British Gestalt Journal 2009, Vol. 18, No.

2, 520

# Copyright 2009 by Gestalt Publications Ltd.

A Gestalt therapy perspective on psychopathology and diagnosis

Gianni Francesetti and Michela Gecele
Received 13 December 2008

Abstract: In Gestalt therapy all attempts at diagnostic categorisation and nosology have always been treated with caution. This paper gives a contribution to the debate on this subject. The main question is: how can diagnosis, and the value given to lived and momentary experience, be combined? The rst part presents a Gestalt perspective on psychopathology as the suering of `the between', that is the contact boundary. The second part distinguishes extrinsic (or map) and intrinsic (or aesthetic) diagnosis. Some hypotheses are presented to illustrate how both map and aesthetic diagnosis can be dealt with in therapeutic relationships, preventing the crystallisation into xed gestalten of people and their experiences. Key words: Gestalt diagnosis, psychopathology, phenomenology, hermeneutics, aesthetics, suering of the contact boundary, co-creation.

Psychopathology as the suering of relationships

The suering of the contact boundary In Gestalt therapy a continuum exists, without clear-cut distinctions, between healthy and so-called pathological experience. Based on this conviction, all attempts at diagnostic categorisation and nosology have always been treated with caution1 (Perls et al., 1994). The value given to momentary experience and to the contingency of each and every situation underpins the legitimacy of all lived experiences. It is this value that prevents the crystallisation into xed gestalten of people and their experiences. Historically, this position has played an important role not only in clinical practice, but also in dening a vision of the world, where the individual and the therapist is considered in relation to the polis (Goodman, 1990). Nevertheless, it does not exhaust the need for further discussion on this issue (Yontef, 1988, 1993; Delisle, 1991; Staemmler, 1997, 2002; Spagnuolo Lobb, 2001a; Amendt-Lyon, 2003; Bloom, 2003; Brownell, 2005; Robine, 2007). In our view, such discussion is necessary for progress to be made in theory, for guidelines to be developed for clinical work with clients, for dialogue to be promoted with colleagues using dierent models, and last but not least, for preparing our students for clinical work. This consideration of ours rst emerges when reecting on the question: how can we treat psychopathology

in Gestalt therapy? And how can we do this without falling back on to categories which crystallise experiences and clients? 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: aection, suering, derives from paschein (indeurop.): to suer. Logos, in Greek: discourse (Cortelazzo and Zolli, 1983). Hence, psychopathology is discourse on the suering of the breath, of something elusive, which cannot be conned within a stable objective form. It is the suering of the animating breath, the suering of the animate,2 living body (Leib), not the object-body (Korper).3 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.4 At this point, we come to a radical bifurcation. We can focus on psychopathology as either the suering of the individual or, alternatively, as the suering of the interaction between the individual and the environment. This change of focus opens up two very dierent universes and two profoundly dierent ways of approaching psychological suering. These two perspectives on the reality of mental suering 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

6 Gianni Francesetti and Michela Gecele

same. Psychopathology can be considered a phenomenon belonging to the individual or a phenomenon emerging from the eld, belonging to the interaction between the subject and his environment, to the Zwischenheit5 (to quote Buber) (Buber, 1993; Salonia, 2001; Spagnuolo Lobb, 2001a, 2005a; Francesetti, 2008). In more strictly Gestalt theory terms, it is a phenomenon that belongs to the contact boundary. Our epistemology is founded on the consideration that experience does not strictly belong only to the organism, or to the environment (Perls et al., 1994; Spagnuolo Lobb, 2001b, 2003a, 2005a). Rather, experience emerges as a `middle voice' at the contact boundary, where the organism and the environment interact. The experiential gure that emerges contextually from the ground (constituting the continuum of experience) is a gure that belongs to the individual (for example, in a discussion group, no two people have the same experiential gure). At the same time though, it does not belong to the individual (again, in our discussion group, the gure of each person also belongs to the others because it is from the others and through the others that it emerges and takes shape) (Robine, 2007). Returning to psychopathology, if we view such phenomena as emerging at the contact boundary, then strictly speaking it is not the subject that suers. What suers is the relationship between the subject and the world: that space which the organism experiences and in which the organism becomes animate. Psychopathology is the pathology of the relationship, of the contact boundary, of the between. The subject is the sensible and creative receptor of this suering. Suering 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 et al., 1994). As such, psychopathology must necessarily refer to the suering of that boundary. This approach entails a number of important consequences. Psychopathology is not simply subjective suering. Psychopathology is the suering of the `between' not in the between but of the between. The eects of the suering of the between (of the contact boundary), of psychopathology, can be felt by anybody standing in the relationship: the other or a third party. Suering is perceived by the organism but it does not belong to it, neither in terms of origin nor cure. Suering emerges and develops within a relationship (Sichera, 2001, pp. 1741; 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 suering 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 boundary.6 Psychopathology is not simply subjective suering. Subjective suering may exist without being psychopathological, that is, without the suering of the between (in this case there is pain, but no harm). Subjective indierence (without perceived pain) is psychopathological because the between suers (in this case, there is harm even though there is no pain). Not all suering felt by individuals is necessarily unhealthy (for example, grief, which is suering but not psychopathology), while a pathology is not always perceived by individuals as suering (for example, with psychopathy or with sociopathy). 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 suering?', but rather, `is the relationship suering?'. Psychopathological pain expresses a lack of signicant contact,7 and is all the more serious the more early and fundamental the relationship is in the development of the self and the growth of the organism. The individual sensation of this suering of the between is a manifestation of awareness (which is always awareness of and at the contact boundary).8 As the pain 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 injury: he cannot feel the pain of the relationship within the couple, which is only felt by the female partner. The fact that she is suering (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 recognise and express their psychological suering when the relationships they are a part of suer. They cannot speak up and say `I am suering', but instead manifest physical disturbances or learning diculties at school, hyperactivity or aggression towards their companions. However, if someone who can perceive what is happening at

