1
Gestalt Therapy Approach to Psychopathology
by Gianni Francesetti, Michela Gecele and Jan Roubal
This chapter was published in a book “Gestalt Therapy in Clinical
Practice. From Psychopathology to the Aesthetics of Contact”
(Francesetti, Gecele, Roubal, 2013)
1. The Suffering of the Relationship at the Contact Boundary
For Gestalt therapy, a continuum exists, without clear-cut distinctions,
between healthy and so-called pathological experience. It is on this
conviction that all attempts at diagnostic categorization and nosology have
always been treated with caution (Perls, Hefferline and Goodman, 1994).
The value given to momentary experience and to the contingency of each
and every situation underpins the legitimacy and the value of all lived
experiences. It is this value that prevents the crystallization into fixed
Gestalten of people and their experiences.
This consideration of ours first emerges when reflecting on the question
“how can we treat psychopathology in Gestalt therapy?”. And how can we
do this without falling back onto categories which crystallize experiences
and patients?
Etymologically, the word “psychopathology” consists of three roots:
‘psycho-‘, ‘-patho-‘, ‘-logy’.
Psyche, meaning soul in Greek, derives from psychein: to breathe.
Patho, from the Greek pathos: affection, suffering, derives from paschein
(indeurop.): to suffer. Logos, in Greek: discourse (Cortelazzo and Zolli,
1983). Hence, psychopathology is a discourse on the suffering of the
breath, of something elusive, which cannot be confined within a stable
object form.
It is the suffering of the animating breath, the suffering of the animate1
living body (in German: Leib), not the object-body (in German: Korper)2
.
1
In this text, we shall not use the noun soul but rather inflected and adjectival forms of
the verb to animate, to refer to living beings in their condition of being animate, and hence
concerned with vital interaction with their environment.
2
For the distinction between Korper and Leib in psychopathology see Galimberti, 1991.
2
All living bodies are living precisely because they have intentional contact
with their environment (Minkowski, 1999). Psychopathological phenomena
concern subjects as they interact with the environment, or more precisely,
the interaction of subjects with the environment. At this point, we come to
a radical bifurcation. We can focus on psychopathology as either the
suffering of the individual or, alternatively, as the suffering of the field: this
suffering becomes manifest in the individual and can be transformed by the
individual: the individual is an organ of choosing of the field (Philippson,
2009). This change of focus opens up two very different universes and two
profoundly different ways of approaching psychological suffering.
These two perspectives on the reality of mental suffering can be likened
to the two perspectives through which light can be understood in physics: is
it a wave or a particle? Reality depends on the way we investigate the
world. Psychopathological phenomena are much the same.
Psychopathology can be considered a phenomenon belonging to the
individual or a phenomenon emerging from the field, belonging to the
Zwischenheit3
, to quote Buber (Buber, 1993; Salonia, 2001; Spagnuolo
Lobb, 2001a, 2005a; Francesetti, 2008). In more strictly Gestalt theory
terms, it is a phenomenon that happens at the contact boundary4
.
Our epistemology is founded on the consideration that experience does
not strictly belong only to the organism, nor only to the environment (Perls,
Hefferline and Goodman, 1994; Spagnuolo Lobb, 2001b, p. 86; 2003a;
2005a). Rather, experience emerges as a “middle voice” at the contact
boundary. The experiential figure that emerges contextually from the
ground (constituting the continuum of experience) is a figure that belongs
to the individual (for example, in a discussion group, no two people have
the same experiential figure). At the same time though, it does not belong
to the individual (again, in our discussion group, the figure of each person
3
The between (Buber, 1993).
4
The often-used term “boundary” is somewhat misleading because 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 constantly changes its position and is the focus of attention for both
parties all the time. This is the point where the contact of the two teams is happening at
every moment. Imagine the camera shots at the football match – what is happening
immediately surrounding 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 the processes enacted at the contact boundary become the camera´s
focus, they become a figure. Every comparison is slightly flawed, of course. The aim of the
therapeutic relationship does not lie in scoring a goal but in the fluent process of contacting
and the wider awareness of the processes enacted at the contact boundary.
3
also belongs to the others because it is from the others and through the
others that it emerges and takes shape) (Robine, 2011). Returning to
psychopathology, if we view such phenomena as emerging at the contact
boundary, then strictly speaking it is not the subject that suffers. What
suffers is the relationship between the subject and the world: that space
which the organism experiences and in which the organism becomes
animate. Psychopathology, in this view, is the pathology of the relationship,
of the contact boundary, of the between.
The subject is the sensible and creative receptor of this suffering: the
subject can feel pain.
Suffering may be perceived and creatively expressed by the subject, but
it emerges from the contact boundary. The agent of this feeling (of all
feeling) is the self, which is a function of contact. For Gestalt therapy,
psychology is the study of what happens at the contact boundary (while
what happens inside the organism is the realm of biology and physiology,
and what happens outside the organism is the realm of sociology and
politics) (Perls, Hefferline and Goodman, 1994). As such, psychopathology
must necessarily refer to the suffering of that boundary. This approach
entails a number of important consequences.
