British Gestalt Journal # Copyright 2009 by Gestalt Publications Ltd.

2009, Vol. 18, No. 2, 5±20

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 su€ering 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,
su€ering of the contact boundary, co-creation.

Psychopathology as the su€ering of in Gestalt therapy? And how can we do this without
falling back on to categories which crystallise experi-
relationships
ences and clients? Etymologically, the word `psycho-
pathology' consists of three roots: `psycho-', `-patho-',
The su€ering of the contact boundary `-logy'. Psyche, meaning soul in Greek, derives from
In Gestalt therapy a continuum exists, without clear-cut psychein: to breathe. Patho, from the Greek pathos:
distinctions, between healthy and so-called pathological a€ection, su€ering, derives from paschein (indeurop.):
experience. Based on this conviction, all attempts at to su€er. Logos, in Greek: discourse (Cortelazzo and
diagnostic categorisation and nosology have always Zolli, 1983). Hence, psychopathology is discourse on
been treated with caution1 (Perls et al., 1994). The the su€ering of the breath, of something elusive, which
value given to momentary experience and to the con- cannot be con®ned within a stable objective form. It is
tingency of each and every situation underpins the the su€ering of the animating breath, the su€ering of
legitimacy of all lived experiences. It is this value that the animate,2 living body (Leib), not the object-body
prevents the crystallisation into ®xed gestalten of people (Korper).3 All living bodies are living precisely because
and their experiences. they have intentional contact with their environment
Historically, this position has played an important (Minkowski, 1999). Psychopathological phenomena
role not only in clinical practice, but also in de®ning a concern subjects as they interact with the environment,
vision of the world, where the individual ± and the or more precisely, the interaction of subjects with the
therapist ± is considered in relation to the polis (Good- environment.4
man, 1990). Nevertheless, it does not exhaust the need At this point, we come to a radical bifurcation. We
for further discussion on this issue (Yontef, 1988, 1993; can focus on psychopathology as either the su€ering of
Delisle, 1991; Staemmler, 1997, 2002; Spagnuolo Lobb, the individual or, alternatively, as the su€ering of the
2001a; Amendt-Lyon, 2003; Bloom, 2003; Brownell, interaction between the individual and the environ-
2005; Robine, 2007). In our view, such discussion is ment. This change of focus opens up two very di€erent
necessary for progress to be made in theory, for guide- universes and two profoundly di€erent ways of
lines to be developed for clinical work with clients, for approaching psychological su€ering.
dialogue to be promoted with colleagues using di€erent These two perspectives on the reality of mental
models, and last but not least, for preparing our su€ering can be likened to the two perspectives through
students for clinical work. which light can be understood in physics: is it a wave or
This consideration of ours ®rst emerges when re¯ect- a particle? Reality depends on the way we investigate the
ing on the question: how can we treat psychopathology world. Psychopathological phenomena are much the
6 Gianni Francesetti and Michela Gecele

same. Psychopathology can be considered a phenom- belongs and in which it is generated: the contact
enon belonging to the individual or a phenomenon boundary.
emerging from the ®eld, belonging to the interaction Hence, psychopathology can be understood as know-
between the subject and his environment, to the ledge concerning the su€ering of the animating breath,
Zwischenheit5 (to quote Buber) (Buber, 1993; Salonia, of the `between', of the contact boundary. The animat-
2001; Spagnuolo Lobb, 2001a, 2005a; Francesetti, ing breath, the `between', and the contact boundary are
2008). In more strictly Gestalt theory terms, it is a not entities belonging to the individual, but rather
phenomenon that belongs to the contact boundary. living spaces that emerge through contact. Psycho-
Our epistemology is founded on the consideration pathology is an emergent property of the contact
that experience does not strictly belong only to the boundary.6 Psychopathology is not simply subjective
organism, or to the environment (Perls et al., 1994; su€ering. Subjective su€ering may exist without being
Spagnuolo Lobb, 2001b, 2003a, 2005a). Rather, experi- psychopathological, that is, without the su€ering of the
ence emerges as a `middle voice' at the contact bound- between (in this case there is pain, but no harm).
ary, where the organism and the environment interact. Subjective indi€erence (without perceived pain) is
The experiential ®gure that emerges contextually from psychopathological because the between su€ers (in
the ground (constituting the continuum of experience) this case, there is harm even though there is no pain).
is a ®gure that belongs to the individual (for example, in Not all su€ering felt by individuals is necessarily
a discussion group, no two people have the same unhealthy (for example, grief, which is su€ering but
experiential ®gure). At the same time though, it does not psychopathology), while a pathology is not always
not belong to the individual (again, in our discussion perceived by individuals as su€ering (for example, with
group, the ®gure of each person also belongs to the psychopathy or with sociopathy).
others because it is from the others and through the To orient ourselves more clearly through psycho-
others that it emerges and takes shape) (Robine, 2007). pathology, we need to move beyond sole reference to
Returning to psychopathology, if we view such phe- the individual and consider the relationship (Salonia,
nomena as emerging at the contact boundary, then 1989a, 1999, 2001; Spagnuolo Lobb, 2003a, 2003b). The
strictly speaking it is not the subject that su€ers. What question leading us is no longer `is the subject su€er-
su€ers is the relationship between the subject and the ing?', but rather, `is the relationship su€ering?'. Psy-
world: that space which the organism experiences and chopathological pain expresses a lack of signi®cant
in which the organism becomes animate. Psychopathol- contact,7 and is all the more serious the more early
ogy is the pathology of the relationship, of the contact and fundamental the relationship is in the development
boundary, of the between. of the self and the growth of the organism. The indi-
The subject is the sensible and creative receptor of vidual sensation of this su€ering of the between is a
this su€ering. Su€ering may be perceived and creatively manifestation of awareness (which is always awareness
expressed by the subject, but it emerges from the of and at the contact boundary).8
contact boundary. The agent of this feeling (of all As the pain belongs to the relationship, it may happen
feeling) is the self, which is a function of contact. For that not all the parties involved feel it. An example can
Gestalt therapy, psychology is the study of what hap- be given by a man whose relationship history has left
pens at the contact boundary (while what happens him with a narcissistic injury: he cannot feel the pain of
inside the organism is the realm of biology and physi- the relationship within the couple, which is only felt by
ology, and what happens outside the organism is the the female partner. The fact that she is su€ering (from a
realm of sociology and politics) (Perls et al., 1994). As profound sense of loneliness and sadness, for instance)
such, psychopathology must necessarily refer to the does not imply that it is she who should be treated to
su€ering of that boundary. overcome her troubles (perhaps with anti-depressants).
This approach entails a number of important con- Rather, her distress is a healthy sign showing that their
sequences. Psychopathology is not simply subjective relationship is in need of support. In this case, therapy
su€ering. Psychopathology is the su€ering of the should assist him to feel the pain of their relationship,
`between' ± not in the between but of the between. The which will probably reveal past relationship wounds
e€ects of the su€ering of the between (of the contact that he guards without touching.
boundary), of psychopathology, can be felt by anybody Children also very often cannot recognise and express
standing in the relationship: the other or a third party. their psychological su€ering when the relationships
Su€ering is perceived by the organism but it does not they are a part of su€er. They cannot speak up and
belong to it, neither in terms of origin nor cure. say `I am su€ering', but instead manifest physical
Su€ering emerges and develops within a relationship disturbances or learning diculties at school, hyper-
(Sichera, 2001, pp. 17±41; Salonia, 1992) or, in more activity or aggression towards their companions. How-
strictly Gestalt theory terms, in the space to which it ever, if someone who can perceive what is happening at
 Psycopathology and diagnosis 7

