British Gestalt Journal 1997. Vo1.6, No.2, 97-106 Copyright1997 by GPTl Publications Ltd. DIAGNOSING IN THE HERE AND NOW: THE EXPERIENCE CYCLE AND DSM-IV Joseph Melnick and Sonia March Nevis Received 2 November 1997 Editor'sNote:This paperutilisesthe'experiencecycle'asthebasisofaGestalt therapy diagnostic system.First, diagnosis is defined and the Gestalt approach is differentiated from other theoretical orientations.Then, the Gestalt experience is described andspecific DSM- IVformulations (borderline, specific phobia, histrionic, post-traumatic stress disorder)are analysed utilising the cycle as a template.Last, intervention strategies are suggested. This paper is adapted from a chapter inExperientialPsychotherapy, edited by Leslie Greenberg, Germain Lietaer, andJeanne Watson, tobepublishedbytheGuilfordPress, NewYorkin 1998. It is published here bypermission. Keywords:Gestalttherapy,diagnosis,assessment, experience cycle, borderline,phobia, histrionic, post-traumatic stress disorder This paperexplores formal diagnosis (DSM-IV) from the theoretical perspective ofGestalt therapy.The Gestalt therapy'experiencecycle'(Polster andPolster,1973; Zinker,1977) willbepresentedas thebasisofa diagnostic system (see Figure1.).Specific diagnostic formulations from DSM-IV(borderline, specific phobia, histrionic and post-traumatic stress syndrome) willbe analysed and intervention strategies will be articulated. What is Diagnosis? Diagnosisisfirst and foremost a descriptive statement that articulates what is being noticed in the present.Yet it also means going beyondthe present,implying a pattern aswellas aprediction,nomatter howminimal.In addition, diagnosis mayor maynotinclude a concept of causality.Thus, to diagnose is to attempt toenlarge the picture, to move from what is observable nowto what is habitual.It includes aschema notonlyofwhat is to be observed, but also of howit is to be observed. Gestalttheorydoes notimplyasystemofcause. Gestalt therapists believe incausation, butperceive itas inherently unknowable.Alignedwith bothasystems (Kraus, 1989;Huckabay,1992) and field theory (Parlett, 1991; 1993) perspective, theyare aware that the number ofinfluences that impinge on any given system is so vast thatafullandmeaningfuldescriptionofcause is improbable, if not impossible. Asindicated previously,Gestalt therapists believe that one constantly derives meaningafter firstorganising unorganised experience.Gestaltists believe thatthis 'meaning making'isarbitrary, since it is selective and incorporates, along with the patient'sbehaviour, boththe diagnostician and the environmental field. Despite thisstrongly-held belief,thereareseveral compelling reasons for diagnosing inamoreformal, narrow and systematic manner.First, diagnosis gives one amapand describes possibilities ofhowapersoncan evolve.Therefore, the therapist benefits from a structure - that is, a compass to help organise the information and provide clues toa direction to navigate throughthe vast field of data. Second, the process ofdiagnosing allows the therapist tocontrol anxiety.Byremovingoneselffrom the data, the therapist mayremain calm while waiting for a figure to emerge.Thus, the process ofdiagnosing is grounding and keeps the therapist from jumpingprecipitouslyinto the infinite while waiting.Simplystated, it gives one something to do. A third reason to diagnose in a more formal way is that itis economical.BylinkingGestalt theorytoother systems ofdiagnosis, a vastarray ofresearch and theory opens to the clinician.Furthermore, it is also efficient in that the therapist can make predictions without having to 98Melnick andNevis waiteachtim for the datato emerge fromimmediate experience. Fourth,Gestalttherapistsinparticular needto be grounded ina wider perspdve that includes rhe future, and particularly the past.Although Gestalt therapists explore the patient's past, this exploration is of a different nature.'We expIore phenomenologically inorderto understand, not klieving that the past caused the present.' (Yontef, 1988). Finally,diagnosing prevents the Gxtalt therapist from kcoming isolatedfromothers withdifferent theoretical orientations.Consequently, Gestalt theorists, even while debating issuesconcerning process versusstructure,still usetraditional diagnostic labels suchas schizophrenia, narcissism andborderline (From, 1984;Tobin,1985). Thus,although the use ofdiagnostic categories may not be totally congruent with our theory, we still employ them in communicating with others. How Do Gesm~~bDiagnose? Traditionally, Gestalt therapists have diagnosed by paying attention to the phenomenon inthe rriofnent.At some point,anaspect ofkhaviour becomes interesting, something stands out and a pattem emerges.This pattern might I d to a diagnostic statement such as 'The patient appears tobe retroflecting'(constrictinghis or her emotions).The remaining theragatic work in the session mightbe focusedonthatretroflection.This form of diagnosis is valuable for a number ofreasons.Hrst,the behaviour is readilyobservable.Second,thetechniques outlining howtoworkwithretroflectionsareclearly articulated and stmightFowad.Andthird,the diagnosis defines a pieceoftherapeuticworkthatcan oftenbe satisfactorily completed in one therapy session. Itshould be pointedout thatGestalt therapists do not have a