Psychopathology is not simply subjective suffering. Psychopathology is
the suffering of the “between”. The presence of this suffering can be felt by
anybody standing in the relationship: the other or a third party. Suffering is
perceived by the organism but it does not belong to it, neither in terms of
origin nor cure. Suffering emerges and develops within a relationship
(Sichera, 2001, pp. 17-41; Salonia, 1992) or, in more strictly Gestalt theory
terms, in the space to which it belongs and in which it is generated: the
contact boundary. Hence, psychopathology can be understood as
knowledge concerning the suffering of the animating breath, of the
between, of the contact boundary. The animating breath, the between, and
the contact boundary are not entities belonging to the individual, but rather
living spaces that emerge through contact. Psychopathology is an emergent
property of the contact boundary5
perceived by the individual.
Psychopathology is not simply subjective suffering. Subjective suffering
may exist without being psychopathological, that is, without the suffering
of the between (in this case there is pain, but no harm). On the other hand,
subjective indifference (without perceived pain) can be psychopathological
5
On the concept of emergent properties, see Bocchi and Ceruti, 1985; Waldrop, 1995.
«At each level of complexity, entirely new properties appear. [And] at each stage, entirely
new laws, concepts, and generalizations are necessary, requiring inspiration and creativity to
just as great a degree as in the previous one. Psychology is not applied biology, nor is
biology applied chemistry» (Anderson quoted in Waldrop, 1992, p. 123).
4
if the between suffers (in this case, there is harm even though there is no
pain). Not all suffering felt by individuals is necessarily unhealthy (for
example, grief, which is suffering but not psychopathology), while a
pathology is not always perceived by individuals as suffering (for example,
with psychopathy that leads to violence). To orient ourselves more clearly
through psychopathology, we need to move beyond sole reference to the
individual and consider the relationship (Salonia, 1989a; 1999; 2001;
Spagnuolo Lobb, 2003a; 2003b). The question leading us is no longer “is
the subject suffering?”, but rather, “is the relationship suffering?”.
We do not see the individual as the bearer of the psychopathology. We
describe patterns of functioning rather then types of people, we talk for
example about anxious or borderline processes rather than people.
(Greenberg and Goldman, 2007). This enables us to see psychopathology
from the field theory perspective, where the psychopathology phenomena
are not attributed to either side of the contact but rather they are functions
of the field.
Psychopathological suffering comes from and expresses a lack of
significant contact6
, and is all the more serious the more precocious and
fundamental the relationship is for the development of the self and the
growth of the organism. The individual sensation of this suffering is a
manifestation of awareness (which is always awareness of and at the
contact boundary)7
. As the suffering belongs to the relationship, it may
happen that not all the parties involved feel it.
An example can be given by a man whose relationship history has left
him with a narcissistic suffering: he cannot feel the pain of the relationship
between the couple, which is only felt by the female partner. The fact that
she is suffering (from a profound sense of loneliness and sadness, for
instance) does not imply that it is she who should be treated to overcome
her troubles (perhaps with anti-depressants). Rather, her distress is a
healthy sign showing that their relationship is in need of support. In this
case, therapy should assist him to feel the pain of their relationship, which
will probably reveal past relationship wounds that he guards without
touching.
Children also very often cannot recognize and express their
psychological suffering when the relationships they are a part of suffer.
6
In this regard, see the perspective offered by phenomenological psychiatry: Minkowski
(1927); Binswanger (1963); Tatossian (2003); Borgna (1989; 1995; 2008); Galimberti
(1991); Callieri (2001).
7
On the concept of awareness in Gestalt psychotherapy see Perls, Hefferline and
Goodman, 1994; Perls, 1969a; Polster and Polster, 1973; Salonia, 1986; Yontef, 2001, and
for a more recent review Spagnuolo Lobb, 2004.
5
They cannot speak up and say “I am suffering”, but instead manifest
physical disturbances or learning difficulties at school, hyperactivity or
aggressiveness towards their companions. However, if someone who can
perceive what is happening at the contact boundary comes into contact with
the child (or the family), s/he will feel the suffering that afflicts the
relationship. Psychopathology can be felt as subjective pain, for instance
when anxiety or melancholy grips us. However, it can also be a suffering
that is perceived only by others, where the pathology – the suffering – lies
precisely in the fact that the individual is incapable of feeling pain (as in the
case of people who act violently). Almost paradoxically, in this case, the
purpose of support is to help the person become capable of feeling pain.
Becoming aware of the suffering of a relationship is a cure in itself.
The shift towards an essentially relationship-based view of
psychopathology sheds new light on pain and the relationship between pain
and harm. If relationship pain is given insufficient support, it becomes
unaware and hence self-destructive. It becomes harm.
2. The Third Party as Constituent of Relationship
In order to understand psychopathological experiences, not only do we
need to go beyond references to the individual, but also beyond the dual
relationship. A relationship never consists solely of two people; there is
always a third party (Spagnuolo Lobb and Salonia, 1986; FivazDeperusinge
and Corboz-Warnery, 1999; Irigaray, 2002; Salonia, 2005;
Spagnuolo Lobb, 2008). Our field theory already implies the presence of a
background that gives meaning to the figure: in different situations
different figures can emerge from the background that anchor – and give
meaning to – the present relationship. We can call these figures, with this
function of anchoring the relationship to the larger field, third party. For
example, in clinical work, the supervisor functions as a crucial third party.