the contact boundary comes into contact with the child relationship, of the environment that contains the
(or the family), she will feel the su€ering that a‚icts the relationship and provides it with its essential existential
relationship. Psychopathology can be felt as subjective space-time coordinates. This containing environment
pain, for instance when anxiety or melancholy grips us. consists of the actualisation of strati®ed relationships
However, it can also be su€ering that is perceived only often left at an embryonic stage, or developed in a `mad'
by others, where the pathology ± the su€ering ± lies dual horizon. Everything appears so fossilised that even
precisely in the fact that the individual is incapable of breathing seems an overwhelming challenge. It is im-
feeling pain (as in the case of people who act violently). portant to build a climate conducive to the relationship
Almost paradoxically, in this case, the purpose of that supports the emergence of these mad and incom-
support is to help the person become capable of feeling plete relationships (which have seldom reached the
pain. Becoming aware of the pain of a relationship is a point of I/Thou separation) (Salonia, 1989b, 2001).
cure in itself. Only at a later stage diagnosis (and therapy) can
The shift towards an essentially relationship-based change, and the therapeutic relationship present here
view of psychopathology sheds new light on pain and and now can become the ®gure and focus of the work. It
the relationship between pain and harm. If relationship is now that the client can begin to see the therapist. And
pain is given insucient support, it remains out of it is now that the therapist can let the relationship rest
awareness and hence self-destructive. It becomes harm. on the `external' third party, always present as the
ground, horizon, and frame of reference. The therapist
The third as constituent of relationships no longer needs to provide the basic ground to the
Not only do we need to go beyond references to the relationship. Gradually, and with great e€ort, that
individual, but also to the dual relationship. It should be ground has become a shared, consistent heritage, both
borne in mind that the relationship in question is containing and founding. The therapist can once again
always a three-way relationship. A relationship never become aware of the spontaneous passage of time,
consists solely of two people; there is always a third marked by a breath that has ®nally become possible.
party that constitutes the background (Spagnuolo Lobb For more serious disturbances, treatment may be
and Salonia, 1986; Fivaz-Deperusinge and Corboz- dicult, not because there is no cure, but because the
Warnery, 1999; Salonia, 2005; Spagnuolo Lobb, 2008). environment (from the family to society) would need to
This triadic perspective is fundamental in reading be changed extensively, and this is not possible. At
both distress and the possibility or impossibility of times, the client may progress to establish a healthy
providing support. A relationship, therefore, always relationship, in which she does not su€er, with the
implies and involves a third party: someone, something, therapist, but not outside the therapeutic setting. It is
the world itself (JankeÂleÂvitch, 19709; Zizek, 200210; true that often it is not only the client that `needs' to
Bruni, 200711). The presence of the `third party' (Levi- change, just as it is true that often it is the family and/or
nas), of `the other Other' (Derrida), in relationships is the social context that is ill. Here, the concept of creative
an ethical issue, touching on the very meaning of adjustment can help, understood as the capacity to ®nd
human life. This was, especially for the twentieth cen- solutions and act at the contact boundary, within the
tury, and still is a philosophical issue of great import- limits of space, time, and given resources. Through this
ance which opens up and addresses other disciplines, psychopathological view, the dichotomy between `indi-
such as sociology, anthropology, politics and psycho- vidual pathology' and `madness determined and made
logy.12 Society, the people bordering on the relation- chronic by the social context' is dissolved.
ship, humanity as a whole: what e€ect does a su€ering An important diagnostic element lies in the over-
relationship have on them? What do they stand to lose? whelming need for a third presence, as a touchstone to
And how, and to what extent, does what happens avoid going mad and to ®nd legitimatisation in a world
contribute to determining a certain `blindness' in perceived as new and without given certainties. We are
society and in people surrounding the relationship? not simply referring to the habitual experience of the
In this sense, torture, indi€erence to one's pain or to client, which the therapist draws out: for us, it is the
the pain of others, the dominion over others, and the immense need for support that is most poignant.
failure to listen all fall within psychopathology, just as The strong need for a third party can be a pointer to
anxiety and depression do. In all these cases, relation- the degree of seriousness. It reveals the extent to which
ships su€er. contact experience has been uprooted from the
Where psychopathological su€ering is most serious ± common world, taken for granted, from the ground
concerning issues of fragmentation and the non- given by assimilated contacts.13 The `feeling' of just how
boundary between the individual and the world ± it is much need there is for a `strong' third party is indicative
vital that the therapist becomes part of the ground. In of psychotic experience, and is relevant for both diag-
doing so, he takes on the role of third party in the nosis and treatment.
8 Gianni Francesetti and Michela Gecele

