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When I was preparing to present a lecture on diagnosis and whether it is useful or not in Gestalt I felt excited and anxious…The dilemma for me is whether to follow others opinions, do lots of research or talk about my own experiences working in this field for 25 years now

My work consists mainly at treatment centres (psychiatric private hospital) working with addiction, eating disorders, personality disorders, relationships issues. I want to be authentic and let you know that I was constantly in two minds. I was really resistant to the use of any “labels” or a diagnostic approach when I started working as a Gestalt therapist in a psychiatric hospital and had struggled for a few years with diagnosis verse just staying with “what is” and I have been very critical about people who use labels. However, working at a treatment centre and with a multi-disciplinary team I slowly, very slowly felt something in me realise that there is a certain flavour with some people entering the treatment centre.

One of the lessons I learned was when a young women came into treatment. Psychiatrists and Doctors and some of the team members labeled her as Personality disorder client. She was in my group, I remember being really resistant and telling them that she was OK –nothing wrong with her. It took two weeks, lots of my patience before I started seeing that what they saw was something that I was unwilling to see. It was an awakening. And what the diagnoses gives me now is a framework to work with people. I found I can work more efficiently and sensitive. So, is diagnosis useful in Gestalt therapy? Yes, very much so. However, it can be very unhelpful if one uses them to label or “box” in clients.

Diagnosis is useful and necessary as it gives the therapist a framework to work with.It informs the therapist of the client-s complex personality structure. Diagnosis like any form of meaning is not correct or absolute, on the contrary it is constructed. First whenever possible I begin clinical interaction by centering and bracketing the diagnosis so that when I am with the client I can allow the obvious to make an impression on me: What do I see, hear, what is the quality of contact, how am I affected? Does the client take initiative or I am irrelevant to them? Therapist needs to be aware of how they are affected and their reaction to the diagnostic value, and need to take responsibility for their own reactions.

When I am working with a client I don’t focus or think about diagnosis or theory. However, I have that in the back of my mind…It is not putting people into boxes or dividing them into good/bad sick/healthy etc. When working with Borderline clients I need to know and understand to what extent they are disordered so I can work more creatively and holistically with them. I found with Borderline clients in a group setting and one to one setting the need to be more sensitive and not as challenging as with other clients. They have a more fragile “sense of self” and sometimes quite vindictive if the therapist triggers their wounds.

The current DSM IV states that Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, affects control over impulses and requires at least five of the following nine criteria qualify.

  1. Frantic efforts to avoid real or imagined abandonment
  2. Unstable and intense interpersonal relationships characterised by alternation between extremes of idealisation and devaluation
  3. Identity disturbance: persistent and markedly disturbed, distorted or unstable self-image or sense of self
  4. Impulsiveness in self-damaging areas: substance abuse, spending, sex, binge eating, reckless driving
  5. Recurrent suicidal threats, behavior, or self-mutilation
  6. Affective instability due to marked reactivity or mood
  7. Chronic feeling of emptiness
  8. Inappropriate intense anger or lack of control of anger
  9. Transient stress-related paranoid ideation or severe dissociative symptoms

Pioneering therapist Yallom wrote on borderline personality disorder. “It has been shown in research and from personal experience that many people diagnosed with PD are survivors of abuse, neglect and traumatic childhood experiences”.

Research indicates that borderline patients highly value their group therapy experience-often more than the individual therapy experience. In one to one setting they are often not able to hide or not be seen, where in a group setting they may be able to hide behind others (due to extreme anxiety). However, it is known that it’s also very challenging for most of the Borderline clients to be in the group. Each client need to be assessed individually and separately. Borderline personality clients often split the team or therapists in an unconscious way through splitting and getting other people to fight their intrapsychic battles in an interpersonal field. I personally saw that often in our meetings.

The danger of using only Gestalt therapy with Borderline clients is that there can be lots of meaningless talk that is disguised as meaningful. This is a common weakness with beginning therapists. The client will gain “awareness” but nothing changes. And it can lead to more fragmentation, regression, decomposition. For example, if primitive rage is stirred up before the client’s self-support system is strengthened, he or she may need to act out, go crazy make calls to therapist etc. but will not be able to assimilate and integrate. The borderline client will engage in lot of talk and emotionality. There needs to be firm boundaries established.