In a supervision group, a colleague tells us how difficult her work is with a
patient with narcissistic suffering: she often feels impotence and
humiliation, she is “never enough for him”. What supports her in those
moments is to remember the support from the supervisor and the group,
from this she can feel herself more grounded and remember that her
feelings belong to the field and are not “absolute definitions” of herself. In
this way she can breathe and stay present with her patient. The group is
working as a third party: it provides ground and meaning to the therapeutic
relationship. Another colleague describes his feelings with a patient: he has
wanted to speak about this therapy for at least two months, but he feels
6
shame about this relationship. He thinks he’s falling in love with her. He is
aware of the risks and at the same time he loves these feelings: he wants to
help and save her and in some way he thinks that the group cannot really
understand her needs. This revelation opens up a lot of important things,
about the patient, the therapist and the group, and provides a good and solid
ground for going on with this therapy. One of these is the awareness that
his love for the patient is a healthy and generous feeling that can support
their relationship, he must just keep the group with him in the therapeutic
room. This is not something he has to do deliberately, it’s enough to have
brought his patient into this larger field, to have received support and
recognition for his feelings and her needs, and to keep the contact between
the therapy and the group. This functions as a third presence that avoids
“craziness” in the dual relationship. In case of difficulty, during or after the
session, he can ask himself: “What would the supervisor or the group say if
they were here in this moment?”. It can be a question that supports him in
this phase of the therapy. Another example could be helpful: an abusing
family is sent to therapy by the public social service because the young
daughter suffers from intense anxiety symptoms. Two therapists start
working with them. In supervision they report that during the sessions
nothing is brought that can be considered “pathological” in classical
diagnostic terms, but to stay with this family – to enter into contact as a
third party – just to sit with them, gives a feeling of being dirty and
involved in a spider’s web that is almost unbearable. They are functioning
as a third party that can feel the suffering of the relationships in that family.
So, psychopathology is not only an issue of the subjective feelings of the
implicated parties: we should always ask “what would a third party feel at
that contact boundary?”. A person present at the contact boundary of a
relationship that suffers would feel pain or distress. On a general and social
level, a third party is always present (Bruni, 2007; Cavarero 2007; Žižek,
2002): society, the people bordering on the relationship, humanity as a
whole: what effect does the relationship have on them? What do they stand
to lose? And how and to what extent does what happens contribute to
determining a certain “blindness” in society and in people surrounding the
relationship? In this sense, torture, indifference to one’s pain or to the pain
of others, the dominion over others, and the failure to listen, all fall within
psychopathology, just as anxiety and depression do. In all these cases,
relationships suffer. This triadic perspective is fundamental in reading both
distress and the possibility or impossibility of providing support. The
presence of the “third party” (Lévinas), of “the other Other” (Derrida), in
relationships is also an ethical issue, touching on the very meaning of
human life. This was, especially for the twentieth century, and still is, a
7
philosophical issue of great importance8
which opens up and addresses
other disciplines, such as sociology, anthropology, politics and psychology.
Where psychopathological suffering is most serious – concerning issues
of fragmentation and the non-boundary between the individual and the
world as happens in psychosis – it is crucial that the therapist support the
consistence of the third party, by functioning as ground her/himself. For
example, a patient tells me about his delirium: he is spied on by a secret
agency, that is mysteriously and continuously checking if he is suitable to
work for them. The therapist can’t talk to him about this unquestionable
figure: this would immediately become a challenge between his definition
of reality and the therapist’s definition and would implicitly confirm his
madness and the therapist’s mental health. The therapist must function as
background where this figure can emerge, waiting and searching for the
meaning that is carried by this suffering. He is the ground in the sense that
he keeps and holds the basic conditions of the situation that are almost lost
in a psychotic field: he continues to breathe, to sit in her/his chair, to feel
the time flow, the floor and the space between, to keep hoping for the
emergence of a shared meaning. He feels the background and doesn’t lose
it and in doing so s/he provides the ground for the patient and for the
relationship. He has to trust that, even in such a condition, there is a contact
intentionality that is striving to emerge. In doing so, he takes on in the
relationship the role of a third party, of an environment able to contain the
relationship, and provides it with its essential existential space-time
coordinates. In this containing environment, archaic and interrupted
intentionalities can re-emerge and find a way to reach the therapist in a
more healthy contact. Sometimes everything appears so fossilized that even
breathing seems an overwhelming challenge. It is important to create an
atmosphere that supports the emergence of archaic – mad and incomplete –
relationships (which seldom have reached the point of I/you separation).
The therapist must be available to feel, bear, give ground and, in some way,
to be contaminated by this field without wanting to affirm her/his definition
of reality (Benedetti, 1992; Stolorow et al., 1999). In this stage the
relationship is filled with anguish and projections: the therapist has to dwell
in this atmosphere, to be the ground that allows this phenomena without
getting lost and trusting that by her/his presence the mist and obscurity will
become more and more clear. In this process the patient will define
her/himself and put down roots in the therapeutic relationship.
Only at a later stage can the therapy change and the therapeutic
relationship present here and now become the figure and focus of the work.
8
See, for example, the work of Lévinas and Derrida.
8
At that moment the patient can begin to see the therapist as an other. And it
is now that the therapist can let the relationship rest on the “external” third
party, always present as the ground, horizon and frame of reference. The
therapist no longer needs to provide the basic ground to the relationship.