Psycopathology and diagnosis

the contact boundary comes into contact with the child (or the family), she will feel the suering that aicts the relationship. Psychopathology can be felt as subjective pain, for instance when anxiety or melancholy grips us. However, it can also be suering that is perceived only by others, where the pathology the suering 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 pain 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 insucient support, it remains out of awareness and hence self-destructive. It becomes harm. The third as constituent of relationships Not only do we need to go beyond references to the individual, but also to the dual relationship. It should be borne in mind that the relationship in question is always a three-way relationship. A relationship never consists solely of two people; there is always a third party that constitutes the background (Spagnuolo Lobb and Salonia, 1986; Fivaz-Deperusinge and CorbozWarnery, 1999; Salonia, 2005; Spagnuolo Lobb, 2008). This triadic perspective is fundamental in reading both distress and the possibility or impossibility of providing support. A relationship, therefore, always implies and involves a third party: someone, something, le vitch, 19709; Zizek, 200210; the world itself (Janke 11 Bruni, 2007 ). The presence of the `third party' (Levinas), of `the other Other' (Derrida), in relationships is an ethical issue, touching on the very meaning of human life. This was, especially for the twentieth century, and still is a philosophical issue of great importance which opens up and addresses other disciplines, such as sociology, anthropology, politics and psychology.12 Society, the people bordering on the relationship, humanity as a whole: what eect does a suering 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, indierence 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 suer. Where psychopathological suering is most serious concerning issues of fragmentation and the nonboundary between the individual and the world it is vital that the therapist becomes part of the ground. In doing so, he takes on the role of third party in the

relationship, of the environment that contains the relationship and provides it with its essential existential space-time coordinates. This containing environment consists of the actualisation of stratied relationships often left at an embryonic stage, or developed in a `mad' dual horizon. Everything appears so fossilised that even breathing seems an overwhelming challenge. It is important to build a climate conducive to the relationship that supports the emergence of these mad and incomplete relationships (which have seldom reached the point of I/Thou separation) (Salonia, 1989b, 2001). Only at a later stage diagnosis (and therapy) can change, and the therapeutic relationship present here and now can become the gure and focus of the work. It is now that the client can begin to see the therapist. 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 eort, that ground has become a shared, consistent heritage, both containing and founding. The therapist can once again become aware of the spontaneous passage of time, marked by a breath that has nally become possible. For more serious disturbances, treatment may be dicult, not because there is no cure, but because the environment (from the family to society) would need to be changed extensively, and this is not possible. At times, the client may progress to establish a healthy relationship, in which she does not suer, with the therapist, but not outside the therapeutic setting. It is true that often it is not only the client that `needs' to change, just as it is true that often it is the family and/or the social context that is ill. Here, the concept of creative adjustment can help, understood as the capacity to nd solutions and act at the contact boundary, within the limits of space, time, and given resources. Through this psychopathological view, the dichotomy between `individual pathology' and `madness determined and made chronic by the social context' is dissolved. An important diagnostic element lies in the overwhelming need for a third presence, as a touchstone to avoid going mad and to nd legitimatisation in a world perceived as new and without given certainties. We are not simply referring to the habitual experience of the client, which the therapist draws out: for us, it is the immense need for support that is most poignant. The strong need 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 common world, taken for granted, from the ground given by assimilated contacts.13 The `feeling' of just how much need there is for a `strong' third party is indicative of psychotic experience, and is relevant for both diagnosis and treatment.

8 Gianni Francesetti and Michela Gecele

deux, on the other hand, can be understood Folie a 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. Even the therapeutic relationship runs the risk of `shared madness'. In this sense, a sort of isolated space-time may be created, disconnected from the stream of life. Breaking down the parties involved, this risk may occur due to the relationship history brought by the client, due to the limits of the therapist, or due to the limits of the context, society, the third party. These three components, of course, are not separable; however, prying them apart can be useful, especially to stress the third. Recognising the limits and conditioning posed by a determinate social context and making them explicit has been a key issue in the history of therapy. Quite clearly, the support provided by the epistemological model and by the community of our colleagues and peers is of great importance in enabling therapeutic work to continue.14 To summarise, psychopathology is the suering 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 suer. 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 of the contact boundary. It can be recognised by the creation of a bright, harmonious, strong and graceful gure (Perls et al., 1994; Bloom, 2003). For such a gure 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 sucient support. Unsustainable pain becomes anaesthetising, leading to the incapacity to perceive the self or the environment/other. When sucient support is provided, `suffering' is pain. When insucient support is provided, `suering' is cruelty or self-destructiveness. One way of preventing and curing harm at the social level is to provide support for pain. This provides us with an ethical key and a political perspective to our work as psychotherapists.

The co-ordinates of Gestalt psychopathology In Gestalt therapy, psychopathology can be based on the analysis of suering of the contact boundary that is a phenomenologically experienced process. Such suering reduces awareness and presence at the contact boundary. It is a contact experience which is lacking in some way (Salonia, 1989a, 2001; Spagnuolo Lobb, 1990, 2001a; special issue of Cahiers de Gestalt, 2006). With such an absence, the symptom is always a plea: it is a way in which the subject is demanding and looking for a new relationship (Sichera, 2001). Standing at the contact boundary helps the therapist understand the contact diculty aecting the relationship, and what to do to provide the relationship itself with support. In Gestalt therapy terms, the clinical understanding of suering is founded on a range of co-ordinates that trace out an epistemological prole. It is on these bases, outlined below, that we believe a Gestalt perspective of psychopathology can be founded, which we would go so far as to call Gestalt psychopathology. Phenomenological: That is, not interpretative but concerned with understanding lived experience.15 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 (Merleau Ponty, 1945; Binswanger, 1963; Minkowski, 1927, 1999; Callieri, 2001; Borgna, 1989; Rossi Monti, 2002). Fixed gestalten cause relationships to suer by inhibiting full contact from being made with present relational reality. It is for this reason that Gestalt psychopathology treats the categorisation of experience with caution, and avoids the categorisation of subjects. The experience of psychopathological suering is anthropologically `normal'. It is accessible to all human beings. All human beings may nd themselves expressing the more or less serious suering of a relationship, for which a continuum exists between healthy and psychopathological experience. Relational: In the sense that: 1. Psychopathology is the suering of relationships. The focus 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 suers is the contact boundary and it is the contact boundary that is cured through therapy. The origins of distress and its cure lie in the relationship (Salonia, 1992, 2001; Spagnuolo Lobb, 2001a, 2005; Sichera, 2001; Yontef, 2001; Philippson, 2001). Subjective suering does not coincide with psychopathology: subjective suffering may exist without psychopathology, and psychopathology may exist without subjective suering. Indeed, the latter case is perhaps the more common.

