can do is to remain
aware of the process of diagnosing and bring our awareness back into contact
with the client.
49
TheThreePerspectivesDiagnosticModel
Acknowledgements:
I would like to thank my colleagues Stana Dudova, Tomas Rihacek and
Frans Meulmeester for the great inspiration and support they bestowed
on me while I was writing this article.
This study was supported by the Czech Science Foundation Grant
GAP407/11/0141. Parts of the text were used as one of the sources for
the chapter “Gestalt Approach to Diagnosis” by J. Roubal, M. Gecele
and G. Francesetti in the book “Gestalt Therapy in Clinical Practice
(From Psychopathology to the Aesthetics of Contact)”, G. Francesetti, M
Gecele, J. Roubal (Eds.), which will be published in 2013.
Notes
1. When I write about a therapist and a client I use the male gender just
not to make the reading complicated by many she/he or her/his.
Every he or his in the text can also mean she or her.
2. In another similar overview publication – the fifth edition of Case
studies in Psychotherapy (Wedding, Corsini, 2008) – the Gestalt
approach is fortunately represented by a carefully written case study
(Denham-Vaughan, 2008) accompanied by the elaborated comments
of other Gestalt therapists (Blaize, Denis, Latner, Jacobs). The aim of
this chapter is neverthless rather to illustrate the concrete clinical
thinking of psychotherapists and not its systematic implementation
into the Gestalt theory.
3. I distinguish between the content and process of diagnosis. I use
the expression “diagnosing” when I want to emphasize the
process of making a diagnosis.
4. I write here on diagnostics and diagnosing in a broader meaning of
the word as of the naming and conceptualizing that serve the
therapist to orientate himself while working with the client. This
“perceptive” part of the therapeutic work is then complemented by
the “action” part in the form of therapeutic intervention.
5. Except for the psychopathological labels of the medical classification
system I also apply the term diagnosis for different namings from the
field of psychotherapy, namely Gestalt therapy.
6. In the later Gestalt approach the Field Theory Perspective and the
dialogical approach are becoming more applied even in describing
clinical cases. For instance, the disturbance of contact caused by
inappropriate mechanisms is no longer spoken of, but rather the
50
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
individually specific way of contacting (Wheeler, 1991; Melnick, Nevis,
1998) which is not evaluated (Mackewn, 2004; Joyce, Sills, 2006).
7. For the sake of remaining comprehensive and illustrative, the introduced
model simplifies a great deal the manifold and multidimensional flow of
encounter of two people in the positions of the therapist and the client.
The whole process of therapeutic relationship including the therapist´s
capacity to step back into metaposition is complex and the individual
stages mutually merge. The concept of metaposition is also merely an
abstract simplification as the therapist is always a part of the field and
even the metaposition itself is a function of the actual field.
8. Rather then “objective” (which might have a negative connotation
among Gestalt therapists) I like to use “observed from a distance”.
With the same client a contact is useful sometimes (e.g. an empathic
stance to the depressive client) and sometimes a distance is useful
(e.g. suicidal risk assesment with depressive client).
9. In this text the term “symptom” is used to describe the individually
specific kind of suffering of the client (e.g. obsessively anxious thoughts,
psychotic displays, insomnia, emotional lability, isolation in human
relationships and so forth). Keeping the principal of “horizontalisation”, I
do not use the term “symptom” here in the medical sense as a label to the
expression of a particular disorder. The term “symptom” remains neutral
throughout this text and it does not indicate pathology. A symptom is a
piece of work of the creative self and a display of personal uniqueness
(Perls et al, 1951), it becomes a “plea”(Sichera, 2001; in Francesetti,
Gecele, 2009) marking next direction.
10. It is the so-called composite case study (Gabbard, 2000) which
combines the description of several actual clients in one sample
case to achieve descriptive illustration of a shared phenomenon.
11. Medical diagnostic systems such as DSM IV or ICD 10 also similarly
apply the systemic view while using more diagnostic axes that map the
client´s personal history and his relationship and social situation.