Gradually, and with great effort, that ground has become a shared,
consistent heritage, both containing and founding. So, an important
diagnostic element lies in the overwhelming need for a third presence, as a
touchstone of reference to avoid going mad and to find legitimacy in a
world perceived as new and without given certainties. In a psychotic field,
not only the patient but the therapeutic relationship itself reveals an
immense need for support: if there isn’t enough support, one of the risks is
confluence with the patient against the context, for example. The therapist
can blindly feel a duty to save the patient despite and against the limits of
the care service, the family, the society. The strong need felt for a third
party can be a pointer to the degree of seriousness. It reveals the extent to
which contact experience has been uprooted from the world commonly
taken for granted, from the ground given by assimilated contacts.
We need to consider that this third party is implicated not only in
therapy but also in psychopathology. Indeed, for most serious disturbances,
treatment may be difficult, not because there is no cure, but because the
environment (from the family to society) would need to be broadly
changed, and often this is not possible. At times, the patient may progress
to establish a healthy relationship, in which s/he does not suffer, with the
therapist, but not outside the therapeutic setting. As our founders pointed
out, it is not only the patient that “needs” to change, often it is the family
and/or the social context that is “ill”.
The Folie à deux – a situation of confluence where two people share the
same delirium and psychotic field – can be understood as a dual
relationship where the third party (the relational network, the work group,
the context) provides no support. In this case, awareness is lacking of the
need for anchorage in a third party. As we said before, even the therapeutic
relationship runs the risk of confluent “shared madness”. In this sense, a
sort of isolated space-time may be created, disconnected from the larger
field. This risk may occur due to the relationship history brought by the
patient, due to the limits of the therapist, or due to the limits of the context
(the third party) that can be too weak. These three components, of course,
are not separable; however, prying them apart can be useful, especially to
stress the third. Among the limits of the context we have to take into
account the way every society defines what is normal and what is not, what
symptoms need to be cured and what behaviours need to be modified (see
Vol. 1, chapter 2.5).
9
To summarize our perspective, psychopathology is the suffering of the
contact boundary. It may or may not be felt as subjective pain. When the
subject does not fully perceive that which happens at the boundary, no
subjective pain is felt. However the other, or a third party, may feel it. From
a clinical point of view, it is not the pain which is pathological, but rather
the impossibility of sustaining it and of being fully aware of it at the
individual, family and social levels. In order to reduce subjective pain, it is
the between, the boundary, which is made to suffer. In this way, the level of
pain perceived is lowered, but so is awareness. In developmental terms, this
capacity to reduce unsustainable pain is a creative adjustment that protects
the individual, the family, and society. But now, that same capacity inhibits
the individual from feeling, living, and acting to the full, from fully
experiencing the self and the environment with which he is in contact.
Full experience is healthy experience, produced by the co-construction
at the contact boundary. It can be recognized by the creation of a bright,
harmonious, strong and graceful figure (Perls, Hefferline and Goodman,
1994; Bloom, 2003). For such a figure to be formed, it is essential that the
self is fully present at the contact boundary. For the self to be fully present,
it needs sufficient support (Laura Perls, 1992). Unsustainable pain becomes
anaesthetization, and thus the incapacity to perceive the self or the
environment/other. When sufficient support is provided, the subject is
present and can feel pain. When insufficient support is provided, the subject
is in some way absent and unaware at the contact boundary, and can act
with cruelty or self-destructiveness. One way of preventing and curing
harm at the social level is to provide support for pain. This gives us an
ethical key and a political perspective to our work as psychotherapists.
3. Healthy, Psychotic, Neurotic Experience
In trying to differentiate these three dimensions of human experience,
we want to remind you that we are not defining people, but a way of
experiencing in the here and now, in the present situation. This kind of
experience – healthy, neurotic, psychotic – is an emergent phenomenon at
the contact boundary, so it is always co-created. This means that during the
session, the therapist contributes to building one of these kinds of
experience. S/he can also contribute to the creation or fixing of a psychotic
experience, so it is important to be aware of these different dimensions, to
be able to recognize them and to know how to stay with them (see also
specific chapters in this book). Another preliminary point: healthy,
psychotic, neurotic, are not proposed here as categories, but as dimensions.
10
This means, firstly, that an experience can be more or less psychotic,
neurotic or healthy – nevertheless they remains three different types of
dimension; secondly, that all of us have the potential for experiencing these
dimensions: there is a dynamic threshold that probably depends on the
situation, circumstances and personal dispositions.
Now, let us try to focus on what are the characteristics of healthy
experiences and how we can evaluate them.
We can identify some elements that have to be present in healthy and
ordinary experiences from a Gestalt point of view. Healthy experience is a
process of contact with a novelty present as a potentiality in the
environment, it implies a co-destructuring that makes the novelty
assimilable and also time for the assimilation itself. The result is a growth
of the organism (Perls, Hefferline and Goodman, 1994). Each situation is in
some way new: healthy experience is the meeting with the incessant
novelty of life. It is by definition unique and nourishing: unique because
the encounter with the novelty is unrepeatable (if not, it is not a meeting
with something new), nourishing because the result is a growth of the
organism (if not, there has not been a nourishment).
In neurotic experiences contact with novelty at the contact boundary is
dimmed: there is reduced contact with the potentialities present in the field.