Psycopathology and diagnosis

2. Lived experience is co-created within the relationship (Spagnuolo Lobb, 2003a; Stern, 1998), as are the underlying experiential co-ordinates of spacetime experience. 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, 2004). 3. It focuses on the moment and the way in which the spontaneity of contacting is interrupted, and intentionality16 is left without support (Spagnuolo Lobb, 2001a). At that moment, disturbances in self functioning emerge 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 intensity and harmony in constructing the gure; it cannot attain the novelty that could emerge from the co-creation of contact experience with the eld's potential. The energy which underpins intentionality is either lost or channelled elsewhere: intentionality is distorted and the arrow does not reach its target.17 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 eld were gathered and expressed. 4. Relationships are never dual: 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 client and the therapist. The therapist accommodates himself to the space-time of the client and (by cobuilding the experience) modies it. The more fragile the ground of the client (and hence the greater his suering), the more the therapist will need to take responsibility for establishing and safeguarding the space-time coordinates of the relationship (Spagnuolo Lobb, 2003b). Time is a constituent of the third party. It roots and situates the relationship in a history, thus making a narration which builds bridges with the possible Other. Essentially, a subject can only be such insofar as it is a subject of a history. Time and reality are correlated (Salonia, 1992; Irigaray, 2002). The relationship gives meaning to time, though time also gives meaning to the relationship (Salonia, 2004). 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). Holistic: Suering is not just mental. The suering 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 et al.,

1994; Kepner, 1993; Frank, 2001; Salonia, 1986; Spagnuolo Lobb, 2004). Oriented towards creativity: The suering of a relationship is the outcome of creative adjustments made within a dicult eld. Original creativity has been lost and has become a xed gestalt (Perls et al., 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 dierent. 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 not yet been created (Salonia, 2001; Conte, 2001; Spagnuolo Lobb, 2003b).18 Contextual: Distress is always determined by a given context, and it is from the context that it emerges. Context does not just dene psychopathology: it is fundamental in generating psychopathology or in protecting a person from it (Robine, 2007; Salonia, 2007; Gecele and Francesetti, 2007). An exemplary case is given by the well-known Stanford Prison Experiment (Zimbardo, 2008).19 Depending on the context, a type of suering (for example, narcissistic suering 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 approach' which is supported and rewarded in the specic historical and cultural moment, becoming the norm for relationships in that context (Salonia, 2007). Developmental and `next' oriented: All distress has a history which holds the key to its meaning. The symptom is the present trace of past relationships actualised in the here and now. Of these traces, relationship experiences from infancy hold signicant weight in the development of the self, and hence for the seriousness of the disturbance (Pine, 1985; Salonia, 1989b, 2001; Stern, 1985; Wheeler and McConville, 2002; Conte, 2001; Spagnuolo Lobb, 2003b; Righetti, 2005; Mione and Conte, 2004). In integrating Gestalt theory with recent ndings in infant research, Salonia proposes a relational reading of infant development which can be used as a hermeneutic key for placing the distress of adults and understanding its provenance (history) and destination (its next). Development stages require an evolution from the primary `we' to `I/Thou' dierentiation; from here, it is then necessary to acquire a new experience of the `we'. All various types of suering can be traced back to a specic moment in the development of relationship skills (Salonia, 1989b, 2001).

10 Gianni Francesetti and Michela Gecele

All distress has its relational `next' towards which it is oriented and which illuminates its meaning (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 heading?' The answer to this question both marks and points to the direction of therapy. Aesthetic: The health criterion is intrinsic to the relationship (Joe Lay quoted by Bloom, 2003). It is an aesthetic criterion: being healthy means being able to create a contact gure which has grace, brightness, rhythm and harmony (Perls et al., 1994; Bloom, 2003; Salonia, 2004; Spagnuolo Lobb, 2007b, 2007c). 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 et al., 1994, p. 65): it is the aesthetic quality of contacting that should orient the therapist (see below, aesthetic or intrinsic diagnosis). Dimensional and non-categorical: The categorical approach denes extrinsic criteria and discrete categories with clear-cut borders which provide objective identity to pathological situations or individuals. The dimensional approach distinguishes itself from this by situating phenomena of suering along a continuum, in which it is impossible to establish a clear-cut boundary between health and illness (DSM by the American Psychiatric Association, 1994; Barron, 1998). All experiences and all relationships have more than one dimension. Everybody can have a narcissistic, borderline, depressive, dependent, psychotic or other dimension, depending on moments in life and situations. Hence, pathology is not a clearly dened entity which can be distinguished from a healthy spectrum. People seeking help nd themselves confronted with the same existential issues that we all face love, loneliness, time, death. What makes the dierence is the possibility or impossibility of drawing on the support necessary for realising 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 behaviour during the French Revolution (Cancrini, 2006) or the narcis-

sistic trend of the nal decades of the last century (Lasch, 1979; Salonia, 2000). This perspective weds perfectly with the concept of `basic relational personality' proposed by Giovanni Salonia (Salonia, 2007, 2008).

Diagnosis in Gestalt therapy: extrinsic and intrinsic diagnosis

The relationship between psychotherapy and diagnosis is a complex one (Bartuska et al., 2008). The issue has attracted, and still attracts, very dierent positions in the eld of psychotherapy. The founding epistemological principles underlying the anthropology of different psychotherapeutic approaches give rise to very dierent perspectives on diagnosis and the therapeutic relationship. In its theoretical foundations and historical and clinical evolution, Gestalt therapy sees the therapeutic relationship as an environment for contact. Through contact, subjects give rise to an authentic, unique, and co-created relationship, which in turn shapes and constitutes them. The aim of the therapeutic relationship, in this model, is to co-create a new, nutritious experience, able to help the subject grow. The client is in no way objectied. Objectication would lead to the irreparable loss of the presence of the other, and would be diametrically opposed to the direction in which Gestalt therapy moves. In this relational horizon, diagnosis becomes a problematic issue. It raises a number of questions: is diagnosis necessarily an objectifying act? Does diagnosis impede contact or support therapeutic contact? As Gestalt psychotherapists, do we really need to diagnose? And more radically, is diagnosis possible in Gestalt therapy? Diagnosis comes from the Greek dia-gnosi, meaning to know through (Cortelazzo and Zolli, 1983). This in itself stresses the impossibility of not using diagnosis, in broad terms at least. In the last century, the philosophy of science and hermeneutics taught us that knowledge free of all lters and foreknowledge cannot exist. If we can only know through, and there is no gnosis without dia, the question transforms into which dia (which prejudices, which presuppositions) should we use (Salonia, 1992). Secondly, we need to avoid the latent risk of confusing behaviours with lived experiences (which would be objectication). Diagnosis can be a dening and denitive act which freezes the Other into a category. Alternatively, diagnosis can be a relational process which is co-built through contact and through the truth released through contact. When it forms part of the relational process in psychotherapy, the intention of diagnosis is to provide support to the therapeutic