Folie aÁ deux, on the other hand, can be understood The co-ordinates of Gestalt psychopathology
as a dual relationship where the third party (the In Gestalt therapy, psychopathology can be based on the
relational network, the work group, the context) analysis of su€ering of the contact boundary that is a
provides no support. In this case, awareness is lacking phenomenologically experienced process. Such su€er-
of the need for anchorage in a third party. Even the ing reduces awareness and presence at the contact
therapeutic relationship runs the risk of `shared mad- boundary. It is a contact experience which is lacking
ness'. In this sense, a sort of isolated space-time may in some way (Salonia, 1989a, 2001; Spagnuolo Lobb,
be created, disconnected from the stream of life. 1990, 2001a; special issue of Cahiers de Gestalt, 2006).
Breaking down the parties involved, this risk may With such an absence, the symptom is always a plea: it is
occur due to the relationship history brought by the a way in which the subject is demanding and looking for
client, due to the limits of the therapist, or due to the a new relationship (Sichera, 2001). Standing at the
limits of the context, society, the third party. These contact boundary helps the therapist understand the
three components, of course, are not separable; how- contact diculty a€ecting the relationship, and what to
ever, prying them apart can be useful, especially to do to provide the relationship itself with support.
stress the third. Recognising the limits and condition- In Gestalt therapy terms, the clinical understanding
ing posed by a determinate social context and making of su€ering is founded on a range of co-ordinates that
them explicit has been a key issue in the history of trace out an epistemological pro®le. It is on these bases,
therapy. Quite clearly, the support provided by the outlined below, that we believe a Gestalt perspective of
epistemological model and by the community of our psychopathology can be founded, which we would go so
colleagues and peers is of great importance in enabling far as to call Gestalt psychopathology.
therapeutic work to continue.14 Phenomenological: That is, not interpretative but
To summarise, psychopathology is the su€ering of concerned with understanding lived experience.15
the contact boundary. It may or may not be felt as Lived experience, under this approach, is granted full
subjective pain. When the subject does not fully per- and unconditional dignity and validity. This position
ceive that which happens at the boundary, no subjective brings us in line with the epistemological approach
pain is felt. However the other, or a third party, may feel taken by phenomenological psychiatry (Merleau Ponty,
it. From a clinical point of view, it is not the pain which 1945; Binswanger, 1963; Minkowski, 1927, 1999; Cal-
is pathological, but rather the impossibility of sustain- lieri, 2001; Borgna, 1989; Rossi Monti, 2002).
ing it and of being fully aware of it at the individual, Fixed gestalten cause relationships to su€er by inhi-
family and social levels. In order to reduce subjective biting full contact from being made with present rela-
pain, it is the between, the boundary which is made to tional reality. It is for this reason that Gestalt
su€er. In this way, the level of pain perceived is lowered, psychopathology treats the categorisation of experience
but so is awareness. In developmental terms, this with caution, and avoids the categorisation of subjects.
capacity to reduce unsustainable pain is a creative The experience of psychopathological su€ering is
adjustment that protects the individual, the family, anthropologically `normal'. It is accessible to all
and society. But now, that same capacity inhibits the human beings. All human beings may ®nd themselves
individual from feeling, living, and acting to the full, expressing the more or less serious su€ering of a
from fully experiencing the self and the environment relationship, for which a continuum exists between
with which he is in contact. Full experience is healthy healthy and psychopathological experience.
experience, produced by the co-construction of the Relational: In the sense that:
contact boundary. It can be recognised by the creation
of a bright, harmonious, strong and graceful ®gure 1. Psychopathology is the su€ering of relationships.
(Perls et al., 1994; Bloom, 2003). For such a ®gure to The focus of treatment is not the individual, but the
be formed, it is essential that the self is fully present at relationship that emerges at the contact boundary. It
the contact boundary. For the self to be fully present, it is the relationship that the psychotherapist treats, by
needs sucient support. standing at the contact boundary. What su€ers is the
Unsustainable pain becomes anaesthetising, leading contact boundary and it is the contact boundary that
to the incapacity to perceive the self or the environ- is cured through therapy. The origins of distress and
ment/other. When sucient support is provided, `suf- its cure lie in the relationship (Salonia, 1992, 2001;
fering' is pain. When insucient support is provided, Spagnuolo Lobb, 2001a, 2005; Sichera, 2001; Yontef,
`su€ering' is cruelty or self-destructiveness. One way of 2001; Philippson, 2001). Subjective su€ering does
preventing and curing harm at the social level is to not coincide with psychopathology: subjective suf-
provide support for pain. This provides us with an fering may exist without psychopathology, and psy-
ethical key and a political perspective to our work as chopathology may exist without subjective su€ering.
psychotherapists. Indeed, the latter case is perhaps the more common.
 Psycopathology and diagnosis 9

2. Lived experience is co-created within the relation- 1994; Kepner, 1993; Frank, 2001; Salonia, 1986; Spag-
ship (Spagnuolo Lobb, 2003a; Stern, 1998), as are nuolo Lobb, 2004).
the underlying experiential co-ordinates of space- Oriented towards creativity: The su€ering of a rela-
time experience. Space and time, along with energy tionship is the outcome of creative adjustments made
and vitality, are not functions of the individual but within a dicult ®eld. Original creativity has been lost
functions of the relationship upon which they also and has become a ®xed gestalt (Perls et al., 1994; Zinker,
depend (Salonia, 2001, 2004). 1978; Spagnuolo Lobb, 1990, 2003a, 2005a). This can
3. It focuses on the moment and the way in which the easily be seen in neurotic adjustment, where a creative
spontaneity of contacting is interrupted, and inten- adjustment made at some stage in a person's history
tionality16 is left without support (Spagnuolo Lobb, results in her diminished presence at the contact
2001a). At that moment, disturbances in self func- boundary. The case of psychotic experience is di€erent.
tioning emerge and the therapist intervenes to sup- Psychosis is the expression of a lack of basic ground.
port the relationship. What is interrupted is not, Here, the goal is not to restore awareness of interrupted
strictly speaking, contact, but the spontaneity of contact, and in so doing assimilate it, with the result
contacting. Contact (the relationship here and that the possibility for new creative adjustments is
now) lacks the necessary support to maintain inten- restored; rather, the task of the therapeutic relationship
sity and harmony in constructing the ®gure; it is to build a ground that has not yet been created
cannot attain the novelty that could emerge from (Salonia, 2001; Conte, 2001; Spagnuolo Lobb, 2003b).18
the co-creation of contact experience with the ®eld's Contextual: Distress is always determined by a given
potential. The energy which underpins intentional- context, and it is from the context that it emerges.
ity is either lost or channelled elsewhere: intention- Context does not just de®ne psychopathology: it is
ality is distorted and the arrow does not reach its fundamental in generating psychopathology or in pro-
target.17 The contact episode goes through all the tecting a person from it (Robine, 2007; Salonia, 2007;
phases of the contacting pattern, but without the Gecele and Francesetti, 2007). An exemplary case is
strength and beauty that would otherwise emerge if given by the well-known Stanford Prison Experiment
all the intentionalities in the ®eld were gathered and (Zimbardo, 2008).19 Depending on the context, a type
expressed. of su€ering (for example, narcissistic su€ering or panic
4. Relationships are never dual: there is always a con- attacks) may be a symptom which is rare and isolated or
stituent third party, to which they are open and endemic and normal; it may be valued and rewarded, or
which restricts them. it may cause disadvantage for the person expressing it.
Salonia observes that all social contexts promote the
Temporal: Time and space are co-created by the emergence of a `basic relational approach' which is
client and the therapist. The therapist accommodates supported and rewarded in the speci®c historical and
himself to the space-time of the client and (by co- cultural moment, becoming the norm for relationships
building the experience) modi®es it. The more fragile in that context (Salonia, 2007).
the ground of the client (and hence the greater his Developmental and `next' oriented: All distress has a
su€ering), the more the therapist will need to take history which holds the key to its meaning. The symp-
responsibility for establishing and safeguarding the tom is the present trace of past relationships actualised
space-time coordinates of the relationship (Spagnuolo in the here and now. Of these traces, relationship
Lobb, 2003b). Time is a constituent of the third party. It experiences from infancy hold signi®cant weight in
roots and situates the relationship in a history, thus the development of the self, and hence for the serious-
making a narration which builds bridges with the ness of the disturbance (Pine, 1985; Salonia, 1989b,
possible Other. Essentially, a subject can only be such 2001; Stern, 1985; Wheeler and McConville, 2002;
insofar as it is a subject of a history. Time and reality are Conte, 2001; Spagnuolo Lobb, 2003b; Righetti, 2005;
correlated (Salonia, 1992; Irigaray, 2002). The relation- Mione and Conte, 2004). In integrating Gestalt theory
ship gives meaning to time, though time also gives with recent ®ndings in infant research, Salonia proposes
meaning to the relationship (Salonia, 2004). This is a relational reading of infant development which can be
why, for example, it is possible to cure a temporal used as a hermeneutic key for placing the distress of
pathology, such as a mood disorder, through the adults and understanding its provenance (history) and
relationship (and not just understand it phenomeno- destination (its next). Development stages require an
logically). evolution from the primary `we' to `I/Thou' di€erentia-
Holistic: Su€ering is not just mental. The su€ering of tion; from here, it is then necessary to acquire a new
the relationship is perceived by the subject in its whole, experience of the `we'. All various types of su€ering can
and through experience, which is always corporeal. The be traced back to a speci®c moment in the development
mind/body dichotomy is a neurotic divide (Perls et al., of relationship skills (Salonia, 1989b, 2001).
10 Gianni Francesetti and Michela Gecele