This limitation is realized by the so-called contact interruptions. These were
healthy protections of the organism when they were established, the best
way to be present in past relationships, but then they became unaware
habits – fixed Gestaltung (Gestalten?) – that limit the possibilities of being
present in the relationship. The neurotic experience is not unique, but rather
stereotyped, and not nourishing, since there is not a full meeting with
novelty to be assimilated.
In order to understand psychotic experiences, we have to consider
another element of the healthy ordinary experience. We define as
“ordinary” the experience that is built on a common and shared ground of
time, space and boundaries. In this case, there is a defined subject that
experiences a defined world, and they are part of the same texture of time
and space, a common world where subject and objects are separated and
connected. This seems obvious because it is our usual way of experiencing.
But it is exactly this structure that is disturbed in psychotic experiences9
where the common ground is lost: the boundaries that separate and connect
the subject and the world are disturbed, causing a loss of differentiation
9
Other non-ordinary experiences, with distortion of the common ground, are, for
example, mystical experiences and experiences under the effects of drugs. So, not all nonordinary
experiences are unhealthy, that means they can be unique and nourishing
experiences.
11
such as “people can read my thoughts”, “my intentions can cause a
financial disaster”, or “I can feel myself far from the others, without any
connections or without future”. The defined subject/world structure,
necessary for ordinary experience, is not a basic state of human life, it is
rather how we build our experience moment by moment. In our senses
there is not a radical differentiation between subject and object, this
separation is a cut that we – pre-cognitively – make in each moment. The
reality as we usually know it is an après coup that emerges at the contact
boundary. The subject that experiences here and now is continuously being
created through an opera of differentiation at the contact boundary. The
self is an emergent phenomenon (Philippson, 2001). Before the emergence
of “my” self, there is an undefined self “of the situation” (Perls, Hefferline
and Goodman, 1994; Robine, 2011). We can feel our stability as subjects
thanks to the personality function, but it is not a primitive data of our life10
.
Psychotic experience is characterized by a lack of this ground, a distortion
in space, time and boundaries that brings an unbearable anguish: the world
is finishing, at least as the person was used to experiencing it. As a
consequence, psychotic phenomena emerge: melancholic depression and
schizophrenic sufferings may perhaps be situated on a continuum where at
one pole at the contact boundary there is no connection and at the other
pole at the contact boundary there is no separation. Melancholic or manic
experiences happen when the subject is disconnected from the situation
(disembodied from space/time of the situation, disconnected from the
between); schizophrenic experiences, when the boundaries are not defined
and what is outside can be felt inside and vice versa (Francesetti, 2011). In
these situations delirium and hallucination can provide a sense of reality
and certitude that is less terrifying than to be completely disoriented and
lost in an uncertain nonsense. These fixed protections often make the
experience stereotyped. In this condition, the sequence of contact can’t
10
We are in the vein of the findings of phenomenological tradition and of psychiatric
elaboration of this philosophy. Phenomenologists (see, for example, Husserl, Heidegger,
Merleau-Ponty, Maldiney, Kimura) teach that our experience is generated before the
separation from subject and object, from self and world: at the very root of our experience
there is the common ground where something happens. It is the embodied borderland
(Callieri, 2001; Maldiney, 2007) where time, space, boundaries are created moment by
moment. It is the realm of the id of the situation, where something undistinguished moves
(Robine, 2011). These are the phenomenological transcendentals that make our ordinary
experience possible: our normal experience is made of time, space and boundaries. When
these fundamentals, that constitute the ground of our ordinary experience, are altered, the
experience is done in a psychotic (or for example mystical) way (see also the chapter ….on
psychosis)
12
flow because, since there is not a process of differentiation, the consequent
possibility of encounter is lost: the novelty is not identifiable as object, it is
like an overwhelming wave, the unconstituted subject can’t destructure it,
so the novelty cannot be met and assimilated.
Both neurotic and psychotic experiences are unable to meet the novelty,
they are not nourishing, so miss two fundamental conditions of healthy and
ordinary experience.
We can consider these two kinds of suffering as qualitatively different
from healthy experience and at the same time possible for everybody, under
certain circumstances. On the other hand, a person in this kind of
experience is never reduced to it alone. As Minkowski said, it is as
important to know “how much” a patient is schizophrenic as it is to
establish how much s/he isn’t. Even though we can see a continuum
between them in the experience of a specific person, and even rapid
passages between them, it is important to keep in mind that neurotic and
psychotic are two qualitative different experiences.
We could also say that an experience is as healthy as the person’s ability
to be present and aware at the contact boundary, and that neurotic and
psychotic experiences are two different ways of being absent from the
contact boundary. This consideration brings us to the issue of evaluation.
Indeed, one of Gestalt therapy’s revolutionary concepts is to have
established an intrinsic criterion to evaluate experience. In order to
establish whether an experience is pathological or not, we don’t need an
external criterion with which to compare what is happening in the contact:
a healthy experience is an experience of a good Gestalt that has grace,
strength, harmony, rhythm, fluidity, intensity etc. This criterion is
aesthetic11
because it is an implicit knowledge that comes immediately
from our senses: we can directly feel how good is the Gestalten (Gestalt?) –
the process of figure forming. Presence and aesthetics at the contact
boundary are the same phenomena: a complete and full experience is
aesthetic. Aesthetic evaluation is not a cognitive judgment: it is an implicit
knowledge, in the sense that it is pre-verbal and pre-cognitive (D’Angelo,
2011; Desideri, 2011). The distortions of these attributes are the ways
through which we can perceive in the here and now the contact
interruptions: the suffering of our co-constructed experience, the limitations
of our present contact, the degree of our absence. On the aesthetic criterion
is based the intrinsic diagnostic process (Bloom, 2003; Francesetti and
Gecele, 2009; see also chapter….on diagnosis). When we are in a psychotic
11
Aesthetic comes from the Greek aisthesis, to perceive by senses (Spagnuolo Lobb,
2003a).