Psycopathology and diagnosis

11

relationship. Two support functions can be identied: the rst lies in giving the therapeutic relationship developmental direction; the second in anchoring the therapeutic relationship in a third party. Diagnosis itself can be a third party, anchoring therapy in an extended corpus of knowledge and experience, in a sedimentary and shared history, in the professional community. The criterion for diagnosis can be either extrinsic or intrinsic to the relationship. In this way, we can distinguish between two kinds of diagnosis: the rst may be called extrinsic or map diagnosis, and the second, intrinsic or aesthetic diagnosis.

Extrinsic or map diagnosis

Extrinsic diagnosis involves comparison between a phenomenon and a phenomenon model. It has all the characteristics the benets and the limits of a map. The purpose of maps is to orient us. A city map, for example, enables tourists to locate themselves and to get to know the city, in a certain sense and within certain limits, before going there. The DSM, as with other nosological classications, serves this purpose (APA, 1994). The limits of maps By their very nature, maps have many limitations. A map, for example, cannot be updated; its form is crystallised and once produced, the map remains disconnected from the stream of life with its many changes. In psychopathology, nosological maps identify various types of suering: schizophrenia, anorexia, panic attacks, and all the other pathologies that a specic map charts. It is interesting to note how unpleasant just citing these diagnostic categories can be, showing a sense of disrespect to the people to whom these terms could possibly be applied. In eect, we are moving within an `I/It' relationship, to use Buber's terms. By objectifying, we show no respect for subjective dignity and uniqueness (Buber, 1993). One of the risks that a diagnostic system runs is that of claiming to be a taxonomic classication of objects in nature, based on the objective gathering of data. Historically this is what has happened. Modern psychiatry was born precisely from the attempt to give a name and classication to psychopathological phenomena. Kraepelin achieved a great step forward for the psychiatry of his time (second half of the nineteenth century) through his clinical distinction between dementia praecox and manic-depressive psychosis (Kraepelin, 1907). He believed he had identied `natural disease entities', comparable to pneumonia or heart attacks. In doing so, he disentangled mental suering from the spires of moral guilt, placing it

squarely in the eld of medicine. In this way, a map was created to help clinical practitioners orient their way through the chaotic world of madness. The prognostic dierences of the two categories were thus established: dementia praecox progressively degenerates, whereas recovery is possible for manicdepressive psychosis. Here we see the vicious circle typical of classication: labelling a client `prematurely demented' means declaring him incurable, which in turn reduces the client's chances of being cured or treated. Bleuler later proposed changing the name of this clinical condition to schizophrenia, so as not to identify it as an incurable condition (Bleuler, 1967). Nevertheless, very soon the problematic nature of using medical diagnosis in the eld of psychopathology began to be appreciated, as were the risks associated with it (Minkowski, 1927, 1999): the risk of objectifying that which cannot be objectied; the risk of crystallising that which is constantly changing; the risk of losing the subjective experience of the client, which is precisely what the therapist seeks to grasp and dene. In short, the risk of making the epistemological error of treating subjective experience as an object of nature. In his General Psychopathology (Jaspers, 1963), Karl Jaspers proposes a phenomenological classication of lived experience that seeks to protect the subjectivity of the ow of consciousness, and hence the suering client, by situating the science of psychopathology within the sphere of the sciences of the spirit. These brief historical examples show how the diagnostic act traces out demarcation lines that always respond to very precise epistemological structures. Diagnosis reects the worldview of the person performing the diagnostic act. Hence, diagnosis is in some sense arbitrary. Psychopathological diagnosis is a map traced out over co-ordinates that are more or less precise and consistent, whether explicit or not. Even the DSM, in its various editions, belongs to this order of diagnostic classications. It is not an atheoretical classication, as it claims to be. Rather, it is a careful, though arbitrary, outline whose purpose is to simplify the distress-territory so as to communicate through the use of a shared map. When extrinsic diagnosis is used, it is important that both the general limits and psychopathological limits of maps are known. The general limits of maps include:
.

The map is not the territory (Korzybski, 1933). The map is based on a foreknowledge of the territory which can be useful for orientation and for calming the anxiety that arises in encounters with the unknown (Salonia, 1992). Ultimately it betrays the territory though, through deletions (a map cannot be exhaustive), distortions (what is represented in many

12 Gianni Francesetti and Michela Gecele

ways does not correspond to the actual territory), and generalisations (the singularity and specificity of elements are lost) (Bandler and Grinder, 1975). The map is drawn by somebody: it implicitly or explicitly represents the perspective, convictions, values and principles of the author.

Maps covering `psychopathological territory' have further, specic limits:

. . .

They are fundamentally inadequate because they use an objective dimension to represent the subjective. They are fundamentally inadequate because they use an individual dimension to represent the relational. In contrast with maps of cities with clear-cut boundaries, in psychopathology, what is pathological and what is not, and the limits between them, is not known a priori. Psychological distress changes over time through historicity and the distress/context relationship. Distress depends on location and different cultural sedimentation. The map drawn may be useful here and now, but we do not know how useful it is in other contexts and for how long.