12. It is necessary here to specify the often used and somewhat misleading
term “boundary”. It implies that there is a Country of The Client and a
Country of The Therapist with a dividing line in between the two – the
contact boundary. This is a structural and static model. Gestalt therapy‟s
focus on process would be better illuminated by another metaphor.
Imagine the therapeutic relationship as a football match (a friendly one
hopefully). The ball then represents the contact boundary. It would
constantly change its position and is all the time in the focused attention
of both parties. This is a point where the contact of the two
51
TheThreePerspectivesDiagnosticModel
teams is just happening at every moment. Imagine the camera shots
at the football match – what is happening in the nearest surroundings
of the ball comes to the foreground and becomes a clear figure, all
else steps back into the background for the moment. The contact
boundary is as changeable as the ball´s position and as the processes
enacted on the contact boundary gets in the camera´s focus, they
become a figure. Every comparison is slightly limping, of course.
The aim of the therapeutic relationship does not lie in scoring a goal
but in the fluid process of contacting and the bigger awareness of the
processes enacted on the contact boundary.
References
Baalen, D. (1999). Gestalt diagnosis. Oslo: Norsk Gestaltinstitutt.
Bartuska, H., Buchsbaumer, M., Mehta, G., Pawlowsky, G., Wieesnagrotzki,
S. (Eds.). (2008). Psychotherapeutic diagnostics. New York, Wien:
Springer.
Beisser, A (1970). The paradoxical theory of change. In Fagan, J., Shepherd, l.
(eds.) Gestalt therapy now. New York, Harper Colophon Books. 77-80.
Brownell, P. (2010). Gestalt therapy. A guide to contemporary practice.
Springer.
Buber, M. (1996). Ja a ty (I and Thou). Votobia, Olomouc. (Original
work published 1923.)
Delisle, G. (1991). A Gestalt perspective of personality disorder. British
Gestalt Journal, 1(1), 42–50.
Denham-Vaughan, S. (2008). First of nowhere? In: Wedding, D., Corsini, R.J.
(eds.) Case studies in psychotherapy. Belmont: Brooks/Cole, 123-146.
Dreitzel, H.P. (2010) Gestalt and process. Clinical diagnosis in Gestalt therapy.
A field guide. Berlin, EHP.
Eells, T.D. (2007). History and current status of psychotherapy case formulation.
In: Eells, T.D. (ed.) Handbook of psychotherapy case formulation. New
York, London: The Guilford Press, 3-32.
Eells, T.D. (Ed.). (2007). Handbook of psychotherapy case formulation.
New York, London: The Guilford Press.
Evans, K., Gilbert, M. (2005). An introduction to integrative psychotherapy.
Houndmills and New York: Palgrave Macmillan.
Francesetti, G., Gecele, M. (2009). A Gestalt therapy perspective on
psychopathology and diagnosis. British Gestalt Journal, 18(2), 5-20.
Fuhr, R., Sreckovic, M., Gremmler-Fuhr, M. (2000). Diagnostics in Gestalt
therapy. Gestalt Review, 4 (3), 237-252.
52
GESTALTJOURNALOFAUSTRALIAANDNEWZEALAND2012.
Greenberg, L.S., Goldman, R. (2007). Case formulation in emotion-focused
therapy. In: Eells, T.D. (ed.) Handbook of psychotherapy case formulation.
New York, London: The Guilford Press, 379-411.
Gabbard, G.O. (2000). Disguise or consent: problems and recommendations
concerning the publication and presentation of clinical material.
International Journal of Psycho-Analysis 81, 1071-1086.
Höll, K. (2008). Integrative gestalt psychotherapy. In: Bartuska, H.,
Buchsbaumer, M., Mehta, G., Pawlowsky, G., Wieesnagrotzki, S. (eds.),
Psychotherapeutic diagnostics. New York, Wien: Springer, 119-122.
