Monday, March 25, 2013


CASE CONCEPTUALIZATION: Therapist Compass, Clarifying Lens, Medical Model Envy ... or a Jumping-off Point for Something Completely Different

A discussion paper by Don Edwards, Ph.D., Jude Johnston, MSW, Julia Balaisis, Ph.D.,Valeri Belyanin, Ph.D. & Inese Gravlejs

CASE CONCEPTUALIZATION (CC): an assessment of the client and their presenting concerns in order to devise a treatment plan or treatment approach. This assessment includes client skills, environmental stressors and supports, cognitive, emotional and behavioural patterns. According to Padesky & Greenberger (1995), case conceptualization consists of identifying the issue or concern with the most leverage in the context of all other contributing and mitigating factors. This issue or concern may not be one that is initially figural for the client, but if not correctly identified by the therapist, the direction of therapy and its outcome may be compromised.

A well-prepared case conceptualization is intended to facilitate communication between professionals, systematize client records, and may help the therapist maintain a consistent frame of reference as well as track and review progress with the client even if the CC is not shared with the client. CC can also link the facts of the case to therapeutic interventions and may suggest areas of psycho-education as well as a session direction if the client does not raise areas of concern. In this era of heightened 'accountability,' 'cost effectiveness' and 'managed health care,' treatment plans, which are more and more demanded by non-practitioner administrators and professional regulatory bodies, are predicated on CC. However, as we will explore, CC's are not without their limitations.


  • therapist's theoretical orientation:
    The theoretical focus of a therapy shines the spotlight on aspects of the client's psychological functioning that the therapy seeks to improve. Every therapy is based on a set of assumptions about what is important. These assumptions manifest in the case conceptualization. For example, a therapy such as Psychoanalysis, based on a developmental stage model, will seek to address developmental arrests. A relational therapy such as Gestalt Therapy will seek to improve the relational skills of the client – the ability to create and experience contact in Gestalt terms. CBT seeks to correct cognitive distortions that affect the emotional functioning and behaviour of the individual and might consider factors such as “schema interference” that would not figure in conceptualizations based on other therapeutic models. Bound up in the theoretical orientation are other fundamental premises that become reflected in how a case is conceptualized:
    • CC is a solution-focused notion that fits in the medical model. CC can be 'diagnosis lite.' Not all therapies embrace this view of the nature and purpose of psychotherapy. Gestalt therapy in its purest form, for example, regards the client's concerns and blocks as emergent. The client is not treated according to some assessment or diagnosis conceived by the therapist in the early stages of therapy.
    • notions of where the 'neurosis' is held: in the body (Maté, 2004) as reflected in Reichian (Totton & Edmondson, 2009) and other somatic therapies and those that focus on energetics
    • the definition of healthy or wellness inherent in the therapist's theoretical orientation
    • the influence of culture as part of the individual's field (Lewin, 1952), lived experience, meaning making, imposed identities or identifications as reflected in an existential stance (e.g., Yalom, 1980) or an anti-oppression orientation (e.g., Aguinaldo, 2008)
  • type of therapy (brief/depth): Clearly conceptualizing a case is limited by the amount of data that can be collected. If the therapy is single session as in a drop in centre, the presenting data is shallow and may be the only basis for conceptualization other than the therapist's intuition and professional acumen. Also elaborate conceptualizations have questionable utility of the therapy is going to be of short duration.
  • therapeutic method, not to be confused with theoretical orientation: to paraphrase, If all you have time for is a hammer, every problem is a nail. These days due to heavy case loads most psychiatrists reach for the prescription pad. If you cannot prescribe medication, medication will only be part of your treatment plan if a prescribing physician is part of the treatment team. Without these medical resources, case conceptualization will be limited to psychodynamic, cognitive and behavioural elements. If you are an ardent CBT practitioner, the whole person may not figure as large in the conceptualization; body language may be noticed and conclusions drawn about it, but interventions are not likely to begin with the body as movement-based therapists would. A Reichian practitioner would begin with somatic energy blocks.
  • presence of medical issues, addictions, trauma, pervasive disorders, psychosis. The DSM IV-TR multi-axial system is one way or organizing this set of criteria into an efficient heuristic or checklist:
    • Axis I: All diagnostic categories except mental retardation and personality disorder
    • Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
    • Axis III: General medical condition; acute medical conditions and physical disorders
    • Axis IV: Psychosocial and environmental factors contributing to the disorder
    • Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

(source: Wikipedia)


CC is not without limitations and drawbacks. The above factors influencing how a case is conceptualized are also potential limitations:
  • within the therapist's paradigm of practice, a blindered view of the case is a considerable risk
  • inherently a CC is imposed on the therapeutic relationship and fosters hierarchy in the relationship
  • if the CC is not allowed to evolve over the course of therapy, it may become out-dated, and the therapy is at risk of becoming sterile, non-organic and irrelevant. Even if the CC evolves, it remains narrowing, though some may think of this as 'focusing.' This focusing can either help or hinder the therapeutic process by either making more figural those aspects that are truly influential or alternatively limit content and vocabulary or and narrowing perspective.