The map inuences the territory in a circular way: the diagnosis made has signicant consequences (pathogenic or supportive) at the individual, family and social levels. Psychopathology is a eld strongly exposed to pressures exerted by the political world view of the time and by the designer of the map: deciding who is mad and who is not in a given context also responds to the logic of power and political utility. Dening power, however, may not only be exercised within a certain social context. It may also be used to dene other contexts and cultural sedimentations as a whole,20 along with the people who belong to or come from such contexts. Deciding to whom the problem belongs also determines who should be brought into play in `recovery processes': if an individual is depressed, is the problem only his? Or does the problem also belong to the couple? To the family? To the social context in which he lives? Extrinsic diagnosis in the naturalistic horizon and the hermeneutic horizon Considerable caution is therefore needed when using extrinsic maps. As an act which inevitably objecties, it presents the risk of `inicting violence' and losing the subjectivity of the person. No map can say all there is to say on the subjectivity of the other: it will always remain a mystery.21 How can we bring this type of diagnosis into the relationship without `imposing a standard on the other instead of helping him to develop his own potentials' (Perls et al., 1994, p. 229)? Two dierent horizons exist

in which to situate diagnosis in therapy: the rst is the naturalistic model, the second the hermeneutic model. The naturalistic model implies an objectifying relationship that is not oriented towards intersubjective contact. It is the medical model whereby the clinic maps symptoms and then uses this map for treatment, without concerning itself with the subjectivity of the client. In the hermeneutic model, on the other hand, the diagnostic process is co-constructed, pooling together the knowledge (and foreknowledge) of the therapist and client (Gadamer, 1960; Salonia, 1992; Sichera, 2001; Staemmler, 2006). Foreknowledge is both a limit and a resource. It does not constitute a priori knowledge (a Procrustean bed) through which to categorise the subject; rather, it is knowledge to contribute to the eld. Circumstantial knowledge is what is provided by the map; via a two-way ow between clinical knowledge and the relationship being created, it is shaped to the uniqueness of the subject and to new contact. Within this hermeneutic framework, in which Gestalt psychotherapy is situated, we can make use of extrinsic maps. In doing so, however, we must be aware of their limits and uphold our respect for the indomitable uniqueness and mysterious elusiveness of each and every person. Why should we need to know and use extrinsic diagnoses? We need to know them for the simple reason that this type of diagnosis exists. It is used not only in the eld of psychotherapy but also in psychiatry, research, forensics, and, last but not least, in popular language. To ignore this aspect would mean shutting ourselves o from our context. As a consequence, we would reduce the possibility of supporting the people entrusted to our care and protecting them from being categorised. In the therapeutic relationship, extrinsic diagnosis can help support contacting where the client feels the need to express his experience in words and compare them to the words and background knowledge of the therapist. In this case, diagnosis is part of a much broader process of denition and the construction of personal identity. Finding the words to describe one's suering together with the therapist can prove a profoundly meaningful and transforming experience, as it is the result of co-creation within a hermeneutic framework. Giving the name and sense of, for example, narcissistic suering to one's distress and diculties can enlighten and liberate providing, once again, that it is not a label imposed from above, and providing that it does not interfere with or replace the emphasis placed on the uniqueness and creativity of the person. The objectifying use of naturalistic diagnoses, on the other hand, creates a gulf between the client and her relational context, which may lead to isolation. It can

Psycopathology and diagnosis

13

become pathogenic, contributing to suering by further wounding the client's relationships (see psychopathology). An objectifying stance creates suering while impeding its perception at the same time. The vicious circle in this approach lies precisely in the fact that it is blind to the suering it creates. All this should always be borne in mind by those who come into contact with psychological suering. That not only means the psychotherapist, but also the pharmacologist and people in other support and assistance roles. From this perspective, how diagnosis is brought into the therapeutic relationship is clearly much more important than the kind of extrinsic diagnosis used. Pondered, critiqued, and assimilated current nosologies can provide a contribution to therapy. It is up to the Gestalt psychotherapist skilfully to include this world and tradition in the relationship, and not just borrow objectifying grids foreign to the eld. Here we nd ourselves faced with the paradox of the hermeneutic circle. A circle in which knowledge of diagnostics and psychopathology is at one and the same time a necessary condition and insurmountable obstacle to understanding suering (Gadamer, 1960, p. 312; Spagnuolo Lobb, 2001b). It is the awareness of this circularity that enables the diagnostic process to become relational. Extrinsic diagnosis as third party The diagnostic process denes, and so circumscribes situations. It opens a relational and then personal space from which to view one's suering. It also represents a process of translation and mediation between the cultural and experiential horizon of the therapist and that of the client. This `other space' that is gradually co-built with the client is important for the therapist from the outset. It constitutes a `third party' in which to anchor the therapeutic relationship. It is a space that emerges from the therapist's need to orient herself, to read the experience co-created with the client, and to avoid conuence with that experience. It is a space that emerges from the client's need to believe that there is a starting point and, therefore, an arrival point. It is also the possibility for a narrative rooted in a shared language: the word as third party, for sharing, for bringing truth into the world, and for bringing the world into the relationship. The map assists us in orienting ourselves, in tolerating reality. Its purpose is not to replace or deny reality, but to prevent us from losing ourselves in its enormous potential. This `other space' is also an `other time'. It is time before the session and time after the session. It is time for supervision, for training, for exchange with colleagues, for theoretical reection. In these moments, words are needed to express the suering of the client, to express the client's experience, and to express the experience of

the therapist-in-session. It is this movement that enables the therapist to avoid conuence and to understand better the ground, the surroundings and the history of the client in her care. It enables the therapist to understand the relational and vital intentionality of the relationship, also through a reading of her own lived experiences, of her awareness of the `between'. This third space/time remains present in the ground during the therapeutic session. It is a dimension to draw upon when orientation is needed. The case is rather dierent when diagnosis becomes a defensive mechanism to distance one's self from the therapeutic relationship. Here, the space/time of diagnosis loses contact with the relationship, and the client remains alone, outside this secure because it is separate space. The therapist positioned in this space can no longer reach out to the person who is suering. This can also happen when, at the contact boundary with the `world', for instance in the work group, the psychological pressure felt in relation to this suering is too great. Instead of being an anchor, making translation possible, the world, the work group, the diagnosis itself is experienced by the client, and even the therapist, as an obstacle an obstacle to creative adjustment which is what the psychotherapist should be supporting. Extrinsic diagnosis, as we have seen, can be used as a tool for rendering subjective distress an object of nature. This means stripping it of its meaning by expelling distress from one's network of meaning, responsibility, and potential. Used in this way, extrinsic diagnosis oers no support to the therapeutic relationship; it responds to other needs those of the client's family, those of the work group, or those of society. These needs can be met in another, more functional way, though, by providing the support necessary for maintaining or re-establishing contact with the client's suering. In Gestalt therapy, expelling suering is a creative adjustment and not a defence mechanism without meaning: it is the best adjustment possible given the eld and support available. This is also true for the therapeutic relationship. In this sense, even an objectifying diagnosis would be a creative adjustment indicating a `next', a broader and more functional possibility of tracing the intentionality of contact. By declaring the client `mad' the therapist loses a part of herself, a part of the potential of the eld and of the relationship; but she protects herself and, in a certain sense, the relationship itself. At times, this may well be the best creative adjustment possible; but it is precisely through this awareness that we can recover unexpressed potential by building support. The social need to objectify and distance madness by labelling it in this way can be seen as a response to the legitimate need to anchor the devastating experience of anxiety and chaos in a `third party' in this case, the label of

