Fundamentals of Phenomenological Gestalt Psychopathology: A Light Introduction

Do not be fooled by the petite size of Gianni Francesetti's Fundamentals of Phenomenological Psychopathology: A Light Introduction, nor by its deceiving subtitle. Phenomenological Gestalt Psychopathology is a diminutive volume with Herculean implications. This tiny volume is characterized by a deeply philosophical explication of Phenomenological Gestalt Psychopathology (PGP) that Francesetti makes accessible through recursively juxtaposing intrinsic and extrinsic diagnoses processes. In 17 chapters, titled as questions, and fulfilled with in-depth answers, Francesetti takes us on an exploration: beginning with the minute (etymological definitions of core concepts in psychopathology, phenomenology, and Gestalt); and spiraling out beyond (through the idiosyncratic individual, therapeutic relationships, spectrum of disorders, and societal implications of/for psychopathology). This journey provides insight toward "understanding human suffering from a phenomenological and field approach creating radically relational reading for the ways in which suffering arises and manifests and the ways in which psychotherapy acts" (13). Francesetti creates the ground from which PGP practitioners can perceive the absences that figure prominently in the psychopathology of their clients; and a framework that supports PGP practitioners in guiding their clients through the journey to presence. Francesetti targets a professional audience from graduate students to experienced clinicians by employing juxtaposition, etymology, and evolution of thought. While the focus is on phenomenology from a Gestalt perspective, we would suggest that its appeal is broader. With references to Freud, Rank, Bateson, Buber, Gendlin, Kernberg, Masterson, and, of course, Perls, among others, there are connections to a broad array of clinical approaches.In the introduction to the book, Gilbert Di Petta's metaphorically oceanic description urges the practitioner to read on with the recognition that the chart is not the territory, to use medical and scientific models as a sailor might use ballast and her boat's keel as righting tools; and to be present to the phenomenological and Gestalt frameworks that function as anemometers and tide tables in the encounter with the patient's changing winds and shifting bathymetry. Francesetti will "firmly separate the road of modeling life-sickness from the road of understanding and approaching it" (8); paradoxically, "to understand anything, therapists must resign themselves to . . . suspending judgement on the models" (9), while simultaneously anchoring in phenomenological and Gestalt approaches. Di Petta captures the embodiment of experience for both patient and therapist by emboldening the reader: "If you want to truly open to encountering the other, if you want to be authentically encountered by the drama of the other, then as therapist you must lay down your epistemic shield and blithely move towards the other, ready and willing to be cast about and unanchored by their wind of passions, letting it cool or heat you" (9–10). This reference to therapists sharing psychological time-space with clients is a key to the book's approach to utilizing phenomenology within the therapeutic context.In Chapter 1, the roots of the text, Francesetti highlights the 1913 publication of General Psychopathology by Jaspers (1963), and the concurrent isolation of Treponema pallidum (the bacterium responsible for syphilis) by Hideyo Noguchi—immediately illustrating the inception of the divergence between phenomenological psychopathology and biological causation models of mental illness: "Phenomenological psychopathology is a method of both studying and describing the subjective experiences of those who suffer starting from a position as free as possible from causal preconceptions, thus highlighting the uniqueness and value of each experience" (17). When approaching a patient from a phenomenological perspective, one, "listens to the patient with as much openness and affective identification as possible" (17) whereas, from a biological perspective, one focuses on organic causes that might be identified by laboratory or instrumental analysis and solved by psychopharmacology. Perhaps, most importantly, Francesetti states: "The two paradigms are irreducible to each other, they are radically different," and "far from irreconcilable," and "the psy-clinician needs both" (18). So, while current advances in neuroimaging and psychobiology are laudable in the realm of brain science, they cannot be expected to elucidate how the mind works; that is the province of phenomenology."What is psychopathology?" (23). Simply answered, it is "the study of the psychic suffering of the human being" (23). But one may choose different definitions for the three critical concepts: suffering, the psyche, and study; and depending on one's choices, different psychopathologies will be generated with consequent theories and treatment methods. This opening to Chapter 2 provides the opportunity for Francesetti to share his clear understanding and love for etymology (an attention/intention sprinkled throughout the text). The most noteworthy example in this chapter is the parsing of the word psychopathology. By revealing the root meanings of psycho- / patho- / -logy, Francesetti arrives at this lyrical definition: "Psychopathology is, therefore, the study of a specific type of phenomena: the pathos phenomena, which are endured, that is suffered and upon which the person cannot exercise a choice" (23). In order to capture the Gestalt therapeutic understanding that the author intends, we need to see the concept of psychopathology elaborated upon. As he expands on the human experience of Heideggerian Befindlichkeit, or how one finds oneself (Gendlin 1978/1979), Francesetti brings us into the existential bedrock that undergirds PGP, that is, this suffering is about the person within the life situation. Simple, but profound in its implications. Since this perspective sees the limits and choices available in the human experience, it is no surprise that Francesetti refines the definition: "From a phenomenological-Gestalt perspective, psychopathology is the study of the forms of absence and how they tend incessantly toward presence" (25).In Chapters 3 through 5, Francesetti recursively illustrates the tension between the uniqueness of the patient's suffering and the universality of academic/biomedical psychopathological understanding. In Chapter 3, "What is the use of studying psychopathology?", Francesetti sets the reader up with a polarity: the forms and processes of human suffering are "infinite in personal differences (ideographic pole) insofar as no