A case conceptualization is a snap-shot of the client from the perspective of a therapist or treatment team. Even if it evolves and is rethought from time to time, we still will have only a set of snap-shots that are static rather than process-based and not matrixed in the larger context of the client's experience which includes the therapy itself. Some criteria for next generation CC that is less susceptible to the above noted limitations might include:

  • shift toward a process orientation: patterns and dynamics versus labels and static facts
  • added focus on relationality: include the impact of therapeutic relationship, by abandoning the car mechanic model of therapy and recognizing that the therapist is person, not just a technical resource, in the client's social matrix, notwithstanding all the tried and true wisdom concerning the maintenance of professional boundaries.
  • more openness to cross-disciplinary integration by including professionals using other modalities or disciplines:
    • know when to bring other practitioners onto the team. Psychotherapy does not address everything that may be contributing to the client's presenting concern and we do the client a disservice trying to make therapy into a panacea.
    • special focus: explore (with the assistance of other practitioners if necessary) the important role of food and diet
    • know when the client's problem does not fit within the therapists frame of reference: recognizing when the limits of one's training and expertise have been reached
  • integration the influence of culture, including religion, ceremony and ritual
  • shift the professional attitude of the CC as a plan (somewhere the therapist is taking the client) to a biography (therapist as more respectful observer or co-traveller)


Aguinaldo, J. P. (2008) "The social construction of gay oppression as a determinant of gay men's health: homophobia is killing us." Critical Public Health, 18(1), pp.87-96.

Lewin, K. (1952) Field Theory in Social Science. London: Tavistock.

Maté, G. (2004) When the Body Says No. Toronto: Knopf/Vintage.

Padesky, C. & Greenberger, D. (1995) Clinician's Guide to Mind Over Mood. New York: Guilford.

Totton, N., & Edmondson, E. (2009 ) Reichian Growth Work: Melting the blocks to life and love. London: PCCS Books.

Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.

Friday, March 2, 2012


Awareness Served Four Ways

The Buddhist notion of sati or mindfulness can be translated loosely as awareness, but encompasses many subtle meanings other than the western notion of awareness as focused attention. Mindful awareness is non-evaluative, non-goal-directed, present moment experiencing without accompanying internal dialogue (Mahathera, 1990). Mindfulness is awareness refined: it abstracts observation from concern about outcome. One simply observes whatever is happening without judging it to be good, bad or otherwise—to the extent that that is possible—and without reacting. When mindful, one is attentively observing without an agenda, rather than vigilantly watching for something. Though one may observe that one has intention, one does not observe with intention. As Daniel Siegel (2011, p.86) describes it, “mindfulness is a form of mental activity that trains the mind to become aware of awareness itself and to pay attention to one's own intention.” The ideas of non-evaluative observation and awareness of awareness seem to capture much of what is meant when mindfulness is used outside a Buddhist context. To be aware of one's awareness, focusing on moment-to-moment changes of one's state both internally and with respect to one's environment, mindful activity represents a high degree of attunement within and outside oneself.

Mindfulness is a process not a state of being. David Wallin (2007, p.6) describes mindfulness as “attend(ing) to the process of experiencing.” Most familiar processes are in the service of goals that are external or consequent. One eats to satisfy hunger. One works to make money. The “goal” of the mindfulness, if can be said to have a “goal,” is mindfulness itself. One does it as an end in itself; one does not arrive there or achieve it.

Mindfulness is thought to promote development of new neural pathways in the pre-frontal cortex (PFC), the area of the brain responsible for impulse control, emotionally self-regulation, empathy, moral sensibility and our ability to relate to other people. In early life, circumstances associated with insecure and disordered attachment are thought to hinder the normal development of the PFC. Mindfulness practice has been shown to be effective in treating depression, mania, anxiety, bipolar disorder and borderline personality which may be related to the individual's attachment history.

The concept of awareness has a developed history in western psychological discourse along the lines of being the activity of focusing attention. In this framework, various types of awareness have been distinguished based on the target of attentional focus. In a therapeutic context, this is useful in that many of the problems for which people seek therapy are the result of habits of attending so some things and not others.

The concept of zones of awareness in Gestalt therapy (Canes, Trier-Rosner & Rosner, 1987, pp.28-29) is a model of awareness with three levels or areas to which attention is focused:

Outer Zone – what is perceived by the five senses (sight, hearing, smell, touch and taste)

Middle Zone - thinking, analyzing, planning, remembering, imagining

Inner Zone – feelings, emotions, body sensations

Siegel (2011) groups things differently, modelling awareness in three broad categories and making an important contribution by distinguishing relational awareness as distinct from the rest:

Body Awareness: contact with the environment (objects, air flow, wetness, heat, cold, etc.--the province of the five senses), internal states (breath, pain, pressure, pleasant sensations, internal changes – proprioception).

Mental Awareness: synonymous with the Gestalt Middle Zone plus feeling

Relational Awareness: our mental model of our relation to others in our social world

Wallin (2007) offers us the four concentric rings of awareness pointing out that attachment theory deals only with our development in terms of the first three rings. The fourth, innermost ring of awareness is the province of mindful practice which may be the key to the remediation of difficulties rooted in one's attachment history.

External reality (the outermost ring): physical and social stimuli in one's environment

Representational World: one's interpretation of perceptual data based on previous experience

Reflective World: one's reflective stance about the meaning of our experience

The Mindful Self (the innermost ring): one's ability to be aware of, observe and think about one's engaging in the other three rings of awareness. This gives rise to our sense of self, which even if it be a fiction as Buddhist psychology contends, is a persistent and useful one.

This model maps best onto distinct areas of the brain responsible for specific functions of which Wallin (2007, Ch.5) gives an excellent account.


Canes, M., Trier-Rosner, L., & Rosner, J. (1987) Peeling the Onion. Toronto: Gestalt Institute of Toronto.