It is totally different when working with a  client with clients presenting with narcissistic traits.

The popular image that is called to mind when the word narcissism or narcissist is used is a picture of a thoroughly self-centred, self-loving person who, with an inflated sense of self ruthlessly pursues his or her own selfish needs without care about other people. To some extent this picture is supported by the description in the DSM. The following are taken from the DSM III description of the Narcissistic Personality Disorder.

  1. Grandiose sense of self-importance or uniqueness
  2. Preoccupation with fantasies of unlimited success, power, brilliance, or ideal love
  3. Exhibitionism: the person requires constant attention and admiration
  4. Cool indifference or marked feelings of rage, inferiority, shame, humiliation, in response to criticism, indifference of other, or defeat

Present with at least two of the following:

1.Entitlement: expectation of special favours without assuming reciprocal responsibilities

2.Interpersonal exploiting: taking advantage of others to indulge own desires for self-aggrandizement, disregard for the personal integrity and right of others

3.Relationships that characteristically alternate between the extremes of over idealisation and evaluation

4. Lack of empathy, inability to recognize how others feel, e.g. unable to appreciate the distress of someone who is seriously ill

It is obvious that the narcissistic client is self-centred…but not centred on his or her “true self”. The true self is of the organism-environment field. As Perls, Hefferline and Goodman say:

“Healthy self-functioning is not self-centred, but self-other centred. Healthy awareness is not awareness of oneself, but of others and self.”

Narcissists are confluent and field dependent. They are very dependent on the opinion of others. The inflated self-image of the inflated narcissists helps them avoid the shameful experience of being depleted and deflated. Under the surface, narcissistic clients are very different and insecure. We are all narcissistic to some degree and need admiration from people around us, however narcissistic personality disorder is basically a severe form of the narcissism of everyday life. As a personality structure it is more deeply and strongly crystallised and thus more rigid than others. To work with narcissists, therapy needs to focus on the relationship and working with how the person can relate and over a period of time facilitating and assisting the client with empathy for others. One main challenge for the narcissist is not having empathy or compassion for other people.

The narcissistic client has a lot of shame, and uses something external to give themselves a feeling of safety, and self-warmth. While I have talked mostly here of narcissistic personality and borderline personality it is obvious however there are other dis-orders that could be explored and understood.

For us Gestalt therapists it’s important to understand the client’s personality structure in order to work with them in a holistic and healing way. The challenge is how to use “labels” and not be rigid about them…It comes to my mind the Carl Jung quote. “Learn your theory well, but put it aside when you touch the miracle of human being”. Most important for me in Gestalt therapy is to understand the individual client and treat each client individually. Good therapy is an art based on clear phenomenologically based awareness and dialogue and any suggestions based on group data such as diagnosis are only suggestive and give a frame for the therapist.

In Summary: In my opinion to work effectively and holistically with clients the therapist must have clear boundaries and the right intention. Without diagnostic sorting no psychotherapy can be considered professional or competent. The therapist must have awareness of client’s self-functions, and be able to best support and guide the client to their best possible health and wellbeing.

The therapist discriminates between good support and challenging the client with the patterns that are working against them. Most important for the client and therapist is to be in a related manner as we only grow and change in presence of the “other”. The therapist needs to be “bracketing” their own understanding about the diagnosis and holding this awareness with great caution and sensitivity…as all clients including us therapists are very sensitive about being labelled or put into boxes. In my opinion the diagnosis is really important to understand and in the course of the session one needs to put that aside and be with the client in a supportive, open and loving way.

About Maria Dolenc

Maria Dolenc is family therapist and constellation facilitator at Byron Private Treatment Centre, Byron Bay. Qualified as a Gestalt Therapist, Family Constellation Facilitator and Addictions Counsellor Maria has over twenty years experience working with individuals, couples, families and groups. She devotes most of her spare time doing what she loves – family systemic / constellation work.

This paper was written by Maria Dolenc for GALTA and shared here with permission.