single waytodealwiththephenomenonof someone who chmcteristicalIy- that is, more often than is usual- retTOflecrsenergywhen f&withstressful situations.Furthermore, we do nothavea theoryfor predicting if the constant work on mfl ect i ons will m l tinsome enduring change byaffecting h egrwndofthe individual.Thegroundconsistsofthetracesof experience,historyand physiologycontained inlarger, deeper grooves out ofwhichlivelyfigures spring forth. This ground must ul hakIy be affected ifa personisto experience a more permstnent change. nt e ~ e ~ e Cycle and Cl?macter Awareness Mobllhtion Senrratlon Adon Withdrawal con?aci Ernotimal Energy Resolution = Emotional Emrgy Figure 1 Experience Cycle. ,Diagnosing in the Here and Now Healthy,organisedfunctioningcanbedefinedby breakingdownfigure formationanddestruction intoan 'experience cycle'(Zinker,1977) whichisillustrated in Figure 1. Theshadedportionrepresentsemotionalenergy. Emotional energy builds from sensation tocontact and thenrecedesthroughthewithdrawal stage.Individual phasesare placedaround the outside oftheouter circle andvarious disorders are placedalongtheinside ofthe inner circle.Theirplacementcorrespondstothe hypothesised original areas ofblockage and distortion.It should be noted that the schema is a beginning attempt at integrating the cycle andDSM-IV diagnostic categories and rests on the following assumptions: I . The stages ofthe experience cycle are infact artificial demarcationsofacontinuous,flowingunitof experience; thus, the phases are overlapping. 2. Competence is directly related to the skills and abilities neededtoarticulateandcompleteeachstage satisfactorily(Zinker and Nevis,1981).Ultimately, being able to complete a cycle, to create and destroy a figure with clarity, defines healthy functioning (Wallen, 1957). 3. Although the cycle was originally intended to describe momentaryexperience,itcanbeextendedto encompass larger periods oftime. 4. Thestagesofthecyclereflectadevelopmental progression.The earlier inthe cycle thedisturbance occurs, themore the experience tendsa) to consist of veryoldingrainedpatterns;b)tobeprimarily physiologically(asopposedtobehaviourally) influenced and c) tobeless observable to others,and thus less amenable to therapeutic change. 5. A disturbance atonestage ofthe cycle willaffect all remaining stages. 6. An understanding ofthe cycle is adequate to articulate therapeutic strategies and interventions.Utilising other theories to explain causality, althoughpossibly useful, is not necessary. 7.Althoughone mightintervene atlater stages ofthe cycle withsome success, character can beaffected ultimatelyonlybyintervening at the phasewhere the disturbance originally occurred. 8. The intervention(s) must occur manytimes before any long-lasting changes occur. 9. Whenworkingas therapists, weare able to utilise direct observation to'see'the patient move through the middlestages ofthe cycle where emotionishighest, that is, mobilisation, action and contact.Therefore, our understandingofthe patient'sexperience duringthe other stages is usually inferred from self reports.Thus, most patientdifficulties are originally noticedasan inability to mobilise emotion, move towardsaction or makecontact.Muchoftherapeutic workinvolves pinpointingother phases that presentdifficultyand helping the patient develop skills andresources to move through and successfully complete these phases. 10.Although werecognise thedifferencebetween personalityandneurotic disturbances, for purposes of illustration weare notdistinguishing betweenthem. This isinkeepingwiththe DSM-IV.'Thecodingof Personality Disorders should not be taken to imply that theirpathogenesis or range ofappropriate treatment is fundamentally different from thatfor the disorders coded on Axis 1.'(DSM-IV, p. 26) 11.Forthe purposeofthisarticleweareignoring relationship patterns as a primaryvehicle for assessing blockage anddistortion(see Evans,1994).Infact, Gestalt therapyplacesmuchemphasis onhere-and- nowdialogue aswellasthedevelopingrelationship between therapist and patient (see Melnick, 1997). Sem&n/AwarenessStage:Borderline Personality =order Borderline Personality Disorder, as described inDSM- IV, is anexample ofblockage at the sensation/awareness level.Diagnostic criteria include: A pervasive patternofinstabilityofinterpersonal relationships,self-image,andaffectsandmarked impulsivity beginning in early childhood and present ina varietyofcontexts, as indicated byfive (or more) ofthe following: 1. Frantic efforts to avoid real or imagined abandonment (does notinclude suicidal or self-mutilating behaviour covered in criterion 5). 2.Apatternofunstableandintense interpersonal relationships characterised byalternating between extremes of idealisation and devaluation. 3. Identitydisturbance:markedlyandpersistently unstable self-image or sense ofself. 4. Impulsivity inatleast twoareas thatare potentially self-damaging (e.g.spending,sex, substance abuse, recklessdriving, binge-eating).(Does notinclude suicidalorself-mutilatingbehaviourcoveredin criterion 5) 5.Recurrentsuicidal behaviour,gestures, threatsorself- mutilating behaviour. 6. Affectiveinstability due toamarked reactivityof mood( e.g.intense episodic dysphoria, irritability or anxiety, usuallylastingafewhours andonlyrarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger ordifficulty controlling anger (e.g. frequent displays oftemper, constant anger, recurrent physical fights). 