Mahathera, Venerable H. Gunaratana (1990) Mindfulness in Plain English. High View, West Virginia: Bhavana Society

Siegel, D. (2011) Mindsight: the new science of personal transformation. NewYork: Bantam.

Wallin, D. (2007) Attachment in Psychotherapy. New York: Guilford Press.

Thursday, December 22, 2011


The Serenity Prayer, so named by the Rev. Reinhold Niebuhr (1943) and attributed to many back to Roman times, begins with the familiar words:

God grant me the serenity to accept things I cannot change
Courage to change things I can, and
Wisdom to know the difference.

These well known words are a life line for many coping with loss, depression or addiction.

Niebuhr chose to unpack his message by adding the Christian exhortations to humility, poverty, penitence and divine redemption:

Living one day at a time;
Enjoying one moment at a time;
Accepting hardships as the pathway to peace;
Taking, as He did, this sinful world as it is, not as I would have it;
Trusting that He will make all things right if I surrender to His Will;
That I may be reasonably happy in this life and supremely happy with Him
Forever in the next. Amen.

Whether one is of faith or agnostic, there are in the opening lines of the Serenity Prayer, a message of importance in psychotherapy. The consequences of neurosis include confusion and the paralysis of action. The opening lines of the Serenity Prayer give us the conditions for taking effective action in our lives. A humanistic psychotherapist might substitute for Niebuhr’s religions completion something more existential. Beyond knowing when to act and when to rest, we also need maturity in being able to delay gratification, the wisdom to take the long view and not get lost in the details of the moment, as well as the perspective to understand our own (relatively small) place in the scheme of things. And thus we might add the following three lines to the original three of the Serenity Prayer:

The patience to accept that things take time to work out
Letting go of asking “why” because I may not be ready to understand the answer, and
The detachment to realize that whatever my problem is, it involves more than me.

Thursday, December 15, 2011


How do I get started in therapy? What are the steps?

At All of You Wellness Centre, your initial enquiry by phone or e-mail will result in booking a free 15 – 20 minute telephone interview (usually at a later time) during which you will be asked to give a rough outline of your reasons for seeking help. In addition during that call, the parameters of treatment will be discussed (confidentiality, fees, insurance coverage, office locations, appointment time preferences, 24 hour cancellation, policy, missed appointment fees, etc.). If the intake coordinator feels that an All of You therapist can help you, and you accept the terms of service, an initial face-to-face appointment will be booked. You may be requested to complete a personal history form and complete some online questionnaires prior to this first appointment.

Is therapy ever complete? Does it just go on forever?

The stereotype of psychoanalysis is that you lie on a couch forever as you talk to yourself endlessly in the presence of the analyst who tries his/her best to be nothing more to you than a blank screen for your projections. Today this is as untrue of psychoanalysis as it is of other forms of therapy, many of which are designed to be brief, targeted and mindful of the economic cost involved.

The duration of therapy cannot be separated from the manner in which a client integrates the changes that arise from therapy. In practice, clients achieve a plateau in their development which must be explored before they are ready to move on to the next stage. During these stages of exploration of new ways of being in the world, therapy may continue and appear to “idle” as the therapist provides only support while the client gathers their forces to move forward again. At this stage, apparent relapses may occur, but usually are quickly overcome as the client's newly acquired coping mechanisms are brought to bear. Sometimes, is may be desirable to interrupt therapy when things plateau if the experience of being self-supporting without the therapist is part of the therapy. We are speaking here of what might be termed “strategic therapies” aimed at personal growth and correction of problems with deep, old roots. Other therapies are tactical: crisis, goal or results-oriented. These types of therapy typically have a short course and may be the entrée to longer term strategic therapy. In practice, most courses of therapy begin with a crisis of some sort –the “presenting problem” that causes the client to seek therapy. With the therapist's help, a new perspective, recognition by the client of existing strengths they can apply and provision by the therapist of information about other supports available within the client's environment, help shift the initial problem from crisis toward being a manageable symptom and it begins to become apparent that the initial reason for seeking therapy is underlain by a more strategic long-standing perhaps pervasive issue.

In principle, therapy is never finished because we are continually in the process of evolving and growing. However, if you have gotten what you wanted from a course of therapy, then, for the time being, you are finished. It is time now to live what you have learned and the feeling that you need help to make your life better may never come up again. If at some time in the future you have a sense that you are getting stuck again, it may be time to do more therapy.

I'm mad at my therapist. Should I quit therapy?

While it is possible that a panel of experts might also disapprove of whatever action of your therapist has upset you, it is far more likely that your therapist has hit upon a core issue that brought you to therapy. One of the most common patterns is to seek approval from people we look up to. Likely you look up to your therapist; otherwise you would have chosen a different one. If you therapist shines a light on something uncomfortable to you, it feels like disapproval. And the most common defensive responses to perceived disapproval and criticism are anger and flight. Why not tolerate your discomfort and hang around for the discovery that will change you? Wasn't that the result you were seeking?

What role do transference and counter-transference play in psychotherapy?

As definitions and lengthy discussions of these terms are available from many sources, we will not repeat them here other than to say that it is perhaps more profitable to look at transference as a naturally occurring process in all relationships, not just in therapy, rather than pathologizing it as Freud did in describing transference as a infantile neurotic pattern. Phenomenologically, we understand new experiences as a function of past ones –it cannot be otherwise –and thus the projective aspect of perception is pervasive. In that sense, transference is just one of the mechanisms by which we find our way in relationships. By learning about ourselves, we may become mindful of our transference, but it is debatable that we can be cured of it or operate without it.