one suffers like an other; and at the same time they are repetitive (nomothetic pole) because . . . the ways of suffering of the human being are also universal" (26). Then he asks the therapist to work between these poles: maintaining the freedom to be relational, open, and sensitive to the unique terrain of one's own self, one's clients, and generational, epigenetic, societal, and cultural journeys to and through suffering; and without being constrained, but rather grounded, by the map for recognizing the echoes of psychopathological patterns in patient presentation, their developmental processes, and options for therapeutic pathways that are created in the study of psychopathology. In Chapter 4, "Are there different psychopathologies?", the reader is cautioned again about the tension between a psychopathology that reduces the psychological suffering of the individual to the map (nomothetic pole) of brain biochemistry and "symptomatic reductionism" (29), and PGP, which looks at the territory by assessing suffering through the lenses of "the relational field that a person has gone through, lives and expresses (ideographic pole)" (29). (This reference to field models echoes throughout the book and teases at the complexity involved in understanding ourselves and others.) The importance of this comprehensive perspective is buttressed in Chapter 5, "What's the relationship between psychopathology and diagnosis?", by Francesetti's definition of PGP as:Thus, a PGP stance allows therapists to recognize the fields "in which they find themselves with their patients" (34) throughout this process-oriented therapeutic journey. Francesetti is extraordinarily clear that outcome-oriented extrinsic "diagnosis does not coincide at all with the psychopathology" (31), such that substituting the study of psychopathology with the study of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is tantamount to malpractice. In so declaring, he clearly distances PGP from the medical model currently in sway and utilized by the most prominent diagnostic manuals in the world, the DSM-5 and the ICD-10 (International Classification of Diseases), which were originally intended to be used actuarially. Thus, the PGP model is a clinician's foundation for an intrinsic diagnosis process. Rather than objectifying via symptom checklists, this approach requires practitioners to tap into their lived experience of being with another to awaken the peregrinations of the healing process.In Chapters 6 through 8, Francesetti distinguishes how PGP approaches suffering. He leads the reader past the mechanical model of mind, briefly visiting cocreation, and then pausing to explore the field model. Rather than correcting the "defective functioning" (35) of the patient as in a mono-personal perspective, or recognizing the dysfunctional behaviors and supporting healing in the cocreational model, a therapist practicing from a phenomenological or field paradigm (36) takes a much more expansive outlook. This therapist would focus on "how an experience . . . emerges in the here and now of the situation"; that is, "what the patient and therapist experiences, what emerges between and around them; what atmosphere they create and how it creates them . . . which themes circulate, how they tend to repeat or transform" (37–38). Thus, therapist and patient hover in that terrain of the "Heideggerian befindlichkeit" (37)—"the landscape that we are here and now without choosing it" (37)—until what is suffered becomes apparent and available for transformation. This suffering is the psychic residue carried through life and into therapy. It is the "unfinished business" (40) of Gestalt therapy, that which resulted from a proto-experience, one which we did not "pass through" (39) nor assimilate; one which our intimate relationships and sociocultural milieu did not support us to absorb.This lack of a full revolution through the cycle of experience creates a stuck-ness, and accordingly, the "personality disorders evidenced in the repetitive, rigid, ego-syntonic ways with which we carry our absences upon us" (44). This is a key construct in PGP, the notion that the suffering presented in psychotherapy is an unintegrated and unassimilated experience. Thus, "any situation including but not exclusively trauma that allows neither the emergence of an experience in the relationship nor supports its assimilation is at the root of psychopathology" (45). Since much of these unassimilated experiences/traumas may have "occurred in the first three years of age" (51), it is unlikely that patients will have a clear narrative of events. Rather than a narrative, there will be a dissociation, either inaccessible or reemerging to absorb the present into the relived trauma (46). Because of its presence to the relational field, PGP practitioners allow what is suffered to become apparent by promoting client awareness of "body memory and long-term fidelity to symptoms" (51)—again, working between the nomothetic (presence to field theory and universal characteristics of particular types of suffering) and ideographic poles (presence to the peculiarities of each client's perceived and unrealized narratives).As the practitioner approaches the interior of this exploration into PGP and the lived experience of treating suffering, Francesetti supports us with his integrative best. He includes writings from such individuals as disparate as Freud, Bateson, Rank, Stern, Masterson, and Perls, leaving us with a conceptual model urging an expansive perspective on suffering. As an example of how his thinking produces a humanistic/existential formulation, Francesetti asks the reader to consider the etiology of borderline personality functioning by asking in which situation this perceptual mode might provide creative adjustments that are "an advantage for the person" (67). Francesetti urges practitioners to consider:These considerations of individual, relational, trans-generational, and sociocultural suffering set up the reader for the description of a bird's-eye view of the psychic environment that develops from individual, relational, epigenetic, and sociocultural climates (76–79). (See Figure 1, A Map of Pathology in Chapter 11.) And then, with this two-dimensional representation of the multidimensional environment of suffering, to step into the possibility that: "the work of psychotherapy can find a horizon of broader sense than lifting the suffering of the individual: in this light, it becomes a work of mending the existential tissue of the world, which transcends the patient and the therapist" (89).A Herculean task? Perhaps, but worthy of aspiration nonetheless. This volume is a port to return to repeatedly throughout the odyssey of a professional psychotherapist.