9. Transient,stress-relatedparanoidideation orsevere dissociative symptoms (p.654). Melnick andNevis As one can surmisefromtheabove diagnostic criteria, the borderline patient haslittle sensorial stabrlitytYThese individuals cannot maintain a stable emotional response to input, whether internalor external.One result is high emotionallabilityandacontextualresponsesto stimulation.TouseGestalt terminology, theground availabletotheborderlinepatientis non-supportive, resulting inan inability to tolerate morethanminimal stimlation. Whetherit is causedbythedistortedintakeof sensations, theinabilityofan individual to code sensory stimuliinto a manageable form, or theoverloading of stimuli thatinterferes with figure formation, is ofmuch theoreticaldebate.Whatis certainisthat, some individuals cannot easily tolerate,manage or translate these sensorystimuli into acceptable and manageable f m and figures. It should be pointed out that sensations are diffidt for all of US.Most of our sensory @tesare too large for what is organismidlyacceptable and thus we have to learn mmagemmt techniques.However, most peaple do nothave to deal withthevariability, largeness and enormous distortion ofsensation with which p p l e who are characteristically bound in this phase must contend. The t herapt i c wotk with a borderline patient is to help withthe managementofsensations bylowering and limiting them at both an intemd and external level.Once sensationis manageable, awareness can emerge and movement h g h the cycle can continue. In psychathmpy,the task is to teachthese patientsto manage sensations bylowering input or, whenthisis impossible and stimulus overload occurs, by chinhg the mobilised energy through supportive and non-destmctive forms of expression,The first task involves leamingto slow down h e input in order for the individual to run less ofa risk ofbeingflooded.Sensatim needtobed esmaller in order to form a figure that can be WisfactoriEy completed.This is accomplished byhelping patients focus on and label accurately their experience. Techniques that increase sensations,suchasthe use of the empty chair,are potentidy dangerous (Fm 19841, asare confrontational,behaviouralandparadoxical interventions thattend toproduce addedor ambiguous sensory. input.Another major thecapti c mistake would be to teach bonkline patie~tsmanagement or repertoire expansion techniquesthatassumethattheirsensory mechanisms are working properlyYThe basic problem is not one of inadequate behavioural sepertoires. Whenflooding occurs, the therapeuticwork involves teaching the patientto drainenergy in a non-destruclive way.Stimulus overload can be ~ r n i s e d in this instance bya therapeutic stance of'soft,clean contact'.It is here that the concept of soothing is important.Ifthe therapist becomes upset- for example, becomes rnobilised or increases hisor her sensations- itwilladd to the patient'salready excessive stimulation.The therapist must learntokeepinternalstimulationlowbyself- soothingand ultimately byteaching the patient soothing techniques.(It isinteresting thatthis approachtothe treatment of borderlines is consistent withthat articulatd bytheself-theorists andoutlined byTobin(1982) and Yontef(1983).However,unlikeself-theorists and as stated in assumption 5, Gestalt theorists do not believe it is neeessrqy to hypothesix a cause,e.g. a specific form of inadequatemothering,inordertoprescribean intervention). Thesecond phase ofthe experkme cycle occurs with the gemationof emotional enew m d sensation.If the energy g&trap@in the body and there is no m I erelease, anxiety occurs.The way that the individual deals with this trappedemotional energyhas historically been labelledpsychoneurosisand,more recently,anxiety disorder.DSM-IVlists withinthiscategorysuch disorders as obsessive-compulsive, panic disorder and various phobias such B agoraphobia and specific phobias. One can also add to these avast army of psychosomatic problemsthatresult from this chronic blockingof emotional energy. Toillustrate mobhti on dysfunction, Specific Phobia has been chosen.I I e clmackristia include: 1. Markedandpersistentfear thatisexcessive or unreasonable, cud by the presenoe or anticipation of a specificobject or situation(e.g.flying,heights, animals, receiving an injection, seeing blood). 2. Exposure to the phobicstimulus almost invariably provokes an immediate anxiety response whichmay takethe form of a sitdoonally boundorsituationally predisposed panic attack.Note:In children, the anxiety rnay be expressed by crying, tantrums, freeZing orclinging. 3. The person recognises thatthe fear is excessive or measonable,Note: In children,this feature maybe absent 4.The phobic situation(s)is avoided w else is endured with intease anxiety or distress, 5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantlywith the person'snormalroutine, occupational (oracademic) functioning, or social activities orrelationships, or there is m&eddistress about having the phobia. 6. h individuals under age18 y e . , the durationis at least six months. 7. 