Transference is what makes the therapeutic relationship non-hypothetical. When transference arises (whether the client is aware of it or not), the energy tied up in the patterns that trouble the client is being brought online. This creates an opportunity for new awareness and growth.

Counter-transference is rooted in your therapist's own life experience and is partly what enables him/her to be of assistance to you, to relate to your problems non-hypothetically, provided that your therapist is able to remain mindfully self-aware, recognizing that their own emotional response to your story implicates their own unresolved issues.

I want to end my therapy but can't face my therapist with my decision. Should I just make excuses and disappear?

At the risk of sounding redundant, your relationship with your therapist is just like any other relationship you have: it's a relationship. And such, it deserves a proper ending. It is more than a commercial transaction that ends with a cash register tape in your pocket.

One of the disservices we do ourselves is neglecting endings everywhere in our lives. Like most errors of omission, they go unnoticed. We break off with people without ever having an open discussion that goes beyond the anger of the breakup; we don't say good-bye to people who are dying; we leave jobs/ parties/community groups without saying good-bye, because we say “it doesn't matter,” but the real reason we do it is that we are not courageous enough to be open about our decision. Ending therapy has a impact on both you and your therapist. The (silent) damage occurs on both sides: you may feel the hollow weight of a lack of integrity; your therapist is confused about your disappearance; and both of you lose out on the opportunity for growth that having closure could bring. By disappearing, you miss yet one more opportunity to become comfortable with bringing about closure without which the accumulated unresolved experiences of life create an emotional backdrop of inauthenticity tinged with a bit of shame. Disappearing isn't a crime.   It's just a lost chance to grow as a person.

People terminate therapy for many reasons. They don't like their therapist; they tell themselves can't afford it; the stress and discomfort of change is too much, at least for now; the change that has been achieved suffices for what they think they want out of life, at least for now. Therapy seldom ends with a mutual realization that the client has arrived at perfection, both client and therapist being exceedingly glad and a grand graduation takes place. In most therapeutic relationships, the client and the therapist do as much as they can within the time and other resources that are available. Movement occurs, hopefully, but perfection remains “out there.” Despite such limitations, one of the things that makes the therapeutic relationship relatively unique is that it is a forum where nothing is outside the relationship: we should be able to tell our therapist anything, including good-bye. When we quit therapy without closure, we are putting that decision outside the relationship, and thereby violating one of the premises of that highly unique relationship.

How do I know if my therapist isn't doing a good job? Sometimes I feel worse after therapy. That can't be right.

There is no comprehensive list of signs against which to check. Egregious misdoings by your therapist are identified in professional codes of ethics and conduct. If you think your therapist is failing you, the best approach is to confront your therapist –which is different from complaining to a friend –knowing that you will grow from the experience even if you are have been mistaken—e.g., you discover your are getting upset because your therapist is doing his/her job in challenging your resistances –or your therapist takes a position where you have to agree to disagree. In any event, if you don't like the answer you get, at least the issue is out in the open and any decision you make is based less on assumption and more on fact.

Is it OK to see more than one therapist at a time?

In principle, different therapeutic approaches should not conflict, but in practice might e.g., a cognitive approach which encourages you to mentalize thereby focusing your awareness away from bodily sensations versus a somatically focused approach which encourages you to “get out of your head.” Some clients might find two simultaneous therapies overwhelming. Even if you can encompass different approaches concurrently, you are adding stress to the stress that brought you to therapy in the first place, not to mention potentially unnecessary expense and perhaps reducing the benefit of each approach. At All of You Wellness Centre, our policy is not to begin therapy with clients who are still receiving psychotherapy elsewhere, with the exception of clients who are being seen by a prescribing psychiatrist or family physician who monitors the client's psychological well-being as a necessary part of psycho-active drug therapy but are not actively engaged in psychotherapy with the client.

Am I getting value from my sessions? Is my therapist doing enough? It seems to me that I am doing all the work.

The real question is would you do this work if you were not seeing your therapist or would your life go on in the same familiar patterns you wanted to change by going to therapy? Some people expect that transformations will occur during the therapy hour. Actually at least half of the change that results from therapy takes place later, after each session, and in the six months following the end of a course of therapy. This makes sense: in the therapy room, you are talking about your life. The living of your life takes place outside the therapy room. The second part of this is who does the work in therapeutic change. Some clients, thinking along the lines of medicine, expect that something will be done to or for them in therapy, that some procedure will be applied, when in fact change is the client's response to the therapeutic relationship. Therapy is a relationship and it is through relationship that human beings change.

Why is psychotherapy expensive? It's just talk!

Like any business operation, your therapist has to pay rent, heat, electricity, ongoing profession development costs to stay current, along with other normal business expenses in order to provide you with an appropriate environment –in this case a safe, quiet and comfortable space in which to hold your sessions. In addition your therapist has to make a living in order to be available to you. If your therapist cannot make a living from their work, they will likely have to work at some other profession.

Psychotherapy is health care. Why do I have to pay for it?

Unfortunately public health care dollars are not equitably distributed across the health care system. The necessity to attend to mental health concerns is still an emerging priority in public health care funding.

I have benefits at work. Why aren't psychotherapy services fully covered?