13
field, a specific aspect we can feel is the need for a third party – often as
fear – as we described above. This is the way the therapist feels the
unbearable lack of ground in the field, it is again an intrinsic evaluation,
perceived by senses at the contact boundary.
4. The Co-ordinates of Gestalt Psychopathology
From a Gestalt perspective symptoms are products of a creative self and
display human uniqueness (Perls, Hefferline and Goodman, 1994).
Psychopathology is a co-creative phenomenon of the field, which
represents a unique creative adjustment in a difficult situation. When it
becomes fixed, it stops serving the needs of the individual and his/her
environment, it narrows the individual’s spectrum of potentials. The
symptoms are viewed not as discrete items but as a narrowed spectrum of
functions (Zinker, 1978). The symptoms indicate limited flexibility in the
reactions of the client. S/he is then limited in her/his ability to have fluent
contact with her/his environment. S/he is not able to act in accordance with
his actual need but his behaviour and present experiencing are determined
by fixed patterns. He follows a habit, not a deliberated choice (Yontef,
1993).
Psychopathological symptoms are phenomenologically observable
manifestations of fixed Gestalten. These rigid patterns cause suffering of
the contact boundary and of relationships (of course the individual
contributes to the organization of her/his relational field). They become a
figure also in the therapeutic relationship: both client and therapist are cocreators
of the psychopathology which emerges in their relationship.
Therapists can step out of the rigid field formation using their awareness. In
that way they give support to the relationship and offer to the clients a
chance of widening their spectrum of possibilities. The therapist provides a
contact experience that was missed by the patient and which s/he was
seeking (Salonia, 1989a; 2001; Spagnuolo Lobb, 1990; 2001a). In this
sense symptoms are always a plea for a specific relationship: a kind of
contact where the symptoms are not needed anymore (Sichera, 2001). In
this sense a panic attack can be a plea for a relationship where there is
enough support from the mutual belonging, a kind of contact that provides
enough support for stepping forward into the world (see also chapter… on
panic disorder). Standing at the contact boundary helps the therapist to
understand the contact difficulty affecting the relationship, and what to do
to provide the relationship itself with support. In Gestalt therapy terms, the
clinical understanding of suffering is founded on a range of co-ordinates
14
that trace out an epistemological profile. It is on these bases that we believe
a Gestalt perspective of psychopathology can be founded, which we would
go so far as to call Gestalt Psychopathology, defined as:
Phenomenological: that is, not interpretative but concerned with
understanding lived experience. Lived experience, under this approach, is
granted full and unconditional dignity and validity. This position brings us
in line with the epistemological approach taken by phenomenological
psychiatry (Jaspers, 1913; Merleau-Ponty, 1945; Binswanger, 1963;
Minkowski,1927, 1999; Callieri, 2001; Borgna, 1989; 2005; 2008; Kimura,
2000; 2005). Fixed Gestalten cause relationships to suffer by inhibiting full
contact from being made with present reality. It is for this reason that
Gestalt psychopathology treats the categorization of experience with
caution, and avoids the categorization of subjects. The experience of
psychopathological suffering is anthropologically “normal”. It is accessible
to all human beings. All human beings may find themselves expressing the
more or less serious suffering of a relationship, for which a continuum
exists between healthy and psychopathological experience.
Relational: in the sense that:
1 Psychopathology is the suffering of relationships. The subject and
object of treatment is not the individual, but the relationship that emerges at
the contact boundary. It is the relationship that the psychotherapist treats,
by standing at the contact boundary. What suffers is the contact boundary,
and it is the contact boundary that is cured through therapy. The origin of
distress and its cure lie in the relationship (Salonia, 1992; 2001; Spagnuolo
Lobb, 2001a; 2005; Sichera, 2001; Yontef, 2001; Philippson, 2001).
Subjective suffering does not coincide with psychopathology: subjective
suffering may exist without psychopathology, and psychopathology may
exist without subjective suffering. Indeed the latter case is perhaps the most
common.
2 Lived experience is co-created within the relationship (Spagnuolo
Lobb, 2003a; Stern, 1998). Even the fundamental experiential co-ordinates
of boundaries, space and time, along with energy and vitality, are not
functions of the individual but functions of the relationship upon which
they also depend (Salonia, 2001; Francesetti, 2011). In therapy, the
patient’s suffering has to be understood as an emerging phenomena of the
therapeutic field (Robine, 2011; Spagnuolo Lobb, 2001a; Stolorow, 1999).