'The anxiety, panicattacks,or phobicavoidance associated with the spe&cobject or situation is not better accounted for byanother mental disodm, such Diagnosingin the Here and Now101 as Obsessive-Compulsive Disorder (e.g. fear ofdirt in someone withanobsession about contamination); Post-Traumatic StressDisorder (e.g. avoidance of stimuli associated withasevere stressor); Separation AnxietyDisorder (e.g. avoidance ofschool);Social Phobia(e.g.avoidance ofsocial situations because of fearofembarrassment);PanicDisorderwith Agoraphobia,or Agoraphobia WithoutHistory of Panic Disorder (p.411). Phobias involve either theinvestmentoftoomuch emotionaroundanapparentlyappropriatefigure (a person will not visit certain countries because ofa fear of poisonous snakes) or the mobilisation ofemotion around anapparently inappropriate awareness (a personavoids all heights buthas no experience withtrauma connected with them).In the second case, the sensation is given the incorrect meaning because the individual's system cannot toleratethecorrectlabellingofearliersensations. Labelling ofasensation is connected to meaninggiven, appropriate andinappropriate;tosensations inprevious awareness.Phobia involves the avoidance of the accurate meaning that couldJead to a completion ofthe cycle that isaccuratetothesensation.Instead,adistorted (symbolic) or incorrect meaning is given to the sensation. Phobias are maladaptive because theydo notlead to satisfactory completion.They do, however, often serve to discharge or deflect emotion, thus temporarily controlling itso thatthe individual cantolerate it.For example, as stated above, one maylabel certain sensations (increased heartbeat,tightness inthe chest, sweaty palmsetc.) as 'fearofheights'.This incorrect attribution ofmeaning allows the individualto functionina relatively anxiety- free manner as long as heights are avoided.However, if therapyproduces the understanding that these sensations are attached to anavoidance ofintimacy, then the patient is faced witha conflicting duality.Nowit is possible to move towardemotional closeness with another, butonly withanawareness ofthe heightenedtensionthatsuch intimacy may create. The two major manifestations ofphobias are a distorted orexaggeratedresponsetoanappropriate object to be feared (e.g.,a poisonous snake) thatis generalised well beyond the object and a distorted or exaggerated response toametaphorical, symbolic orpsychologically-linked object that has little or no correlation with the appropriate sensation.Treatment involves thesymbolic orin vivo matchingofthecorrect figure withthestimulus so that completioncanoccur.Since muchofwhatwecall psychotherapy deals withthe above, itmightbebestto categorise the approaches briefly. Certain techniques lead to diminution ofanxiety so that the personcan re-experience thesituation andattach the correct meaningtothesensation.These include many desensitisation and cognitive approaches.Others, such as meditative andbreathing techniques, help theindividual to tolerate the sensations so that a less distorted meaning canemerge.Still other approaches providesupport so that people do nothavetobeartheir painandanxiety alone, thus helping them tocomplete the cycle.The financial, psychological andideologicalsupport thatour society is beginning to provide for Vietnamveterans and victimsofsexual andpsychological abuse are examples ofthissupport.Itshould be notedthatifaspecific meaning emerges, thenthe patient maybe diagnosed as suffering from post-traumatic stress, which is described in the last section. In summary, to move through the mobilisation stage of the cyclemeans todischarge thetrappedemotional energyso thatacontactfulfigure thatmayleadto completion can be created.Aswithother stages, the workmust bedone.over andover again inorder for the emotional energyto beavailable for the generation of appropriate andadequate contact.The Gestalt approach allowsthetherapisttodrawfromawiderangeof techniques to craft a procedure which fits both the patient and the symptomatology (Melnick, 1980). Contact Phase: Histrionic Personality LXsorder The fourthstage ofthe experience cycle occurs when awareness,supported byappropriate emotional energy, resultsina flexible and meaningful meeting oftheself and the environment, usuallyin the form ofanother.To meetphenomenologicallyimplies that notonlydo I see, butalso I am seen;thatnotonly do I speak inorder to reachyou, butalso Iamheard.Inthe moment, each noticesthatthere is a'we'that is different from either alone. Disturbance of contact results in experiences that do not fit within the rangeof'goodenough',butratherare too littleortoomuchfor aspecific environmental context. An example is a hug that either has too little energy or is notwarmenough oris inappropriately passionate given the environmental situation. Either extreme is jarringand incompatible and does notresult ina joiningexperience. Bothextremes are contextual disturbances inthatthe evaluation oftoo little or too much is made in relation to theother,totheself,tothesituation,tothetotal phenomenologicalfield.The expression'toolittle energy',whichtypically involves the pulling backfrom another, has beenhistoricallylabelled as retroflection, whereas'toomuchenergy'has beentraditionally called hysterical or histrionic. Itshould benotedthat disturbances ofcontact, rather than reflecting characterological issues, might instead be a functionofinadequatebehaviouralrepertoires. (Repertoire