Benefit plans cover psychotherapy in varying ways, sometimes separately with a separate limit per session and per annum, sometimes additionally restricted by being bundled in with a set of supplemental health care services all taken from the same annual total reimbursable sum. In addition psychotherapy may be reimbursable only if provided by particular practitioners. Read your plan details and do the math on the total cost of your therapy when selecting a therapist. For example: suppose your plan reimburses $50 per session for a max of $500 per annum.

CASE I: Suppose the therapists on the approved list on average charge $175/session. In order to collect the full annual limit from the insurance ($500 at $50 per session over 10 sessions), you will be paying $125/session over and above the amount reimbursed by your benefit plan, a total of $1250 for 10 sessions.

CASE II: You select a therapist whose services are not reimbursable by your benefit plan but charges $100 / session. Over the course of the same 10 sessions, your outlay would be $1000, AND you would have the luxury of choosing the therapist you feel is most suited to your concerns and personality.

I can't afford to pay for therapy every week. Can't we do something in one session?

There are two pieces here: 
  1. What can be accomplished in one session and what is accomplished in longer courses of therapy?
  2. What is therapy worth to you?

2. Let's deal with the second question first. Before starting anything, asking whether you can afford it is one of the first considerations. Are you already spending what therapy would cost on other discretionary purchases? Can you truly not afford therapy or do you just not want to spend the money? Is your reluctance to invest in your well-being and your future happiness really about money? Or is money a front for your resistance to confront issues in your life? Do any of these questions have resonance for you? If you really cannot afford therapy, there may be options like student clinics (lower cost but not likely free), or community agencies offering free counselling provided by volunteers (usually a waiting list). Neither of these options is likely to be highly specialized.

1. Brief therapy or single session/drop-in therapy deals with crises and tactical issues. Deeper issues such as the origins of patterns in your life cannot be addressed in one session and may not even be focal if the first session is devoted to addressing a crisis. The aim of such a session is shift the client's perspective on their presenting issue (reframing), increase the client's awareness of the resources they can draw on both within themselves and in their social circle and community to support them in dealing with their presenting issue, and ascertain whether other agencies or services should be involved. It is helpful to your therapist to know that it is your intention to see them only once.

As a final note, therapy need not be weekly, or may begin at that frequency, later shifting to a longer inter-session interval. The time between sessions is as important as the sessions themselves because change has to be lived, not just talked about. In addition, you are not helped if you become dependent on your therapist. Therapy is intended to support you in your life, not become your life. The frequency of sessions must be based on keeping that perspective as well as on cost and other practical considerations.

Some therapists offer a sliding fee scale. How do I get that?

At All of You Wellness Centre, fee reduction and pro bono consultation is at each Member Therapist's discretion. You may be asked to complete an Application for Reduced Fee. Reduced fees are a made possible by other clients paying the full fee for the services rendered. Therefore, there is a maximum number of clients who can be seen on a reduced fee basis at a given time. Availability and the factors below are weighed in determining reduced fee eligibility. Filing an Application for Reduced Fee does not imply a guarantee that a fee reduction will be approved. Reduced fee eligibility will be reviewed if there is a change in your circumstances. Any personal information you provide is strictly confidential.

Wednesday, December 7, 2011


... a selection of useful titles ... by no means exhaustive


Duncan, B., Miller, S., Wampold, B., & Hubble, M. (2010) The Heart & Soul of Change: delivering what works in psychotherapy. 2nd ed. Washington, DC: APA Press.

Hicks, J. (2005) 50 Signs of Mental Illness. New Haven: Yale University Press.

Ekman, P. (2003) Emotions Revealed: recognizing faces and feelings to improve communication and emotional life. Revised ed. New York: Holt.

Elliott, R., Watson, J.C., Goldman, R. N., & Greenberg, L. S. (2004) Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington, D.C.: American Psychological Association.

Golden, B. (2001) Portraits of Self-Esteem: 16 paths to competency and self-worth. Gainesville, Fla.: Center for Applications of Psychological Type.

Herman, M., ed. (2010) Clinical Pearls of Wisdom. New York: Norton.

Maté, G. (2004) When the Body Says No. Toronto: Knopf/Vintage.

Seligman, M. (2002) Authentic Happiness. New York: Free Press.

Steiner, C. (1971) Scripts People Live. New York: Grove Press.

Stout, M. (2001) The Myth of Sanity: divided consciousness and the promise of awareness. New York: Penguin.

Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.

Yalom, I. (2010)  Staring at the Sun:  overcoming the terror of death.  New York:  Wiley.


Mate, G. (2008) In the Realm of Hungry Ghosts: close encounters with addiction. Toronto: Knopf.


Neufeld, G., & Maté, G. (2004) Hold on to Your Children: Why parents matter. Toronto: Knopf.

Safren, S., Perlman, C., Sprich, S,m & Otto M. (2005) Mastering Your Adult ADHD. Oxford: Oxford University Press.

Solanto, M. (2011) Cognitive-Behavioural Therapy for Adult ADHD: targeting executive dysfunction. New York: Guilford.

Neufeld, G. Making Sense of Attention Problems (DVD). Vancouver: Neufeld Institute & Mediamax Interactive Productions.

Maté., G. (1999) Scattered Minds. Toronto: Knopf.

Ramsay, J. & Rostain, A. (2008) Cognitive-Behavioural Therapy for Adult ADHD. New York: Routledge.


Bourne, E. (2005) The Anxiety & Phobia Workbook, 4th ed. Oakland, CA: New Harbinger Publications.