All distress has its relational `next' towards which it is sistic trend of the ®nal decades of the last century
oriented and which illuminates its meaning (Polster, (Lasch, 1979; Salonia, 2000). This perspective weds
1973; Salonia, 1989a, 1992; Spagnuolo Lobb, 2007b, perfectly with the concept of `basic relational per-
2008). In giving support, the fundamental question sonality' proposed by Giovanni Salonia (Salonia,
orienting the therapist is `towards which relational 2007, 2008).
experience is the person heading?' The answer to this
question both marks and points to the direction of
therapy. Diagnosis in Gestalt therapy: extrinsic
Aesthetic: The health criterion is intrinsic to the and intrinsic diagnosis
relationship (Joe Lay quoted by Bloom, 2003). It is an
aesthetic criterion: being healthy means being able to The relationship between psychotherapy and diagnosis
create a contact ®gure which has grace, brightness, is a complex one (Bartuska et al., 2008). The issue has
rhythm and harmony (Perls et al., 1994; Bloom, 2003; attracted, and still attracts, very di€erent positions in
Salonia, 2004; Spagnuolo Lobb, 2007b, 2007c). There is the ®eld of psychotherapy. The founding epistemo-
no need to use extrinsic evaluation methods, based on a logical principles underlying the anthropology of dif-
comparison between what happens and an external ferent psychotherapeutic approaches give rise to very
norm taken as a benchmark (Perls et al., 1994, p. 65): di€erent perspectives on diagnosis and the therapeutic
it is the aesthetic quality of contacting that should relationship. In its theoretical foundations and histor-
orient the therapist (see below, aesthetic or intrinsic ical and clinical evolution, Gestalt therapy sees the
diagnosis). therapeutic relationship as an environment for contact.
Dimensional and non-categorical: The categorical Through contact, subjects give rise to an authentic,
approach de®nes extrinsic criteria and discrete categor- unique, and co-created relationship, which in turn
ies with clear-cut borders which provide objective shapes and constitutes them. The aim of the therapeutic
identity to pathological situations or individuals. The relationship, in this model, is to co-create a new,
dimensional approach distinguishes itself from this by nutritious experience, able to help the subject grow.
situating phenomena of su€ering along a continuum, in The client is in no way objecti®ed. Objecti®cation
which it is impossible to establish a clear-cut boundary would lead to the irreparable loss of the presence of
between health and illness (DSM by the American the other, and would be diametrically opposed to the
Psychiatric Association, 1994; Barron, 1998). All experi- direction in which Gestalt therapy moves.
ences and all relationships have more than one dimen- In this relational horizon, diagnosis becomes a prob-
sion. Everybody can have a narcissistic, borderline, lematic issue. It raises a number of questions: is diag-
depressive, dependent, psychotic or other dimension, nosis necessarily an objectifying act? Does diagnosis
depending on moments in life and situations. Hence, impede contact or support therapeutic contact? As
pathology is not a clearly de®ned entity which can be Gestalt psychotherapists, do we really need to diagnose?
distinguished from a healthy spectrum. People seeking And more radically, is diagnosis possible in Gestalt
help ®nd themselves confronted with the same existen- therapy?
tial issues that we all face ± love, loneliness, time, death. Diagnosis comes from the Greek dia-gnosi, meaning
What makes the di€erence is the possibility or impos- to know through (Cortelazzo and Zolli, 1983). This in
sibility of drawing on the support necessary for realising itself stresses the impossibility of not using diagnosis, in
and living one's art. broad terms at least. In the last century, the philosophy
A dimensional approach can be integrated with a of science and hermeneutics taught us that knowledge
perspective that takes into consideration thresholds for free of all ®lters and foreknowledge cannot exist. If we
each of the various dimensions (Cancrini, 2006). From can only know through, and there is no gnosis without
this perspective, for example, all individuals can man- dia, the question transforms into which dia (which
ifest borderline experience depending on the circum- prejudices, which presuppositions) should we use
stances. What changes from one person to the next is (Salonia, 1992).
the threshold at which such experience sets in. For some Secondly, we need to avoid the latent risk of confus-
people, their threshold is lower than for others, for ing behaviours with lived experiences (which would be
which they easily manifest this type of experience. objecti®cation). Diagnosis can be a de®ning and de®-
Therefore any given situation or relationship can give nitive act which freezes the Other into a category.
rise to borderline, narcissistic, psychotic or other Alternatively, diagnosis can be a relational process
experiences. In certain historical and social circum- which is co-built through contact and through the
stances, a certain type of experience becomes the truth released through contact. When it forms part of
norm. Examples include borderline behaviour during the relational process in psychotherapy, the intention of
the French Revolution (Cancrini, 2006) or the narcis- diagnosis is to provide support to the therapeutic
 Psycopathology and diagnosis 11