14 Gianni Francesetti and Michela Gecele

`madness'. By recognising and legitimating this act of classication as a need for anchorage, the possibility for other, non-objectifying creative adjustments is thrown open. Gestalt extrinsic diagnosis? Having looked at the risks and possible ways of bringing the extrinsic diagnostic process into the therapeutic relationship, what diagnostic map can be developed in Gestalt therapy? `Being fully in contact, in terms of the capacity to consider both one's own perceptions and that of the other, realizing a ``fusion of horizons'' (Gadamer, 1960): this is the basis upon which a specic theory of diagnosis can be developed in Gestalt Therapy and used for understanding countertransference in the therapeutic relationship' (Salonia, 1992; Spagnuolo Lobb and Salonia, 1986). It is the phenomenological reality of the here and now of the therapeutic relationship, of contact between the therapist and client, which lies at the basis of a Gestalt diagnostic methodology. This reality is the framework of reference which the Gestalt therapist should draw from in considering diagnosis. It is upon this reality that models need to be built if they are to belong strictly to the Gestalt approach, and not to a hybrid of other theories which, however valid they may be, are based on dierent epistemological principles (Spagnuolo Lobb, 2001a, p. 90). Shared clinical and diagnostic models grounded in Gestalt theory have yet to be developed. Historically, opposition to the objectication of clients has underpinned criticism of the use of such models. Antipsychiatry, along with other movements, has taken a similar stance. We believe that today this risk can be addressed, providing that extrinsic diagnosis is used with the awareness and caution we spoke of earlier. Steps need to be made in this direction.22 Any extrinsic diagnosis system can be used by the Gestalt psychotherapist providing it is used hermeneutically, that is, in a manner enhancing contact. But how can we read psychological suering through our theory? In Gestalt therapy, extrinsic hermeneutic diagnosis is an attempt to read relationship suering without considering it as an attribute of the isolated individual (see above). Gestalt conceptual tools enable experience to be punctuated, named, and communicated. In this way, the client's experience is translated though it is also inevitably betrayed. This paradox, however, is useful: the truth of our words and diagnoses comes from the fact that they are co-constructed through the contact experience. The resulting diagnosis is not of or about the person; it concerns the relational phenomena that have been co-built, representing the expression and evaluation of the relationship, not the individual. Although it may be dicult to remain within a rela-

tional paradigm, this is the horizon towards which we should be moving. The time is ripe for us to begin clarifying this approach, as much still needs to be done by the Gestalt community before an actual model is built. Diagnosis needs to be able to gauge and communicate the suering of relationships. What we seek to bring out is the way that a relationship suers, and which intentionality needs to be supported during contact. Some authors have turned their attention to the connection, briey addressed in the nal part of Perls, Heerline and Goodman, between suering and the manner in which contact is interrupted. Their original analyses oer guidance for the therapeutic process and dierent interpretative keys (Salonia, 1989a, 1989b; Muller, 1989; Spagnuolo Lobb, 2003b). A Gestalt interpretation of relationship suering has various theoretical instruments at hand: 1. 2. 3. 4. 5. 6. gure/ground dynamics the self and its functions: ego, id and personality intentionality and the interruption of contact stages in the life cycle existential issues the relationship ground and history (family, couple, society) 7. the next: which relational experience is the subject unsuccessfully striving towards? In more relational terms: what relationship is needed for contact to be made? (The answer to this question tells us which relationship will cure the specic suering.) Through their reading of suering, these tools oer the orientation needed to identify the support which the client specically needs.23 In this way, diagnosis becomes a pathway along which the therapist guides the client towards recognising, naming, and sharing his experience of suering, towards placing the experience and giving it meaning. From a denition which may be more or less external and extraneous, i.e. `panic attack', we thus move towards a co-constructed narrative through which the meaning and relationality of the suering experienced emerges. From `what pathology do I have?' we progress to `that is what I am experiencing!'. Depending on the case and moment this may become: `in that moment I lose the support of my roles and my body'; or `I can't manage to control the environment as I usually do'; or `my ties are changing, I am becoming more autonomous and at certain times I feel alone'; or `my life is fragmented'; or `I need a ground of relationships to support me', and so on. This approach enables other expressions of human suering to be read in Gestalt terms, thus providing support and orientation to therapeutic contact.

Psycopathology and diagnosis

15

Intrinsic or aesthetic diagnosis

There also exists a second kind of diagnosis: it is a diagnostic method specic to Gestalt therapy. It is diagnosis because it oers orientation for the therapist and because it is knowledge (gnosis) of the here and now of the relationship through (dia) the senses; it is another kind of diagnosis because this act of diagnosis is not a comparison between a model and a phenomenon. We shall call this second kind of diagnosis `intrinsic or aesthetic diagnosis'. This kind of diagnosis emerges from moment to moment from the contact boundary. Instant after instant, interactions between the therapist and the client unpredictably and chaotically take place, bringing into play thousands of elements every fraction of a second. Interaction is incredibly complex: it is visual, aural, tactile, muscular, glandular, neurological, gustatory and olfactive, reactivating layers of memory which uctuate in waiting, ready to participate in forming gure. Moreover, it involves expectations and comparisons with thousands of contacts and faces. What orients us in this complexity? One possible option is to withdraw from all of this, or simply not to step foot in it. This is done by establishing an objectifying relationship and making naturalistic use of an extrinsic diagnostic map. Another option is to remain rmly within this incredible relational chaos, to navigate or oat on the waves of this sea `which never stands still'.24 To be aware, awake, with senses active, and at the same time relaxed, allowing yourself to be touched by what happens (Spagnuolo Lobb, 2004). To remain condent, that this chaos does indeed make `sense' (here, the etymology and connotation of `sense' coincide). Intentionality is the breath that moves this sea. The therapist is not disoriented, but present. He is not idle, but ready to join the dance that unfolds at the boundary where, through the senses, the client and therapist make contact. The therapist is ready to gather intentionality and to support the unfolding of breath. It is intentionality that brings order to intersubjective chaos. When the arrow of intentionality loses energy and falls, it is recovered by the therapist, who gives it new momentum. When the arrow falls and is recovered and re-launched, the emotive intensity of the moment is heightened. Moments of fullness of contact are always unpredictable: we do not know when they will occur, in which minute or second of contacting. They do not occur by chance though:25 it is the therapist who helps deliver those moments by supporting the intentionality of contact. Intentionality orients the therapeutic process. Therapy itself is contact between the client and the therapist. A loss of momentum, a drop or interruption in intentionality will prompt the