evaluation canalso occur atthemovement actionphase,whichwasdescribedpreviously). Melnick and Nevis Traditionally,inadequak repertoires have been analysed andincreasedbyeducation,includingbehaviour mcdf~cation.Furthermorr; the haeasing and refinement ofrepertoires had,untilrecently, generallynotbeen considered as falling within the domain of psychotherapyY However,ifthetherapeutic di!emmais notone of inadequate but, instead, one of fixed reptoires that limit and narrow aperson'sability to makecontact withthe environment, thenthe behavioursdo fd1 withinthe di os t i cguidelines of disorders. Histrionic PersonalityDisorderis an exampleof disturbanceofthecontact boundary,as described by DSM-IV.Qiagnostic criteria include: Apervasivepattern ofexcessiveemotionality and attention-seeking,beginningin earlyadulthoodand ptesent ina varietyofcontexts, as indicated byfive (or more) of the following: 1.Is uncomfortab1e in situations in which he or she i s not the centre of attention. 2.Interactionwithothers is often characterisedby inappropriate sexuallyseductiveorprovocative behavia. 3. Displays rapidlyshifting and shdew expression of emotions. 4. Consistentryusesphysicalappearance to draw attention to self. 5.Has a style of speech that is excessiveIy bpmsionistic and lacking in detail. 6.Shows seIf-dmnahation, t hdcal i t y and exaggemted expmsion of emotion. 7. Issuggestible,i.e.easily influenced byothers or circumstances. 8. Considers relationships to be more intkmk than they actuaIly m (p.658). The stavotypical model of histrionic functioning is that ofthe flamboyant actor.Unfommately this stereotype is often true for thehistrionic character whowishes to be m,heard, appreciated and applauded and is notvery inkmzkd in others in mwe deep, complex ways.Thus, if a therapist attempts prematurely to create for the patient a morecontacthl experience, thetherapist mayencounter indifference at k c and mculgat worst. The emotional energy in histrionic patients is i ~ e rdekmined,undisciphed and exaggerated and does not keepintunewiththeenvironmental field.Theyare perpetuallyinaction withoutbenefitofanaccurate awareness.Thus, the existential work with histrionic people is to help them bear the truthof their overly large existence.They are fated to take up a lot of room, to say a Id and to do a lot.Even though they may suffer from an energy disturbance,it wouldbe a mistake to attempt directlytoteach them tobeaware oforchange their energy.Hishionic people are only mi nhdy inkrated in awareness for it complicates life and makes itless exciting. Thus the dilemma for the therapist is how to help these patientsslow down as wellasbecomeinterestedinthe environmental field.Ex pe e i t sthat deal d k t l ywith slowing downtheaction, suchas reading a menu completely before ordering food or counting to ten before acting,maybe utitised.Further* having the patient learn togo inwardbefore achg heightens the@abilitythat theforthcoming action may betrulycontactful.Thus, directing tlpe patient to notice tension, breathing and so an might ultimately lead to a slowing down of movement. To help these patients trade in their wish for simplicity for a more complex orientation tothe world is Micult at best.However,experiments that teachthem tonotice environmentalcontexts,includingother people,are bend~cid.Examples include having the patientask the therapistquestionsas well as notice andarticulate physical and psychological boundaries. The last stage will belabelleddemobilisationas it incorporatesboth the resolutiodclosure andwithdrawal stages ofthe e x p i e m cycle previously discussed.The purpose of demobilisation is to &owfor the absorption of anexperienceinto thegroundoftheindividual, principally bymaking meaning of ifso that it will not be elicited inam,mFe1y. Aswithotherstagesofthe cycle, whenthereis a synergy between the expience ofthe individual and the individual'scapacityto deal withit, demobilisation prmds in a smooth and graceful manner.The person is able to disengage from the experience, to chew it over and absorb and digest it.Ultimately, the individual b m z ssomehow different andwiser in a subtle way. Ifthe experience is too chargedtobe easily absorbed into the ground, then a fom for expelhg orusing up the excess emotional energymust beinitiated.If thisis not done, then the old figure will not be properly ink-and will have a ~~ydistorting anddiqmprcionate effect on dK current and fu-e x p i e mof the individd. This needtodemobikeis a complex process that has been largelyignoredbyWesternsociety as wellas by Gestalt therapists.Society supports a cultural bias against demobilisation by underestimating the amount oftime needed to understand and integrate experiences.Among Gestalt therapists there is often a biasagainst 'talking about'experiences. Furthermore, asa culture we do not value aloneness andmovementinward.When one mobi l k,it is movement outside the skin toward contact. However, demobihation involves a movement inward to a non-public place where one may be alone. Diagnosing in the Here and Now Gestalt therapists, too,haveignored andhaddifficulty inarticulating the demobilisation process. In the past,it has been taught as a less significant part ofthe experience cycle than in fact it is.The difficulty in understanding