3 It focuses on the moment and the way in which the spontaneity of
contacting is interrupted, and intentionality is left without support
(Spagnuolo Lobb, 2001a). At that moment, the self is not fully present at
15
the contact boundary, and the therapist intervenes to support the
relationship. What is interrupted is not, strictly speaking, contact, but the
spontaneity of contacting. Contact (the relationship here and now) lacks the
necessary support to maintain the intensity and the harmony of the
intentionalities in play; it cannot attain the novelty that could emerge from
the co-creation of the contact experience in all its field’s potentialities. The
energy which underpins intentionality is either lost or channeled elsewhere:
intentionality is distorted12
and the arrow does not reach its target13
. The
contact episode goes through all the phases of the contacting pattern, but
without the strength and beauty that would otherwise emerge if all the
intentionalities in the field were gathered and expressed.
4 Relationships are never dual: as we have seen, there is always a
constituent third party, to which they are open and which restricts them.
Temporal: time and space are co-created by the patient and the
therapist. The therapist accommodates himself to the space-time of the
patient and (by co-building the experience) modifies it. The more fragile
the ground of the patient (and hence the greater his suffering), the more the
therapist will need to take responsibility for establishing and safeguarding
the space-time coordinates of the relationship (Spagnuolo Lobb, 2003b;
Francesetti, 2011). Time is a constituent of the third party. It roots and
situates the relationship in a history, thus making a narrative which builds
bridges with the Other possible. Essentially, a subject can only be such
insofar as he is a subject of a history. Time and reality are correlated
(Salonia, 1992; Maldiney, 2007; Irigaray, 2008). The relationship gives
meaning to time, though time also gives meaning to the relationship. This is
why, for example, it is possible to cure a temporal pathology, such as a
mood disorder, through the relationship (and not just understand it
phenomenologically).
12
«[…] this is a possible definition of psychopathology for Gestalt therapists: the
spontaneity is interrupted (excitation becomes an anxiety to avoid); the intentionality is
distorted; the contacting carries anxiety (which is unaware, forgotten) and happens via
introjecting, or projecting, or retroflecting (we could add egotism)» (Spagnuolo Lobb,
2001a, p. 62).
13
«The arrow does not always reach its target. Due to lack of energy or direction, it may
drift off the trajectory that leads to the target, interrupting the sequentiality of stochastic
processes. […] Even the interaction between organism and environment does not always
achieve the full contact towards which it tends. At a certain point, the process, or
sequentiality (Polster, 1973), is interrupted. Lived time breaks away from relationship time,
contact is interrupted, and the organism develops a pathology, a dysfunctional behaviour»
(Salonia, 1989, p. 78).
16
Holistic: suffering is not just mental. The suffering of the relationship is
perceived by the subject in its whole and through experience, which is
always corporeal. The mind/body dichotomy is a neurotic divide (Perls,
Hefferline and Goodman, 1994; Kepner, 1993; Frank, 2001; Salonia, 1986;
Spagnuolo Lobb, 2004). Moreover, suffering is always phenomenologically
visible at the contact boundary where lived-bodies emerge: the intercorporeity
is the dimension where suffering reveals itself and it can be met
and cured (Merleau-Ponty, Salonia, Frank).
Oriented towards creativity: the suffering of a relationship is the
outcome of creative adjustments made within a difficult field. Original
creativity may have been lost and have become a fixed Gestalt, though it
may still have held positive meaning in the person’s life (Perls, Hefferline
and Goodman, 1994; Zinker, 1978; Spagnuolo Lobb, 1990, 2003a, 2005a).
This can easily be seen in neurotic adjustment, where a creative adjustment
made at some stage in a person’s history results in her diminished presence
at the contact boundary. The case of psychotic experience is different.
Psychosis is the expression of a lack of basic ground. Here, the goal is not
to restore awareness of interrupted contact, and in so doing assimilate it,
with the result that the possibility for new creative adjustments is restored;
rather, the task of the therapeutic relationship is to build a ground that has
never been created (Spagnuolo Lobb, 2003b; Salonia, 2001; Conte, 2001)14
.
Situational: suffering is always determined by a given situation, and it
is from the context that it emerges. Situation does not just define
psychopathology: it is fundamental in generating psychopathology or in
protecting a person from it (Robine, 2011; Salonia, 2007; Gecele and
Francesetti, 2007). An exemplary case is given by the well-known Stanford
Prison Experiment (Zimbardo, 2008)15
. Depending on the context, a type of
14
On creativity in psychotic experience, Margherita Spagnuolo Lobb writes:
«Creativity, a human quality exercised freely in situations when spontaneous contacting is
possible, is limited: it cannot be relaxed, and what could appear to us as an artistic
eccentricity is in effect a hard-won solution, charged with anxiety, which attempts to hold a
catastrophe in check. I do not mean that there is no creativity in the experience and behavior
of psychotics, but rather that theirs is a creativity that does not resolve a grave existential
anxiety, at least until such time as it is recognized within a meaningful relationship»
(Spagnuolo Lobb, 2003b, p. 340).
15
The experiment consisted of creating a prison setting in which one group of students
played the role of detainees, and another group the role of prison guards. In less than one
week, the experiment had to be interrupted because the level of violence exercised by the
“guards” had become dangerously unacceptable. One of the main conclusions drawn from
17
suffering (for example, narcissistic suffering or panic attacks) may be a
symptom which is rare and isolated or endemic and normal; it may be
valued and rewarded, or it may cause disadvantage for the person
expressing it. Salonia observes that all social contexts promote the
emergence of a “basic relational model” which is supported and rewarded
in the specific historical and cultural moment, becoming the norm for
relationships in that context (Salonia, 2007; 2008).