relationship. Two support functions can be identi®ed: squarely in the ®eld of medicine. In this way, a map
the ®rst lies in giving the therapeutic relationship was created to help clinical practitioners orient their
developmental direction; the second in anchoring the way through the chaotic world of madness. The
therapeutic relationship in a third party. Diagnosis itself prognostic di€erences of the two categories were
can be a third party, anchoring therapy in an extended thus established: dementia praecox progressively
corpus of knowledge and experience, in a sedimentary degenerates, whereas recovery is possible for manic-
and shared history, in the professional community. depressive psychosis. Here we see the vicious circle
The criterion for diagnosis can be either extrinsic or typical of classi®cation: labelling a client `prematurely
intrinsic to the relationship. In this way, we can distin- demented' means declaring him incurable, which in
guish between two kinds of diagnosis: the ®rst may be turn reduces the client's chances of being cured or
called extrinsic or map diagnosis, and the second, treated. Bleuler later proposed changing the name of
intrinsic or aesthetic diagnosis. this clinical condition to schizophrenia, so as not to
identify it as an incurable condition (Bleuler, 1967).
Extrinsic or map diagnosis Nevertheless, very soon the problematic nature of
using medical diagnosis in the ®eld of psycho-
Extrinsic diagnosis involves comparison between a pathology began to be appreciated, as were the risks
phenomenon and a phenomenon model. It has all the associated with it (Minkowski, 1927, 1999): the risk of
characteristics ± the bene®ts and the limits ± of a map. objectifying that which cannot be objecti®ed; the risk
The purpose of maps is to orient us. A city map, for of crystallising that which is constantly changing; the
example, enables tourists to locate themselves and to get risk of losing the subjective experience of the client,
to know the city, in a certain sense and within certain which is precisely what the therapist seeks to grasp
limits, before going there. The DSM, as with other and de®ne. In short, the risk of making the epistemo-
nosological classi®cations, serves this purpose (APA, logical error of treating subjective experience as an
1994). object of nature. In his General Psychopathology (Jas-
pers, 1963), Karl Jaspers proposes a phenomenological
The limits of maps classi®cation of lived experience that seeks to protect
By their very nature, maps have many limitations. A the subjectivity of the ¯ow of consciousness, and
map, for example, cannot be updated; its form is hence the su€ering client, by situating the science of
crystallised and once produced, the map remains dis- psychopathology within the sphere of the sciences of
connected from the stream of life with its many the spirit. These brief historical examples show how
changes. the diagnostic act traces out demarcation lines that
In psychopathology, nosological maps identify vari- always respond to very precise epistemological struc-
ous types of su€ering: schizophrenia, anorexia, panic tures. Diagnosis re¯ects the worldview of the person
attacks, and all the other pathologies that a speci®c map performing the diagnostic act. Hence, diagnosis is in
charts. It is interesting to note how unpleasant just some sense arbitrary.
citing these diagnostic categories can be, showing a Psychopathological diagnosis is a map traced out
sense of disrespect to the people to whom these terms over co-ordinates that are more or less precise and
could possibly be applied. In e€ect, we are moving consistent, whether explicit or not. Even the DSM, in its
within an `I/It' relationship, to use Buber's terms. By various editions, belongs to this order of diagnostic
objectifying, we show no respect for subjective dignity classi®cations. It is not an atheoretical classi®cation, as
and uniqueness (Buber, 1993). it claims to be. Rather, it is a careful, though arbitrary,
One of the risks that a diagnostic system runs is that outline whose purpose is to simplify the distress-terri-
of claiming to be a taxonomic classi®cation of objects tory so as to communicate through the use of a shared
in nature, based on the objective gathering of data. map.
Historically this is what has happened. Modern psy- When extrinsic diagnosis is used, it is important that
chiatry was born precisely from the attempt to give a both the general limits and psychopathological limits of
name and classi®cation to psychopathological phe- maps are known. The general limits of maps include:
nomena. Kraepelin achieved a great step forward for
the psychiatry of his time (second half of the nine- . The map is not the territory (Korzybski, 1933). The
teenth century) through his clinical distinction map is based on a foreknowledge of the territory
between dementia praecox and manic-depressive psy- which can be useful for orientation and for calming
chosis (Kraepelin, 1907). He believed he had identi®ed the anxiety that arises in encounters with the
`natural disease entities', comparable to pneumonia or unknown (Salonia, 1992). Ultimately it betrays the
heart attacks. In doing so, he disentangled mental territory though, through deletions (a map cannot be
su€ering from the spires of moral guilt, placing it exhaustive), distortions (what is represented in many
12 Gianni Francesetti and Michela Gecele

ways does not correspond to the actual territory), in which to situate diagnosis in therapy: the ®rst is the
and generalisations (the singularity and specificity of naturalistic model, the second the hermeneutic model.
elements are lost) (Bandler and Grinder, 1975). The naturalistic model implies an objectifying relation-
. The map is drawn by somebody: it implicitly or ship that is not oriented towards intersubjective con-
explicitly represents the perspective, convictions, tact. It is the medical model whereby the clinic maps
values and principles of the author. symptoms and then uses this map for treatment, with-
out concerning itself with the subjectivity of the client.
Maps covering `psychopathological territory' have In the hermeneutic model, on the other hand, the
further, speci®c limits: diagnostic process is co-constructed, pooling together
. They are fundamentally inadequate because they use the knowledge (and foreknowledge) of the therapist
an objective dimension to represent the subjective. and client (Gadamer, 1960; Salonia, 1992; Sichera,
. They are fundamentally inadequate because they use 2001; Staemmler, 2006). Foreknowledge is both a
an individual dimension to represent the relational. limit and a resource. It does not constitute a priori
. In contrast with maps of cities with clear-cut bound- knowledge (a Procrustean bed) through which to cat-
aries, in psychopathology, what is pathological and egorise the subject; rather, it is knowledge to contribute
what is not, and the limits between them, is not to the ®eld. Circumstantial knowledge is what is pro-
known a priori. vided by the map; via a two-way ¯ow between clinical
. Psychological distress changes over time through knowledge and the relationship being created, it is
historicity and the distress/context relationship. Dis- shaped to the uniqueness of the subject and to new
tress depends on location and different cultural contact.
sedimentation. The map drawn may be useful here Within this hermeneutic framework, in which Gestalt
and now, but we do not know how useful it is in psychotherapy is situated, we can make use of extrinsic
other contexts and for how long. maps. In doing so, however, we must be aware of their
limits and uphold our respect for the indomitable
The map in¯uences the territory in a circular way: the uniqueness and mysterious elusiveness of each and
diagnosis made has signi®cant consequences (patho- every person.
genic or supportive) at the individual, family and social Why should we need to know and use extrinsic
levels. diagnoses? We need to know them for the simple
Psychopathology is a ®eld strongly exposed to pres- reason that this type of diagnosis exists. It is used not
sures exerted by the political world view of the time and only in the ®eld of psychotherapy but also in psychiatry,
by the designer of the map: deciding who is mad and research, forensics, and, last but not least, in popular
who is not in a given context also responds to the logic language. To ignore this aspect would mean shutting
of power and political utility. De®ning power, however, ourselves o€ from our context. As a consequence, we
may not only be exercised within a certain social con- would reduce the possibility of supporting the people
text. It may also be used to de®ne other contexts and entrusted to our care and protecting them from being
cultural sedimentations as a whole,20 along with the categorised.
people who belong to or come from such contexts. In the therapeutic relationship, extrinsic diagnosis
Deciding to whom the problem belongs also determines can help support contacting where the client feels the
who should be brought into play in `recovery processes': need to express his experience in words and compare
if an individual is depressed, is the problem only his? Or them to the words and background knowledge of the
does the problem also belong to the couple? To the therapist. In this case, diagnosis is part of a much
family? To the social context in which he lives? broader process of de®nition and the construction of
personal identity. Finding the words to describe one's
Extrinsic diagnosis in the naturalistic horizon and su€ering together with the therapist can prove a pro-
the hermeneutic horizon foundly meaningful and transforming experience, as it
Considerable caution is therefore needed when using is the result of co-creation within a hermeneutic frame-
extrinsic maps. As an act which inevitably objecti®es, it work. Giving the name and sense of, for example,
presents the risk of `in¯icting violence' and losing the narcissistic su€ering to one's distress and diculties
subjectivity of the person. No map can say all there is to can enlighten and liberate ± providing, once again, that
say on the subjectivity of the other: it will always remain it is not a label imposed from above, and providing that
a mystery.21 it does not interfere with or replace the emphasis placed
How can we bring this type of diagnosis into the on the uniqueness and creativity of the person.
relationship without `imposing a standard on the other The objectifying use of naturalistic diagnoses, on the
instead of helping him to develop his own potentials' other hand, creates a gulf between the client and her
(Perls et al., 1994, p. 229)? Two di€erent horizons exist relational context, which may lead to isolation. It can
 Psycopathology and diagnosis 13