this process is connected withits largelyintrapsychic nature. Asindicated previously, itis harderfor others tosee. Thus, like the sensation stage ofthe experience cycle, the processoftheindividualmustoften beinferred rather than actually observed. Furthermore, demobilisation is often unpleasant.When the event is large and negative, the experience is a grief reaction.Thus, demobilisation is associated withdeath, illness,divorce anddefeat.However,demobilisation is alsoapositiveprocess,such asfallingofftosleep, dreaming, fantasising and celebrating. Hypothetically, demobilisation can be broken down into foursub-stages:turningaway,assimilation, encountering the voidandacknowledgement.By describing theexperiencecycle asreflectinglarger experiences inthe life ofthe individual, one expands beyond the original definition of the cycle as a description ofpresentexpetiences.Hopefully,describing demobilisation in terms ofsub-stages is useful, despite the distorting and stretching of the cycle experience. The first sub-stage involves either a turning away from (e.g.stopping drinking) ora beingturned awayfrom a figure inwhichenergy is still invested (e.g. deathofa spouse).The needofparents inoursociety todiminish their interest in their children as the children grow older is a common experience ofturning away.The relationship begins in confluence and progresses into the stage where the child introjects the parents'ideas and values.In some cultures, children maycontinue tointroject for muchof their lives, but in Western society, which values autonomy and independence, an increasing psychological separation between parentand child is preferred.Forchildren to develop integrity- thatis, to experience boundaries cleanly and clearly- they must detach from their parents and create other interests.As a child leaves, so must the parents distance themselves or they will be faced with one oftwo equally sad alternatives:either a hard rupturing of the child-adult boundary resulting inmutual traumaor a typeofdeadly confluence that restricts developmental maturation.One aspect ofmaturityis the capacity to move away from a boundary gently. Toturnawaywhenone still has energy requires much support.It can come in manyways, in the form ofeither self-generated or external support.To be self-supportive, to relyonlyonone'sown resources, is difficult and runs contraryto thenaturalinclinationtomove towards energised objects in the environment.Not only does self- supportincorporate anintellectualandemotional introjection ofvalues,italso includes aninvoking ofan internalised rhythm sadly absent for manyinour society. For to have faith, to holdone'shand, to rock gentlyand talksoftlytooneself,tosoothe oneself, ultimately involves the introjection of good nourishing parenting. The generationofexternalsupportofteninvolves placing oneselfwithinastructure thatprovides highly detailed proceduresfor leadingone'slife while inthe process ofturning away.Therefore choice, aswellas temptation, is minimised.Examplesofthistypeof structure areAlcoholicsAnonymousandsimilar organisations that deal withaddictive behaviours.These organisations articulate boththe techniques for andthe potential pitfalls in the turning-away process. Anotherexternaloption utilisedinturningaway involves the creation ofa large and compelling figure to which to transfer unspent emotional energy.Love on the reboundandsome born-againreligious conversions are examples of this typeof figure substitution.The problem withmovingquicklytowardsomethinglargeand captivating is that it does not allow for the next sub-stage ofthe demobilisation process, assimilation, tooccur. Consequently, little is ultimatelylearnedand the person maybedoomedtoskip fromoneloveor religious experience to another. Assimilation involves a chewing-over ofthe experience inordertodrainemotional energy.The processis difficult for manytherapists inthat the workmayappear redundant and boring.Furthermore, because our society underestimatestheamount oftime necessaryto chew over experience, patients maybe faced notonlywith doing the hard work but also with having to deal with the embarrassment engendered bythe intensityoffeelings and the surprisingly long timethat their interest remains. Itisthe therapist'stask to normalise theexperience and support the process.However, ifa patient'srestlessness with the duration and intensity offeelings is joined bythe therapist'sboredom, blockage may ensue. The thirdsub-stage, encounteringthevoid, canbe terrifying.Our society does notvalueor providemuch training for the experience offeeling emptied ofinterest, ofcaring, offigures.The voidconsists ofa segment in time when nothing matters.Often we avoid it bycreating artificialengagements such as self-talk and non-contactful activities.Ultimately, it is the fear ofthe unknownthat keepsmanylockedinto either painful or non-nourishing figures.Anditis this inability toturnfrom the old, the painfulandthe non-nourishing to the unknown that isa preconditionfor manyofthe'addictions'so prevalent in our society today,suchas workaholism, love addiction and codependency. The fourth sub-stage, acknowledgement,involves a soft, low-emotional energy and anowningofhowthe experience has changed the individual.Itis duringthis time thatindividuals are able toarticulate the learnings, bothgood and bad,from the experience aswellas to MeInick and Nevis expnzss and live out the changes in their lives.Thus the patientshave gained a piece of wisdom and are abIeto interactwiththeenvironmentina freshand more profound m e r .An example ofan inability to demobilk can be found in Post-Traumatic Stress Disorder (PTSB).Criteria incl* A.The personhas beenexposed to a tmnmtic event in which both of the following were present: I. The person e x p i e n d ,witnessed or was confronted withanevent or events thatinvolvedactual or thmkned death or seriousinjury ora threatto the physical integrity of self or others. 