Developmental and next oriented: all suffering has a history which
holds the key to its meaning. The symptom is the trace left by the past on
the present relational field crossed and actualized in the here and now. Of
these traces, relationship experiences from infancy hold significant weight
in the development of the self, and hence for the seriousness of the
disturbance (Pine, 1985; Salonia, 1989b; 2001; Stern, 1985; Wheeler and
Mc Conville, 2002; Spagnuolo Lobb, 2003b; Righetti, 2005; Mione and
Conte, 2004). There are many understandings that try to relate infant
researches with Gestalt therapy (Salonia, 1989b; 2001; Frank, 2001;
Wheeler and McConville, 2002; Spagnuolo Lobb, 2011), focusing on how
the competences to contact are acquired or missed. What is missed emerges
in therapy as a need for a specific and new contact experience. This is the
relational need that the patient is looking forward to satisfying – or of
which to become aware and be recognized – in therapy, it is her/his
interrupted contact intentionality, it is at the same time her/his history and
her/his next step. All suffering has its relational “next” towards which it is
oriented and which illuminates its meaning (Polster and Polster, 1973;
Salonia, 1989a; 1992; Spagnuolo Lobb, 2007b; 2008). In giving support,
the fundamental question orienting the therapist is “towards which
relational experience is the person headed?” The answer to this question
marks and points the direction of therapy. For example, the narcissistic
suffering carries on a needy part that has not been possible to express in
any past relationship; in the contact this part is hidden and covered by
shame; the “next” of the therapeutic relationship is to provide the
conditions to let this part emerge as a relational need.
Aesthetic: the criterion that distinguishes what is healthy and what is
unhealthy is intrinsic to the relationship (see above). It is an aesthetic
criterion: being healthy means being able to create a contact figure which
has grace, brightness, rhythm and harmony (Perls, Hefferline and
the Stanford Prison Experiment was the demonstration of the pervasive power, however
intangible, of situational and contextual variables.
18
Goodman, 1994; Bloom, 2003; Spagnuolo Lobb, 2007b, 2007c; Robine,
2006). There is no need to use extrinsic evaluation methods, based on a
comparison between what happens and an external norm taken as a
benchmark (Perls, Hefferline and Goodman, 1994): it is the aesthetic
beauty of contacting that orientates the therapist. The therapist perceives
continuously the contact qualities and creatively adjusts her/his presence at
the contact boundary: this constitutes the unity of the diagnostic and
therapeutic act (Perls, Hefferline and Goodman, 1994; Bloom, 2003). By
sensing the drops of intentionality and losses of spontaneity, the therapist
re-positions her/his self in the relationship, co-creating and curing it,
moment by moment.
Dimensional rather than categorical: the categorical approach defines
discrete categories with clear-cut borders which provide an objective
identity to pathological situations or individuals. The dimensional approach
distinguishes itself from this by situating phenomena of suffering along a
continuum, in which it is impossible to establish a clear-cut boundary
between health and illness (APA, 1994; Barron, 1998). All experiences and
all relationships have more than one dimension. Everybody can have a
narcissistic, borderline, depressive, addictive, psychotic or other dimension,
depending on moments in life and situations. Hence, pathology is not a
clearly defined entity which can be distinguished from a healthy spectrum.
People seeking help find themselves confronted with the same existential
issues that we all face – love, loneliness, time, death. What makes the
difference is the possibility or impossibility of drawing on the support
necessary for realizing and living one’s art. A dimensional approach can be
integrated with a perspective that takes into consideration thresholds for
each of the various dimensions (Cancrini, 2006). From this perspective, for
example, all individuals can manifest borderline experience depending on
the circumstances. What changes from one person to the next is the
threshold at which such experience sets in. For some people, their threshold
is lower than for others, for which they easily manifest this type of
experience. Therefore any given situation or relationship can give rise to
borderline, narcissistic, psychotic or other experiences. In certain historical
and social circumstances, a certain type of experience becomes the norm.
Examples include borderline behavior during the French Revolution
(Cancrini, 2006) or the narcissistic trend of the final decades of the last
century (Lasch, 1979). This perspective weds perfectly with the concept of
the “basic relational model” proposed by Giovanni Salonia (Salonia, 2007;
2008).
19
5. Conclusion
Gestalt Therapy theory provides a very rich ground and precious tools
with which to understand human suffering: we think that on this basis it is
possible to found a Gestalt psychopathology, coherent with our theoretical
epistemology and useful for our clinical practice. It is possible to look at
human suffering as an emergent figure expressed by the individual, but
carried on by the relational field.
Each person receives from life, through relationships, a heritage of pain
and joy, limits and resources and it is her/his chance to transform it into
beauty and full presence. This can be seen as the artistic oeuvre of every
life. As therapists, we are daily committed in this transformational work: to
support people in their endeavour to transform pain into beauty, to “distill
joy from suffering”, as a patient told one of the authors. And from this
perspective, a wide and deep meaning of our work emerges. But, in order to
be able to support it, we have to be sensible and capable to understand
which contact and relationship the suffering person is calling for. And we
have to be ready to participate in this challenge with our lives.
As Alda Merini, a poet that suffered from psychotic experiences, said:
«Pain is nothing but the surprise of not knowing each other».
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