Wehrenberg, M. (2008) The 10 Best-Ever Anxiety Management Techniques. New York: Norton.

Wehrenberg, M. & Prinz, S. (2007) The Anxious Brain: the neurological basis of anxiety disorders and how to effectively treat them. New York: Norton.


Haddon, M. (2002) The Curious Incident of the Dog in the Nighttime (novel). Toronto: Doubleday.

Picoult, J. (2010) House Rules (novel). New York: Washington Square Press.


Bowlby, J. (1998) A Secure Base: Parent-child attachment and healthy human development. New York, NY: Basic Books.

Neufeld, G., & Maté, G. (2004) Hold on to Your Children: Why parents matter. Toronto: Knopf.

Siegel, Daniel J. (1999) The Developing Mind: How relationships and the brain interact to shape who we are. New York, NY: Guilford Press.

Titelman, P. ed. (2003) Emotional Cutoff: Bowen Family Systems Theory Perspectives. New York: Routledge.

von Franz, M. (1981) Puer Aeternus, 2nd ed. Los Angeles: Sigo Press.

Wallin, D. (2007) Attachment in Psychotherapy. New York: Guilford Press.


Solomon, A. (2001) The Noonday Demon: an atlas of depression. New York: Scribner.

Styron, W. (1990) Darkness Visible. New York: Random House.

Wehrenberg, M. (2010) The 10 Best-Ever Depression Management Techniques. New York: Norton.

EMDR (Eye Movement Desensitization and Reprocessing)

Grand, D. (2001) Emotional Healing at Warp Speed: the power of EMDR. New York: Crown (Random House).


Brass, P.  (1999)  How to Survive Your Own Gay Life.  Bronx, NY:  Belhue Press.

Denborough, D.  (2002)  Queer Counselling and Narrative Practice.  Adelaide, Australia:  Dulwich Centre Publications.

Issay, R.  (1996)  Becoming Gay:  the Journey to Self-acceptance.  New York:  Henry Holt & Co.

Nimmons, D.  (2002)  The Soul Beneath the Skin.  New York:  St. Martin's Griffin.

O'Neill, C. & Ritter, K. (1992)  Coming Out Within:  Stages of Spiritual Awakening for Lesbians and Gay Men.  New York:  Harper Collins.

Siegel, S., & Lowe, E. Jr. (1994)  Uncharted Lives:  Understanding the Life Passages of Gay Men.  New York:  Dutton/Penguin. 


Beisser, Arnold  (1970) "The Paradoxical Theory of Change."  Gestalt Therapy Now.

Clarkson, P. (1989) Gestalt Counselling in Action. London: Sage.

Feder, B., & Ronall, (1980) Beyond the Hot Seat: Gestalt approaches to group. Highland, NY: Gestalt Journal Press.

Fleming, S. (1999) A Well-Lived Life: essays in gestalt therapy. Cambridge, MA: Gestalt Institute of Cleveland Press.

Mann, D. (2010) Gestalt Therapy: 100 Key Points & Techniques. New York: Routledge.

Kirchner, M. (2000) “Gestalt Therapy Theory: An Overview." Gestalt! 3(4). Also online at:

Perls, F. (1947) Ego, Hunger and Aggression. New York: Vintage.

Perls, F., Hefferline, R., Goodman, P. (1951) Gestalt Therapy. New York, NY: Bantam.

Satir, V. (1976) Making Contact. Millbrae, CA: Celestial Arts.

Shaffer, J. (1978) Humanistic Psychology. Englewood Cliffs, NJ: Prentice-Hall.

Yontef, G. (1993) “Gestalt Therapy: An Introduction," in Awareness, Dialogue, and Process. Gouldsboro, ME: Gestalt Journal Press. Also online at


Raphael, K. (2003) The Mastery of Awareness. Colorado Springs, CO: Lightwurks Publishing

Ruiz, D. M. (1997) The Four Agreements. San Rafael, CA: Amber Allen.

Ruiz, D. M. (2003) Toltec Prophecies. Tulsa, OK: Council Oak Books.

Ruiz, D. M. & Ruiz, D.J. (2003) The Fifth Agreement. San Rafael, CA: Amber Allen.

Walsch, N. D. (1995) Conversations With God, Book I. NY: Putnam.

Walsch, N. D. (1999) Friendship With God. NY: Berkley Books.

Walsch, N. D. (2000) Communion With God. NY: Berkley Books.


Ferucci, P. (1982) What We May Be. London: Thurstone Press.

Mutke, P. (1976) Selective Awareness. Glendale, CA: Westwood.

Siegel, D. (2011) Mindsight. New York: Bantam.

Wallin, D. (2007)  Attachment in Psychotherapy.  New York:  Guilford Press.


Denborough, D. (2002) Queer Counselling and Narrative Practice. Adelaide, Australia: Dulwich Centre Publications.

Dunne, P., & Rand, H. (2003) Narradrama: integrating drama therapy, narrative and the creative arts. Los Angeles: Drama Therapy Institute.

Epsteon, D. (1998) Catching up with David Epston: a collection of narrative practice-based papers published between 1991 and 1996. Adelaide, Australia: Dulwich Centre Publications.

White, M. (1995) Re-Authoring Lives: interviews and essays. Adelaide, Australia: Dulwich Centre Publications.

White, M. (2011) Narrative Practice: Continuing the Conversations. New York: Norton.


Borderline Personality

Mason, P. & Kreger, R. (1998) Stop Walking on Eggsheels: taking your life back when someone you care about has borderline personality disorder. Oakland, CA: New Harbinger.