2. Theperson'sresponseinvolvedintensefear, helplessness or honor.No&: In childrem, this may be expressedinsteadbydisorganisedoragitated behavim. B. The traumaticevent is persistentlyreexperienced in one (or more) of the following ways: 1. Recurrent and intrusive dismsing recollections of the event,including images,thoughts or perceptions. Note:In y m g children repetitive playmay occur in which themes or aspects of the trauma are expressed. 2.Recurrent distressing dreamsoftheevent,including images, thoughts or perceptions.Note: Fn children, theremay be fsightening dreams without mgnisable we n t .3.Actingor feelingas ifthetraumatic event were nxumhg (includes a sense of reliving the experience, illusions, hallucinations anddissociative flashback episodes, including h s e thatoccur onawakening or whenintoxicated).Note: Inyoung children, trauma- specific I'e-mxtment may occut 4. Intense psychological d i ms at exposure to internal or extend cuesthatsymbolise or resemble anaqxct of the t camt i c event. 5. Physiological reactivityonexposure tointernal or extend ~ u e s thatsymbolise or resemble an aspect of the mumatic event. C.Persistent avoidance of stimuli associatedwith the traumaandnumbingofgeneral responsiveness (not present before the-ma),as indicated bythree (or mm)ofthe following: 1. Efforts to avoidthoughts, feelings or conversations associated with the trauma 2.Efforts to avoid activities, places or people that amuse recoflection of the trauma. 3. Inability to redlan important aspect of the lmuma A Markedlydiminished interest or participation in significant activities. 5. F~eiingof detachment ot estrangement from others. 6. Restricted rangeofaffect (e.g.unable to haveloving feelings). 7.Sense offoreshortened future (e.g. d m not expect to have weer, marriage, chiddren or a normal life span). D.Persistent symptoms of inmas& arousal (not present before a trauma) as indicatedby two {or more) of the following: 1. Dficultyfalling or staying asleep. 2.Irritability or autbursts ofanger. 3.Difficulty concentrating. 4.Rypmvigilame. 5. Exaggerated d e response. E. hat i on of the dimmbance (symptoms in &&aB, C and D) is more than one month. F. The dis-causes ~linically~significantdistress or impairment in social, oc~uptionalor o t kimportant mas of functioning (p.427). The Iirst thaq~uti ctask in the demobilisation of PISD involves helping patients acoept that a turning awaymust occur.Once this acknowledgement takes place,themthe work ofdmhhg the interest can lxp. However, since trauma canbemesmerising, wemusthelp patients acknowledge bothsides:that theybothwishtolose inkrest and wish to stay interested in the traumatic event. A second therapeutic task involves helping patients fmd form through which they canexpress theirfeelings in a s d way. 1These forms usuallyinvolve repetitive actions thatcause noharm.Talkingis theprimarymethod utilised as a form of 'doing'without a large mobilisation. The patientmustfeel supporkd in the expressionofa feeling without an external outcome or without an aim to change anything. When dembilisation from powerful events associated with PrSD is dealt with,sadness is often elicited naturally as the seasons of the year and anni vehes trigger affect- ladenmemories andsensations.Whenthesadnessis evoked,the task is then softly to talk throughthe events. However, thetherapist mayget stuck and experience difficultyinhelpingpatientsmovebeyondthe mrnatistng event.There are several possible reasons for this. The f i is pacing.Demobilisation is a slow pmes that must be supported. The therapist must struggle not to becomeimpatientorjudgmentalregardingthe redundancy andamount oftimeinvolved.Second, patientswill sometimes become frightenedbyemotions thatare engendered.It is thetherapist'sjobto provide adequate support for the patient to tolerate the emotional arousal as well as to help keep he emotions at a level that canIbeabsorbed into theindividual'sground.Third, patients may have an inadequate repertoh withwhichto Diagnosing in the Here and Now drain the energy.To'singthe blues',protest,light a candleorplantaflower are ritualsthataresocially sanctioned for dealing withtrauma andcan be usedto expand patients'repertoire. Lastly,the therapist must carefully monitor hisor her own interest.One must learn to be interested just enough. Too little interest will not provide enough support and too much on the part ofthe therapist will generate energy that fuelsthepatient'sattachmentandprevents demobilisation.Whendemobilisation is beingworked on, arealdangeris createdifthe therapistis more interested than the patient. It should be pointed out that we are describing an ideal, for one can never demobilise