become pathogenic, contributing to su€ering by further the therapist-in-session. It is this movement that
wounding the client's relationships (see psychopathol- enables the therapist to avoid con¯uence and to under-
ogy). An objectifying stance creates su€ering while stand better the ground, the surroundings and the
impeding its perception at the same time. The vicious history of the client in her care. It enables the therapist
circle in this approach lies precisely in the fact that it is to understand the relational and vital intentionality of
blind to the su€ering it creates. All this should always be the relationship, also through a reading of her own lived
borne in mind by those who come into contact with experiences, of her awareness of the `between'. This
psychological su€ering. That not only means the third space/time remains present in the ground during
psychotherapist, but also the pharmacologist and the therapeutic session. It is a dimension to draw upon
people in other support and assistance roles. when orientation is needed.
From this perspective, how diagnosis is brought into The case is rather di€erent when diagnosis becomes a
the therapeutic relationship is clearly much more im- defensive mechanism to distance one's self from the
portant than the kind of extrinsic diagnosis used. therapeutic relationship. Here, the space/time of diag-
Pondered, critiqued, and assimilated current nosologies nosis loses contact with the relationship, and the client
can provide a contribution to therapy. It is up to the remains alone, outside this secure ± because it is
Gestalt psychotherapist skilfully to include this world separate ± space. The therapist positioned in this
and tradition in the relationship, and not just borrow space can no longer reach out to the person who is
objectifying grids foreign to the ®eld. Here we ®nd su€ering. This can also happen when, at the contact
ourselves faced with the paradox of the hermeneutic boundary with the `world', for instance in the work
circle. A circle in which knowledge of diagnostics and group, the psychological pressure felt in relation to this
psychopathology is at one and the same time a necessary su€ering is too great. Instead of being an anchor,
condition and insurmountable obstacle to understand- making translation possible, the world, the work
ing su€ering (Gadamer, 1960, p. 312; Spagnuolo Lobb, group, the diagnosis itself is experienced by the client,
2001b). It is the awareness of this circularity that enables and even the therapist, as an obstacle ± an obstacle to
the diagnostic process to become relational. creative adjustment which is what the psychotherapist
should be supporting. Extrinsic diagnosis, as we have
Extrinsic diagnosis as third party seen, can be used as a tool for rendering subjective
The diagnostic process de®nes, and so circumscribes distress an object of nature. This means stripping it of
situations. It opens a relational and then personal space its meaning by expelling distress from one's network of
from which to view one's su€ering. It also represents a meaning, responsibility, and potential. Used in this
process of translation and mediation between the cul- way, extrinsic diagnosis o€ers no support to the ther-
tural and experiential horizon of the therapist and that apeutic relationship; it responds to other needs ± those
of the client. of the client's family, those of the work group, or those
This `other space' that is gradually co-built with the of society. These needs can be met in another, more
client is important for the therapist from the outset. It functional way, though, by providing the support
constitutes a `third party' in which to anchor the necessary for maintaining or re-establishing contact
therapeutic relationship. It is a space that emerges with the client's su€ering. In Gestalt therapy, expelling
from the therapist's need to orient herself, to read the su€ering is a creative adjustment and not a defence
experience co-created with the client, and to avoid mechanism without meaning: it is the best adjustment
con¯uence with that experience. It is a space that possible given the ®eld and support available. This is
emerges from the client's need to believe that there is also true for the therapeutic relationship. In this sense,
a starting point and, therefore, an arrival point. It is also even an objectifying diagnosis would be a creative
the possibility for a narrative rooted in a shared lan- adjustment indicating a `next', a broader and more
guage: the word as third party, for sharing, for bringing functional possibility of tracing the intentionality of
truth into the world, and for bringing the world into the contact. By declaring the client `mad' the therapist loses
relationship. The map assists us in orienting ourselves, a part of herself, a part of the potential of the ®eld and of
in tolerating reality. Its purpose is not to replace or deny the relationship; but she protects herself and, in a
reality, but to prevent us from losing ourselves in its certain sense, the relationship itself. At times, this may
enormous potential. well be the best creative adjustment possible; but it is
This `other space' is also an `other time'. It is time precisely through this awareness that we can recover
before the session and time after the session. It is time for unexpressed potential by building support. The social
supervision, for training, for exchange with colleagues, need to objectify and distance madness by labelling it in
for theoretical re¯ection. In these moments, words are this way can be seen as a response to the legitimate need
needed to express the su€ering of the client, to express to anchor the devastating experience of anxiety and
the client's experience, and to express the experience of 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 tional paradigm, this is the horizon towards which we
classi®cation as a need for anchorage, the possibility for should be moving. The time is ripe for us to begin
other, non-objectifying creative adjustments is thrown clarifying this approach, as much still needs to be done
open. by the Gestalt community before an actual model is
built.
Gestalt extrinsic diagnosis? Diagnosis needs to be able to gauge and communi-
Having looked at the risks and possible ways of bringing cate the su€ering of relationships. What we seek to
the extrinsic diagnostic process into the therapeutic bring out is the way that a relationship su€ers, and
relationship, what diagnostic map can be developed in which intentionality needs to be supported during
Gestalt therapy? `Being fully in contact, in terms of the contact. Some authors have turned their attention to
capacity to consider both one's own perceptions and the connection, brie¯y addressed in the ®nal part of
that of the other, realizing a ``fusion of horizons'' Perls, He€erline and Goodman, between su€ering and
(Gadamer, 1960): this is the basis upon which a speci®c the manner in which contact is interrupted. Their
theory of diagnosis can be developed in Gestalt Therapy original analyses o€er guidance for the therapeutic
and used for understanding countertransference in the process and di€erent interpretative keys (Salonia,
therapeutic relationship' (Salonia, 1992; Spagnuolo 1989a, 1989b; Muller, 1989; Spagnuolo Lobb, 2003b).
Lobb and Salonia, 1986). It is the phenomenological A Gestalt interpretation of relationship su€ering has
reality of the here and now of the therapeutic relation- various theoretical instruments at hand:
ship, of contact between the therapist and client, which
lies at the basis of a Gestalt diagnostic methodology. 1. ®gure/ground dynamics
This reality is the framework of reference which the 2. the self and its functions: ego, id and personality
Gestalt therapist should draw from in considering 3. intentionality and the interruption of contact
diagnosis. It is upon this reality that models need to 4. stages in the life cycle
be built if they are to belong strictly to the Gestalt 5. existential issues
approach, and not to a hybrid of other theories which, 6. the relationship ground and history (family, couple,
however valid they may be, are based on di€erent society)
epistemological principles (Spagnuolo Lobb, 2001a, 7. the next: which relational experience is the subject
p. 90). unsuccessfully striving towards? In more relational
Shared clinical and diagnostic models grounded in terms: what relationship is needed for contact to be
Gestalt theory have yet to be developed. Historically, made? (The answer to this question tells us which
opposition to the objecti®cation of clients has under- relationship will cure the speci®c su€ering.)
pinned criticism of the use of such models. Anti-
psychiatry, along with other movements, has taken a Through their reading of su€ering, these tools o€er
similar stance. We believe that today this risk can be the orientation needed to identify the support which the
addressed, providing that extrinsic diagnosis is used client speci®cally needs.23
with the awareness and caution we spoke of earlier. In this way, diagnosis becomes a pathway along
Steps need to be made in this direction.22 Any extrinsic which the therapist guides the client towards recognis-
diagnosis system can be used by the Gestalt psycho- ing, naming, and sharing his experience of su€ering,
therapist providing it is used hermeneutically, that is, in towards placing the experience and giving it meaning.
a manner enhancing contact. But how can we read From a de®nition which may be more or less external
psychological su€ering through our theory? and extraneous, i.e. `panic attack', we thus move
In Gestalt therapy, extrinsic hermeneutic diagnosis is towards a co-constructed narrative through which the
an attempt to read relationship su€ering without con- meaning and relationality of the su€ering experienced
sidering it as an attribute of the isolated individual (see emerges. From `what pathology do I have?' we progress
above). Gestalt conceptual tools enable experience to be to `that is what I am experiencing!'. Depending on the
punctuated, named, and communicated. In this way, case and moment this may become: `in that moment I
the client's experience is translated ± though it is also lose the support of my roles and my body'; or `I can't
inevitably betrayed. This paradox, however, is useful: manage to control the environment as I usually do'; or
the truth of our words ± and diagnoses ± comes from `my ties are changing, I am becoming more autono-
the fact that they are co-constructed through the con- mous and at certain times I feel alone'; or `my life is
tact experience. The resulting diagnosis is not of or fragmented'; or `I need a ground of relationships to
about the person; it concerns the relational phenomena support me', and so on.
that have been co-built, representing the expression and This approach enables other expressions of human
evaluation of the relationship, not the individual. su€ering to be read in Gestalt terms, thus providing
Although it may be dicult to remain within a rela- support and orientation to therapeutic contact.
 Psycopathology and diagnosis 15