Jacobs, L. (2008). Comment 4: being a repeat. Repeating being. In:
Wedding, D., Corsini, R.J. (Eds.). Case studies in psychotherapy.
Belmont: Brooks/ Cole, 135-138.
Joyce, P., Sills, C. (2006). Skills in gestalt counselling & psychotherapy.
London: Sage Thousand Oaks.
Knijff, E. (2000). De therapeut als clown, randopmerkingen van een
Gestalttherapeut. EPO, Berchem.
Mackewn, J. (1999). Developing Gestalt counselling. London: Sage.
Melnick, J., Nevis, S.M. (1998). Diagnosing in the here and now: A Gestalt
therapy approach. Handbook of experiential psychotherapy: foundations
and differential treatment. Guilford, New York, 428-447.
Parlett, M. (1991). Reflections on field theory. British Gestalt Journal, 1, 69-
81. Perls, F. (1969). Gestalt therapy verbatim. Moab, UT, Real People Press.
Perls, F., Hefferline, R. F., Goodman, P. (1951). Gestalt therapy: excitement
and growth in the human personality. New York: Julian Press.
Polster, E., Polster, M. (1974). Gestalt therapy integrated. New York:
Vintage Books.
Pritz, A. (2008). World council for psychotherapy. In: Bartuska, H.,
Buchsbaumer, M., Mehta, G., Pawlowsky, G., Wieesnagrotzki, S. (eds.),
Psychotherapeutic diagnostics. New York, Wien: Springer, 1-2.
Roubal, J. (2007). Depression - A Gestalt theoretical perspective. British
Gestalt Journal, 16 (1), 35-43.
Roubal, J. (2008). Proces diagnostikovani v terapeutickem vztahu (The
process of diagnosing within a therapeutic relationship). Psychoterapie, 2
(1), 12-16.
Roubal, J. (2009). Experiment: A creative phenomenon of the field.
Gestalt Review, 13 (3), 263-276
Roubal, J. (2010). Gestalt terapie. In: Vybiral, Z., Roubal, J. (eds.).
Soucasna psychoterapie [Current Psychotherapy], 164-194.
Staemmler, J. (2006). A babylonian confusion?: On the uses and meanings
of the term “Field”. British Gestalt Journal, 15/2, 64-83.
53
TheThreePerspectivesDiagnosticModel
Stemberger, G. (2008). Gestalt theoretical psychotherapy. In: Bartuska, H., Buchsbaumer, M., Mehta, G., Pawlowsky,
G., Wieesnagrotzki, S. (eds.), Psychotherapeutic diagnostics. New York, Wien: Springer, 97-108.
Swanson, C., Lichtenberg, P. (1998). Diagnosis in Gestalt therapy: A modest beginning. The Gestalt Journal,
21, 5–17.
Wedding, D., Corsini, R.J. (Eds.). (2008). Case studies in psychotherapy. Belmont: Brooks/Cole.
Wheeler, G. (1991). Gestalt reconsidered. New York: Gardner Press. Williams, L. (2006). Spirituality and
Gestalt: A Gestalt-Transpersonal perspective. Gestalt Review. 10(1), 6-21.
Yontef G.M. (2006). Gestalt therapy theory of change. In: Woldt, A.L., Toman, S.M. (eds.) Gestalt therapy. History, theory,
and practice. Sage Publications, Thousand Oaks.
Yontef, G.M. (1993). Awareness, dialogue and process. New York: The Gestalt Journal Press.
Zinker, J. (1978). Creative process in Gestalt therapy. New York: Vintage Books.
Jan Roubal, M.D.
Jan Roubal, M.D. is a psychotherapist, psychiatrist and supervisor. He is the Senior Trainer of the Institute for Gestalt
Therapy in Prague, founder and trainer of the Training in Psychotherapy Integration in Czech Republic. He teaches
psychotherapy and psychiatry at Masaryk University in Brno. He co-edited a Czech book “Current Psychotherapy”.
He is a member of EAP, EAGT and SPR.
jan.roubal.cz@gmail.com