Golomb, E. (1992) Trapped in the Mirror: adult children of narcissists in their struggle for self. New York: Harper.

Lowen, A. (1985) Narcissism. New York: Touchstone.

Rappoport, AD. (2005) “Co-Narcissism: How We Accommodate to Narcissistic Parents.” The Therapist, Online at:


Bushe, G. (2001) Clear Leadership. Mountain View, CA: Davies-Black.

Hirsh, S; & Kise, J. (2000) Introduction to Type and Coaching. Palo Alto, CA: CPP, Inc.

Hirsh, S; & Kummerow, J. (1998) Introduction to Type in Organizations. Palo Alto, CA: CPP, Inc.

Johnson, B. (1991) Polarity Management. Amherst, MA: HRD Press.

Myers, I; & Kirby, L., & Myers, K., eds. (1998) Introduction to Type. 6th ed. Palo Alto, CA: CPP, Inc.

Pearman, R. (2002) Introduction to Type and Emotional Intelligence. Palo Alto, CA: CPP, Inc.

Wallin, D. (20007) Attachment in Psychotherapy. New York: Guilford.


Briere, J. (2004) Psychological Assessment of Adult Post-traumatic States. 2nd ed. Washington, DC: APA Press.

Briere, J. (2009) Treating PTSD and Complex Psychological Trauma. J&K Seminars:

Briere, J. & Scott, C. (2006) Principles of Trauma Therapy. Thousand Oaks, CA.: Sage.

Muller, R. (2010) Trauma and the Avoidant Client: attachment-based strategies for healing. New York: Norton.

Tuesday, October 4, 2011



The Gestalt Cycle, describing the fluid, changing and sometimes interrupted process of the contact boundary that in theory surrounds the self, models a) at the micro level, the transactional nature of our interaction with the environment including others, and b) at the macro level, the arc of longer processes with a beginning and an ending, such as a vacation, a course of therapy, or one's time at college. Each such transaction or arc represents a whole or gestalt.

Our sensory capabilities, not being able to apprehend everything in the environment simultaneously, filter the constant incoming bombardment of sensory information. Out of this fertile void, some part becomes prominent or figural against the rest, the ground. The Gestalt Cycle follows the stages of response of a perceiver to a figural stimulus through mobilizing to interact with it, taking action to approach the stimulus, continuing on to engagement or contact, satisfaction or closure in the interaction, and ultimately disengagement or withdrawal, allowing, from the perspective of the perceiver, the figural stimulus to merge back into the field. Several representations of the Gestalt Cycle have been proposed; an excellent review of them is presented by Mann (2010). The cyclical model of the Gestalt Cycle proposed by Clarkson (1989, Fig. 1 below) includes the recognizable organismic responses to stimulation: sensation, awareness, mobilization, action, contact, satisfaction and withdrawal. Though we may refer to them as stages, each is a mini-process, all in sequence making up one complete Gestalt Cycle. Clarkson's model is detailed and sequentially structured, organizing and expanding upon the processes discussed by Perls, Hefferline and Goodman (1951) in their definitive volume, Gestalt Therapy.


The contact boundary is a theoretical construct, not something that can be objectively examined and measured. It is described as forming and dissolving over the course of a complete gestalt, shifting constantly in between like the boundary between smoke and air, lake and beach. The contact boundary is central to the psychodynamics of the interaction of the self with the environment including others and its changes are thought of in ways that are tightly coupled with observed changes in awareness. The contact boundary forms concurrently with the perceptual process of a stimulus becoming a figure in contradistinction to the surround of other less prominent stimuli that comprise ground. The contact boundary disappears with disengagement from the stimulus. The Gestalt Cycle models the process cycle of the contact boundary.
Clarkson's delineation of the Gestalt Cycle is paralleled by a corresponding sequence of psychodynamic processes identified by Perls Hefferline and Goodman (1951) reflecting psychoanalytic theoretical roots –confluence, introjection, projection, retroflection and egotism and supplemented by the processes of desensitization (Clarkson) and deflection (Polster & Polster, 1973) All of these psychodynamic processes are in principle non-neurotic if passed through on the way to the next or occasionally interrupted, but neurotic of chronically interrupted and inappropriate. To be clear confluence, introjection, projection, retroflection, egotism, desensitization and deflection may be thought of as completely non-neurotic contact boundary processes, but they become contact boundary disturbances. neurotic psychodynamic processes at the contact boundary between self and the environment, when “...they are fixated on impossible or non-existent objects (or) when they involve an impoverishment of awareness (or) when they prevent meaningful integration of needs and experiences” (Clarkson, 1989, p.46).