therapist to intervene; intervention may also be silence, immobility, or almost imperceptible movement (Bloom, forthcoming). How does the therapist notice the movement or interruption of intentionality? The answer lies in being present at the contact boundary, with senses alert and an awareness of one's bodily, emotive, and cognitive resonances. These resonances emerge indistinctly and only through reection can they be distinguished. A rigorous criterion is what guides this awareness: the aesthetic criterion26 (Joe Lay, quoted by Bloom, 2003). In this diagnostic approach, no comparison is made between a model of the phenomenon and the phenomenon itself, as happens with diagnostic maps. Here we have the perception of the uidity and grace of what happens, or what fails to happen, which is what orients the therapist in adjusting his manner of being-with the client. It is a note out of key, a brushstroke out of place, a touch too much or a touch too little, a little too soon or a little too late. It is not an a priori model that guides us, but the unique, special aesthetic qualities of all human relationships. Just as we know how to recognise a note out of key, we can sense that something is out of place or out of time, or so indenably strange or fatigued in ongoing reciprocal responses. Gestalt therapy has studied interruptions in contact, these drops in intentionality and losses of spontaneity; it knows how and when they can occur. It teaches us to sense these fractures and bridge them so as to support the relationship (Perls et al., 1994; Salonia, 1989a; Spagnuolo Lobb, 1990; Robine, 2006). The cardinal points of this `second by second' diagnostic approach are in the here the experience of space and now experience of time of lived experience, as it manifests itself at the contact boundary. The therapist is the sensitive needle to changes in these seismographs which record (via individual resonances) the aesthetic values of the relationship here and now, and not individual parameters. Time slows down, space dilates, and breathing follows the rhythm of these variations (Riccamboni and Francesetti, to be released). The therapist gauges these variations and continuously positions herself in relation to them, with sensorial-physical unity. In this way, the therapist not only brings about the intrinsic diagnostic act, but also the therapeutic act itself: this constitutes the unity of the diagnostic-therapeutic act (Perls et al., 1994; Bloom, 2003). Sensing the interruption of intentionality, the therapist re-positions herself in the relationship, guiding and curing it, moment by moment.

16 Gianni Francesetti and Michela Gecele

Extrinsic diagnosis or intrinsic diagnosis?

As Gestalt psychotherapists, which diagnosis do we need? In our opinion, the answer is both, as long as a clear awareness of the limits of extrinsic diagnosis is included. This becomes progressively less important as the therapist gains greater expertise. All travellers need maps to orient themselves, but it is also true that the more experienced a traveller you are, the more you can rely on your sense of direction. Sense of direction is something developed moment by moment during your journey, without the use of too many maps. This, however, is the prerogative of the expert traveller; if not what we have is a reckless traveller (or a savage psychotherapist). Then again, the only way to explore new, uncharted territory for which no maps exist is by orienting yourself moment by moment. And in a certain sense, every relationship is new, uncharted territory. This second kind of diagnosis, aesthetic diagnosis, is essential in orienting ourselves moment by moment through interaction. It is fundamental in providing specic support in Gestalt therapy.27 No map will ever be detailed enough to warn us of the potholes in the road and the bends along the track. Just like Alice in Wonderland, even if such a map existed, it would be too big and cumbersome to be used. No map is ever updated to the point of what is happening here and now. This second kind of orientation is sucient when, after having travelled widely and assimilated countless maps, the traveller is condent of how to move across unknown territories. Over time, relational experience enables us to be in synch with the other in a therapeutic way, without the need to establish diagnostic background co-ordinates: they become assimilated and are a part of the vision and sense of the therapist. They are the therapist's ground. However, to be ground, they must in turn have been gure. Diagnostic maps are important for those new to travelling, because they enable travellers to communicate when they are not `on location', and by looking over a map, they can compare their positions. When travelling through a territory though, maps tend to remain folded away in our backpacks. They retreat into the background, while it is our senses that guide us moment by moment. But they are always within reach: we can consult them at any time when we get lost, when we need to tell somebody where we are, when we stop for a break and want to check up on the situation. But it should never be forgotten that you can never step into the same river twice.

Acknowledgements
This article collects theoretical considerations developed within the Istituto di Gestalt HCC. We are overwhelmingly grateful to Margherita Spagnuolo Lobb and Giovanni Salonia, the directors of the institute, as it was on the basis of their teachings that this article could emerge as gure. We also wish to express our gratitude to Dan Bloom for his precious comments and suggestions.

Notes
1. `The therapist needs his conception in order to keep his bearings, to know in what direction to look. It is the acquired habit that is the background for this art as in any other art. But the problem is the same as in any art: how to use this abstraction (and therefore xation) so as not to lose the present actuality and especially the ongoingness of the actuality? And how a special problem that therapy shares with pedagogy and politics not to impose a standard rather than help develop the potentialities of the other?' (Perls et al., 1994, pp. 2289) 2. In this text, we shall not use the noun soul but rather inected 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. 3. For the distinction between Korper and Leib in psychopathology see Galimberti, 1991. 4. Sedation, in fact, reduces acute psychopathological crises progressively to the point of anaesthetisation, where the psychopathological condition disappears although other medical pathological conditions (a tumour or inammation, for example) persist. Indeed, no trace of psychopathology can be found in anaesthetised subjects. 5. The between (Buber, 1993). 6. On the concept of emergent properties, see Bocchi and Ceruti (Eds.), 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) 7. In this regard, see the perspective oered by phenomenological psychiatry: Minkowski (1927); Binswanger (1963); Borgna (1989, 1995, 2008); Galimberti (1991), Callieri (2001). 8. On the concept of awareness in Gestalt psychotherapy see Perls et al., 1994; Perls, 1969a; Polster and Polster, 1973; Salonia, 1986; Yontef, 2001, and for a more recent review, Spagnuolo Lobb, 2004. 9. `The relationship, if open and civilising, not limited to eros and philia, but also touched by agape, is always a third party to the le vitch, 1970, p. 798) I-Thou relationship.' (Janke 10. `Today, more than ever, the lesson of Marguerite Duras's novels is relevant: the way the only way to have an intense and fullling personal (sexual) relationship is not for the couple to look into each other's eyes, forgetting about the world around them, but, while holding hands, to look together outside, at a third point (the Cause for which both are ghting, in which both are engaged).' (Zizek, 2002, p. 85) 11. `In the ancient world, including Greece, the inter-human relationship was always mediated by the Absolute, by a Third