Intrinsic or aesthetic diagnosis therapist to intervene; intervention may also be silence,

immobility, or almost imperceptible movement
There also exists a second kind of diagnosis: it is a (Bloom, forthcoming). How does the therapist notice
diagnostic method speci®c to Gestalt therapy. It is the movement or interruption of intentionality? The
diagnosis because it o€ers orientation for the therapist answer lies in being present at the contact boundary,
and because it is knowledge (gnosis) of the here and now with senses alert and an awareness of one's bodily,
of the relationship through (dia) the senses; it is another emotive, and cognitive resonances. These resonances
kind of diagnosis because this act of diagnosis is not a emerge indistinctly and only through re¯ection can
comparison between a model and a phenomenon. We they be distinguished. A rigorous criterion is what
shall call this second kind of diagnosis `intrinsic or guides this awareness: the aesthetic criterion26 (Joe
aesthetic diagnosis'. Lay, quoted by Bloom, 2003).
This kind of diagnosis emerges from moment to In this diagnostic approach, no comparison is made
moment from the contact boundary. Instant after between a model of the phenomenon and the phenom-
instant, interactions between the therapist and the enon itself, as happens with diagnostic maps. Here we
client unpredictably and chaotically take place, bringing have the perception of the ¯uidity and grace of what
into play thousands of elements every fraction of a happens, or what fails to happen, which is what orients
second. Interaction is incredibly complex: it is visual, the therapist in adjusting his manner of being-with the
aural, tactile, muscular, glandular, neurological, gusta- client. It is a note out of key, a brushstroke out of place,
tory and olfactive, reactivating layers of memory which a touch too much or a touch too little, a little too soon
¯uctuate in waiting, ready to participate in forming or a little too late. It is not an a priori model that guides
®gure. Moreover, it involves expectations and compar- us, but the unique, special aesthetic qualities of all
isons with thousands of contacts and faces. What human relationships. Just as we know how to recognise
orients us in this complexity? a note out of key, we can sense that something is out of
One possible option is to withdraw from all of this, or place or out of time, or so inde®nably strange or
simply not to step foot in it. This is done by establishing fatigued in ongoing reciprocal responses.
an objectifying relationship and making naturalistic use Gestalt therapy has studied interruptions in contact,
of an extrinsic diagnostic map. Another option is to these drops in intentionality and losses of spontaneity;
remain ®rmly within this incredible relational chaos, to it knows how and when they can occur. It teaches us to
navigate or ¯oat on the waves of this sea `which never sense these fractures and bridge them so as to support
stands still'.24 To be aware, awake, with senses active, the relationship (Perls et al., 1994; Salonia, 1989a;
and at the same time relaxed, allowing yourself to be Spagnuolo Lobb, 1990; Robine, 2006). The cardinal
touched by what happens (Spagnuolo Lobb, 2004). To points of this `second by second' diagnostic approach
remain con®dent, that this chaos does indeed make are in the here ± the experience of space ± and now ±
`sense' (here, the etymology and connotation of `sense' experience of time ± of lived experience, as it manifests
coincide). Intentionality is the breath that moves this itself at the contact boundary. The therapist is the
sea. sensitive needle to changes in these seismographs
The therapist is not disoriented, but present. He is which record (via individual resonances) the aesthetic
not idle, but ready to join the dance that unfolds at the values of the relationship here and now, and not
boundary where, through the senses, the client and individual parameters. Time slows down, space dilates,
therapist make contact. The therapist is ready to and breathing follows the rhythm of these variations
gather intentionality and to support the unfolding of (Riccamboni and Francesetti, to be released).
breath. It is intentionality that brings order to inter- The therapist gauges these variations and continu-
subjective chaos. When the arrow of intentionality loses ously positions herself in relation to them, with sensor-
energy and falls, it is recovered by the therapist, who ial-physical unity. In this way, the therapist not only
gives it new momentum. When the arrow falls and is brings about the intrinsic diagnostic act, but also the
recovered and re-launched, the emotive intensity of the therapeutic act itself: this constitutes the unity of the
moment is heightened. Moments of fullness of contact diagnostic-therapeutic act (Perls et al., 1994; Bloom,
are always unpredictable: we do not know when they 2003). Sensing the interruption of intentionality, the
will occur, in which minute or second of contacting. therapist re-positions herself in the relationship, guid-
They do not occur by chance though:25 it is the therapist ing and curing it, moment by moment.
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
16 Gianni Francesetti and Michela Gecele