fully.Ifone is lucky, most figures will naturally be assimilated into background and the remaining energy will be used in a productive way. Thelastsub-stageofdemobilisationisan acknowledgement ofthe process.If patients have learned well,theywill knowsomething that theynever knew before.Ifdemobilisationhasproceededcorrectly, patients willbeable to answer the question:'Howam I different?. Insum,theworkdealingwithproblemsin demobilisationistohelptheindividual createsmall experiences to reduce the level ofemotional arousal.The dangeris increatingaremobilisation experience. It should be pointed out that as with other stages of the cycle ofexperience,aninabilitytodemobilise might bea function ofa person'sinability to experience or integrate sensations, to mobilise or to make contact.Ifthisis the case, then the work must include dealing with these other aspects of the cycle. Summary In this article a basic human dilemma is posed:How is one to know and describe another?To answer that query, theissues facedbyGestalt therapistsinattempting meaningfullytodiagnose and assess patients andthe Gestalt experience cycle and its utilisation for describing character have been discussed.Finally, an effort has been made tofita fewcommonDSM-N diagnoses into the paradigm ofthe experience cycle as wellas to prescribe appropriate methods of intervention. Diagnosis is an art as well as a science, for its purpose, after all, is to provide a useful modelofexperience.As Gleick (1987) so aptly writes: The choice is always the same.You can make your model morecomplexandmorefaithful toreality,oryoucan make it simpler and easier to handle.Only the most naive scientist believes thattheperfect modelis theone that perfectly represents reality.Such a model would have the same drawbacks as a map as large and detailed as the city itrepresents, a mapdepicting every park,everystreet, every building, every tree, every pothole, every inhabitant and every map.Were such a map possible, its specificity woulddefeat its purpose:togeneralise andabstract. Mapmakers highlight such featum as their clients choose. Whatever their purpose, maps and models must simplify as much as they mimic the world. (p.279) In retrospect, this attempt at mapmaking is but a rough beginning fded with contradictions and exceptions.But thisishowitshouldbe,forGestalttherapyis phenomenologically-basedtheorygroundedinthe celebration of the uniqueness of the individual. References AmericanPsychiatricAssociation.(1994).Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Washington. Delisle, G.(1991).A Gestalt Perspective ofPersonality Disorders.British Gestalt Journal,1, pp. 42-50. Evans,K.(1994).A Reviewof'Diagnosis:The Struggle for a Meaningful Paradigm'byJ.Melnick and S. M. Nevis.British Gestalt Journal, 3, pp. 40-41. From, I.(1984).Reflections onGestalt Therapyafter Thirty-two Years ofPractice:A Requiem for Gestalt. The Gestalt Journal, VII, pp. 4-12. Gleick, J.(1987). Chaos.Viking, New York. Huckabay, M.(1992).AnOverview ofthe Theory and Practice ofGestalt Group Process.In E.Nevis(Ed.) GestaltTherapy:Perspectives and Applications. Gardner Press, New York. Kraus, M.(1989).Beyond Homeostatis:Towards Understanding Human Systems.Gestalt Institute ofCleveland Review, III, 2, pp.1-7. Latner, J.(1984).The Kingdoms ofExperience.The Gestalt Journal, VII, pp. 84-109. Melnick,J.(1980).The UseofTherapist-Imposed Structure in Gestalt Therapy.7he Gestalt Journal, III, pp. 4-20. Melnick, J.(1997). Welcome to Gestalt Review.Gestalt Review, 1, pp. 1-8. Melnick J.and Nevis,S.(1987).Power, Choice and Surprise.The Gestalt Journal, M,pp. 43-5 1 Milan, T.(1981).Disorders of Personality, DSM III: Axis II.Wdey, New York. Miller, M.J.(1985).Some Historical Limitations of Gestalt Therapy.The Gestalt Journal, VIU, pp. 51-54. Parlett, M.(1991).Reflections on Field Theory.British Gestalt Journal, 1, pp. 69-81. Parlett, M.(1993).Towardsa More Lewinian Gestalt Theory.British Gestalt Journal, 2, pp.115- 120. Melnick and Nevis Perl s, ~S. , Ht f f erl i oe, R. F. dGdman, P. (1951).Psychology.PaperpresentedattheOhio Gestalt 7kmpy.Julian h s , New Yo&.Psychologid Association &g,1957. Polster, E. andPolster. M.(1973).Gestalt TherapyYmkfI G. (1 983).The Self in Gestalt Therapy: Reply to Ihtegmted.Brunner-I,New Yo&.Tobin. The Gesurlt J m l , pp. 55-70. Tobin,S.(1 985).LacksandShortcomings inGestaltYontef,G. (1988).AssimilatingDiagnosticand Therapy.The Gestalt J o u d , Ym,pp. 65-7 1.Psychoanalytic Perspectives info Gestalt Therapy.7 % ~Wallen,R. ( 1957).GestaltTherapy andGestaltGestalt Journal, XI, pp. 5-32. Joseph MMck Ph. D.,is a clinical psychologist specialking in supvision, couples, group andorganisatid wurk.Heis a former academician whohas published extensively on a wide range of topics relevant to Gesdt therapy.He is the editor-inchief of the Gestalt Review Sonia MarchNevis Ph.D, is dimtor of theCenter for theStudyof Mimate Systems and was formerly director ofprofessional training of the Gestalt Institute ofCleveland.She i s chairperson of the Cape Codsection ofthe Third-Year Specialization:WorkingwithCouples, Families andotherIntima& Systems. She uses Gestalt methods towork withcouples, families and systemsinher practice, in workshops and as a cond.tanL Address forcorrespo&e:17 South Street, Portland, Maine 04101, USA.