Psycopathology and diagnosis inserted between direct contacts, symbolised by the community itself and by its representatives.' (Bruni, 2007, p. 29) See the work of Levinas and Derrida. For a dierential analysis in Gestalt therapy terms of neurosis and psychosis see Giovanni Salonia (Salonia, 2001) and Margherita Spagnuolo Lobb: `To summarize these dierences in Gestalt therapy terms, in neurosis what seems new is dened as ``not for me'', via the ego function; the support of personality function of self is lacking in this case. The self cannot adjust creatively to changes in social relationships, on account of a split between the denition of ``who I am'', as assimilated from previous contacts, and the new social requirement.In psychosis, because the ground of security built on assimilated contacts is missing (id function of self), the ego cannot exercise its ability to deliberate on this ground. Contacting is thus dominated in the psychotic by sensations that invade the self with ``no skin'', and so invade the world.' (Spagnuolo Lobb, 2003b, p. 340) According to Gilligan, Freud moved from being `he that does not know', open to contact and experience, to `he that knows', the `solver of enigmas'. `But Freud is a man and also a father, and as he aligns himself with women, he nds himself in the position of women, isolated and embattled in his claim to knowledge. It is a position I have seen parents and teachers and therapists come to when they align themselves with a child or adolescent's perceptions and join their resistance to a disassociation that is part of a process of initiation. In aligning themselves with such resistance and opting for relationship, they are coming into conict with voices of authority and risk being called bad parents, or jeopardizing their positions as teachers and therapists.' (Gilligan, 2002, p. 190) Phenomenological perspective is a widely discussed root of Gestalt therapy. Among recent contributions, see for instance, Crocker (2009); Philippson (2009); Bloom (forthcoming). In this paper we refer to intentionality in a phenomenological sense, as discussed recently in Crocker (2009), Philippson (2009), and Bloom (forthcoming) (see his concept of therapeutic intentionality). `The arrow does not always reach its target. Due to lack of energy or direction, it may drift o 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 behavior.' (Salonia, 1989, p. 78) 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 eect 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) 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 the Stanford

17

12. 13.

20. 21. 22. 23. 24.

14.

25. 26.

27.

15. 16.

Prison Experiment was the demonstration of the pervasive power, however intangible, of situational and contextual variables. A good example is given by the psychiatry of the colonial age, as well as the inationary use today of the concept and term `culture' in social, political, legal and even diagnostic contexts. Italiana Salonia, address to the First Conference of the Societa Psicoterapia Gestalt, Siracusa, 7 December 2007. This need is perhaps heightened for us by the fact that we work in an educational context and our students often ask precisely about diagnosis. These co-ordinates were used, for example, for a Gestalt perspective on the experience of panic disorder (Francesetti, 2007). `I would not be a phenomenologist if I did not see what is obvious, that is, the experience of being bogged down. I would not be a Gestalt therapist if I did not step into the experience of being bogged down without the condence that some gure will emerge from that chaotic ground.' (Perls, 1969b) On this point we disagree with the view of Daniel Stern, for whom `now moments' occur by chance, in an unpredictable way (Stern, 2004). `These interruptions are felt. They are sensed, or sensible, by the client and the therapist. These are not hypotheses or abstractions they are sensed actualities aecting the stream of contacting. This is the aesthetic criterion as a clinical value.' (Bloom, 2003, p. 72) Interruptions in contact belong to both diagnostic registers: they can be used as a map for orientation (extrinsic diagnosis), or they can be treated as perceptible phenomena marking a drop in intentionality in the here and now (aesthetic diagnosis). Each and every time we speak of interruption in contact, it is important to specify to which register we refer.

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Gianni Francesetti, psychiatrist, Gestalt psychotherapist, teaches on the Gestalt Psychotherapy Training Programs of the Istituto di Gestalt HCC Italy, Istituto di Gestalt Therapy HCC Kairos, and Scuola Gestalt Torino. He is in charge of the Masters course in Gestalt Counseling at the Turin branch of the Istituto di Gestalt HCC Italy and an Associate Member of the New York Institute for Gestalt Therapy. He is President of the SIPG (Italian Gestalt Psychotherapy Association), Chair of Training Standards Committee and member of the Executive Committee of the EAGT (European Association for Gestalt Therapy), and a member of the Executive Board of FIAP (Italian Federation of Psychotherapy Associations). He is on the editorial board of Quaderni di Gestalt and of Studies in Gestalt Therapy: Dialogical Bridges. He has authored articles, chapters, and books in the eld of psychiatry and psychotherapy. Address for correspondence: Via Cibrario 29, 10143 Torino, Italy. Email: gianni.francesetti@gestalt.it Michela Gecele, psychiatrist, Gestalt psychotherapist, teaches on the Gestalt Psychotherapy Training Programs of the Istituto di Gestalt HCC Italy, and Istituto di Gestalt Therapy HCC Kairos. She is in charge of the Masters course in Gestalt Counseling at the Catania branch of the Istituto di Gestalt HCC

20 Gianni Francesetti and Michela Gecele Italy. She is an Associate Member of the New York Institute for Gestalt Therapy and a member of the Human Rights and Social Responsibility Committee of the EAGT (European Association for Gestalt Therapy). She has been working for fteen years in a public mental health service, and for three years she has coordinated a psychological and psychiatric prevention and support service for immigrants. She has authored articles, chapters, and books in the eld of psychiatry, psychotherapy, and transcultural matters. She is on the editorial board of the journal Quaderni di Gestalt. Address for correspondence: Via Avigliana 52, Torino, Italy. Email: mgecele@hotmail.com