Extrinsic diagnosis or intrinsic Acknowledgements

diagnosis? This article collects theoretical considerations devel-
As Gestalt psychotherapists, which diagnosis do we oped within the Istituto di Gestalt HCC. We are over-
need? In our opinion, the answer is both, as long as a whelmingly grateful to Margherita Spagnuolo Lobb and
clear awareness of the limits of extrinsic diagnosis is Giovanni Salonia, the directors of the institute, as it was
included. This becomes progressively less important as on the basis of their teachings that this article could
the therapist gains greater expertise. All travellers need emerge as ®gure. We also wish to express our gratitude
maps to orient themselves, but it is also true that the to Dan Bloom for his precious comments and sugges-
more experienced a traveller you are, the more you can tions.
rely on your sense of direction. Sense of direction is
something developed moment by moment during your Notes
journey, without the use of too many maps. This,
however, is the prerogative of the expert traveller; if 1. `The therapist needs his conception in order to keep his
bearings, to know in what direction to look. It is the acquired
not what we have is a reckless traveller (or a savage
habit that is the background for this art as in any other art. But
psychotherapist). Then again, the only way to explore the problem is the same as in any art: how to use this
new, uncharted territory for which no maps exist is by abstraction (and therefore ®xation) so as not to lose the present
orienting yourself moment by moment. And in a actuality and especially the ongoingness of the actuality? And
certain sense, every relationship is new, uncharted how ± a special problem that therapy shares with pedagogy and
territory. politics ± not to impose a standard rather than help develop the
potentialities of the other?' (Perls et al., 1994, pp. 228±9)
This second kind of diagnosis, aesthetic diagnosis, is
2. In this text, we shall not use the noun soul but rather in¯ected
essential in orienting ourselves moment by moment and adjectival forms of the verb to animate, to refer to living
through interaction. It is fundamental in providing beings in their condition of being animate, and hence con-
speci®c support in Gestalt therapy.27 No map will ever cerned with vital interaction with their environment.
be detailed enough to warn us of the potholes in the 3. For the distinction between Korper and Leib in psychopathol-
road and the bends along the track. Just like Alice in ogy see Galimberti, 1991.
4. Sedation, in fact, reduces acute psychopathological crises
Wonderland, even if such a map existed, it would be too
progressively to the point of anaesthetisation, where the
big and cumbersome to be used. No map is ever psychopathological condition disappears although other
updated to the point of what is happening here and medical pathological conditions (a tumour or in¯ammation,
now. for example) persist. Indeed, no trace of psychopathology can
This second kind of orientation is sucient when, be found in anaesthetised subjects.
after having travelled widely and assimilated countless 5. The between (Buber, 1993).
6. On the concept of emergent properties, see Bocchi and Ceruti
maps, the traveller is con®dent of how to move across
(Eds.), 1985; Waldrop, 1995. `At each level of complexity,
unknown territories. entirely new properties appear. [And] at each stage, entirely
Over time, relational experience enables us to be in new laws, concepts, and generalizations are necessary, requir-
synch with the other in a therapeutic way, without the ing inspiration and creativity to just as great a degree as in the
need to establish diagnostic background co-ordinates: previous one. Psychology is not applied biology, nor is biology
they become assimilated and are a part of the vision and applied chemistry.' (Anderson quoted in Waldrop, 1992,
p. 123)
sense of the therapist. They are the therapist's ground.
7. In this regard, see the perspective o€ered by phenomenological
However, to be ground, they must in turn have been psychiatry: Minkowski (1927); Binswanger (1963); Borgna
®gure. Diagnostic maps are important for those new to (1989, 1995, 2008); Galimberti (1991), Callieri (2001).
travelling, because they enable travellers to communi- 8. On the concept of awareness in Gestalt psychotherapy see Perls
cate when they are not `on location', and by looking et al., 1994; Perls, 1969a; Polster and Polster, 1973; Salonia,
over a map, they can compare their positions. When 1986; Yontef, 2001, and for a more recent review, Spagnuolo
travelling through a territory though, maps tend to Lobb, 2004.
9. `The relationship, if open and civilising, not limited to eros and
remain folded away in our backpacks. They retreat into philia, but also touched by agape, is always a third party to the
the background, while it is our senses that guide us I-Thou relationship.' (JankeÂleÂvitch, 1970, p. 798)
moment by moment. But they are always within reach: 10. `Today, more than ever, the lesson of Marguerite Duras's
we can consult them at any time ± when we get lost, novels is relevant: the way ± the only way ± to have an intense
when we need to tell somebody where we are, when we and ful®lling personal (sexual) relationship is not for the
stop for a break and want to check up on the situation. couple to look into each other's eyes, forgetting about the
world around them, but, while holding hands, to look together
But it should never be forgotten that you can never outside, at a third point (the Cause for which both are ®ghting,
step into the same river twice. 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 17

inserted between direct contacts, symbolised by the commu- Prison Experiment was the demonstration of the pervasive
nity itself and by its representatives.' (Bruni, 2007, p. 29) power, however intangible, of situational and contextual vari-
12. See the work of Levinas and Derrida. ables.
13. For a di€erential analysis in Gestalt therapy terms of neurosis 20. A good example is given by the psychiatry of the colonial age, as
and psychosis see Giovanni Salonia (Salonia, 2001) and Mar- well as the in¯ationary use today of the concept and term
gherita Spagnuolo Lobb: `To summarize these di€erences in `culture' in social, political, legal and even diagnostic contexts.
Gestalt therapy terms, in neurosis what seems new is de®ned as 21. Salonia, address to the First Conference of the SocietaÁ Italiana
``not for me'', via the ego function; the support of personality Psicoterapia Gestalt, Siracusa, 7 December 2007.
function of self is lacking in this case. The self cannot adjust 22. This need is perhaps heightened for us by the fact that we work
creatively to changes in social relationships, on account of a in an educational context and our students often ask precisely
split between the de®nition of ``who I am'', as assimilated from about diagnosis.
previous contacts, and the new social requirement.In psycho- 23. These co-ordinates were used, for example, for a Gestalt per-
sis, because the ground of security built on assimilated contacts spective on the experience of panic disorder (Francesetti,
is missing (id function of self), the ego cannot exercise its ability 2007).
to deliberate on this ground. Contacting is thus dominated in 24. `I would not be a phenomenologist if I did not see what is
the psychotic by sensations that invade the self with ``no skin'', obvious, that is, the experience of being bogged down. I would
and so invade the world.' (Spagnuolo Lobb, 2003b, p. 340) not be a Gestalt therapist if I did not step into the experience of
14. According to Gilligan, Freud moved from being `he that does being bogged down without the con®dence that some ®gure
not know', open to contact and experience, to `he that knows', will emerge from that chaotic ground.' (Perls, 1969b)
the `solver of enigmas'. `But Freud is a man and also a father, 25. On this point we disagree with the view of Daniel Stern, for
and as he aligns himself with women, he ®nds himself in the whom `now moments' occur by chance, in an unpredictable
position of women, isolated and embattled in his claim to way (Stern, 2004).
knowledge. It is a position I have seen parents and teachers and 26. `These interruptions are felt. They are sensed, or sensible, by
therapists come to when they align themselves with a child or the client and the therapist. These are not hypotheses or
adolescent's perceptions and join their resistance to a disas- abstractions ± they are sensed actualities a€ecting the stream
sociation that is part of a process of initiation. In aligning of contacting. This is the aesthetic criterion as a clinical value.'
(Bloom, 2003, p. 72)
themselves with such resistance and opting for relationship,
27. Interruptions in contact belong to both diagnostic registers:
they are coming into con¯ict with voices of authority and risk
they can be used as a map for orientation (extrinsic diagnosis),
being called bad parents, or jeopardizing their positions as
or they can be treated as perceptible phenomena marking a
teachers and therapists.' (Gilligan, 2002, p. 190)
drop in intentionality in the here and now (aesthetic diagno-
15. Phenomenological perspective is a widely discussed root of
sis). Each and every time we speak of interruption in contact, it
Gestalt therapy. Among recent contributions, see for instance,
is important to specify to which register we refer.
Crocker (2009); Philippson (2009); Bloom (forthcoming).
16. In this paper we refer to intentionality in a phenomenological
sense, as discussed recently in Crocker (2009), Philippson
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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: [email protected]

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: [email protected]