What is significant is that when one of these psychodynamic processes fails to resolve normally, a corresponding organismic process is also altered in some way both in the moment and possibly in later similar circumstances. When the normal fluidity of these processes, psychodynamic and organismic, becomes habitually disturbed or interrupted, a pattern of neurotic thinking, feeling and behaving is established. For example, incompleteness of introjection (as in failing to differentiate whether a stimulus is relevant and not relevant to the self) goes hand in hand with a disturbance of normal mobilization (the organismic process) in response to stimuli.
Contact boundary disturbances describe habits in which a response (e.g., retroflection/avoidance of contact) manifests in the individual even though the original circumstances under which the disturbance may have had adaptive value (e.g., threat of punishment for speaking out) are not present (e.g., speaking the truth to others will not engender punishment). When one of these contact boundary disturbances occurs, the Gestalt Cycle is interrupted: a gestalt remains incomplete. In the sense that the post-disturbance phases of the Gestalt Cycle do not occur or may not occur fully, there remains unfinished business, a phrase common in Gestalt Therapy.
One may debate whether confluence occurs at awareness or withdrawal on the Gestalt Cycle. The discussion of Perls et al. suggests the former. Clarkson favours the latter, breaking the post-contact phase of the Gestalt cycle into satisfaction and withdrawal with respective boundary disruptions, egotism and confluence. Clarkson's inclusion of deflection (see below) early in the Gestalt Cycle may in part explain her placement of confluence later in the sequence. A complication with this is that in general discourse, confluence is mentioned in contexts that involve circumstances other than interrupted withdrawal such as:
  • being confluent prior to awareness. There is no I/Thou or I/It relationship. The contact boundary has yet to form: the stimulus has yet to fully emerge as figural and differentiated from the self, and the other is never outside the contact boundary of the perceiver. We are often confluent with the physical environment in this way, for example, as we might be with the controls of a familiar automobile. This contrasts with confluence at the end of the Gestalt Cycle at which point the boundary has formed and then been displaced or transgressed and is not allowed to dissolve to make way for new stimuli to become figural.
  • being confluent with the needs and desires of another in codependency (mobilization / introjection).
  • being confluent with one's social location as in interpreting a situation without awareness of one's biases which are projected onto the environment (action / projection). It can be argued that all perception involves some element of this type of confluence and thus confluence cannot be completely eliminated.
  • being confluent with one's projections such identifying with a character in a stage play (no contact occurs).

At the awareness, Clarkson identifies the contact boundary disturbance of deflection or rejection of the stimulus whereby “...the person is not fully aware of his or her own needs or the demands and invitations of the environment” (Clarkson, 1989, p.47) as in passive-aggression. Miriam and Erving Polster (1973) describe deflection as a means of avoiding contact which suggests examples such as looking away at an awkward moment or responding irrelevantly to another person's remarks. The critical difference lies in what is considered to be deflected: awareness or contact. Neurotic “not noticing” is a deflection at awareness if no contact subsequently arises, or possibly at contact, if one chooses to ignore some aspect of the other. Alternatively, one may consider smaller micro gestalts (moments of noticing) within the arc of a longer gestalt such as a conversation; e.g., within the conversation (macro gestalt), we fail to notice the stain on the other's clothing because it is inconsistent with our view of them as a meticulous person (deflection at awareness in the micro gestalt concerning noticing the stain); or we may notice the stain and momentarily consciously choose to ignore it (deflection at contact in the micro gestalt) or make an unspoken judgement about the other and abruptly end the conversation (deflection at mobilization in the macro gestalt) .


Perls, Hefferline & Goodman (1951) elaborate the Gestalt language of contact boundaries, boundary processes and boundary disturbances, detailing aspects of boundary disturbances which may occur in conjunction with confluence, introjection, projection, retroflection, and egotism. These aspects of a boundary disturbance are:
  1. the characteristic
  2. the emergency
  3. the satisfaction
  4. the aggression against the organism
  5. the aggression against the environment
For introjection, these five aspects contact boundary disturbances are detailed in Table 1 and for all boundary disturbances in Figures 2a / 2b. PHG also reference other psychoanalytic concept of deflection, repression and sublimation in their discussion of boundary processes but do not elaborate their boundary model as fully for these. 

Table 1. Aspects of Boundary Disturbances. Perls, Hefferline & Goodman (1951, Chapter 15: Loss of Ego Functions)
a key externally observable characteristic rejection of the excitation as it appears dangerous to respond to it
one or more environmental events that will trigger feelings of emergency excitement (danger) or decision making (danger, loss of contact with ego functions)
as a secondary gain of neurosis, a satisfaction masochism (creates a subjective impression of buying safety)
some form of aggression against the organism reversal of affect (consequence of above; e.g., belief that joy may trigger an abuser may lead to the experience of sadness instead)
some form of aggression against the environment Resignation (perceived as safe relationship to self)

   Figure 2a. Aspects of Contact Boundary Disturbances: Characteristic, Emergency, Satisfaction
(after Perls, Hefferline & Goodman, 1951, Chapter 15: Loss of Ego Functions)
Figure 2b. Aspects of Contact Boundary Disturbances: Aggression toward the Organism, Aggression toward the Environment (after Perls, Hefferline & Goodman, 1951, Chapter 15: Loss of Ego Functions)
If the contact boundary is “disturbed,” evidently it is not situated between the person and the environment as it would be in non-neurotic process. The answer to this is suggested in the discussion provided by PHG and is briefly summarized as:
  • confluence: the boundary is sufficiently displaced from the self as to include a significant portion of the field; in the sense of merging, it may seem to be dissolved altogether
  • introjection: the boundary is displaced to include certain other individuals or aspects of them such as their beliefs
  • projection: the boundary is displaced inward such that perceptions or introjected material is experienced as belonging to others or the environmental
  • retroflection: the boundary is displaced inward such as to create a split within the self, one part of which takes the place of the other, the function of which is permit self-comfort or inward expressiveness in place of the more feared contact with another person or the environment.
  • egotism: an attempt to prevent the dissolution of the contact boundary that naturally happens at the withdrawal stage of the Gestalt Cycle
and if we extend this model of characterizing contact boundary disturbances to deflection and desensitization:
  • deflection: an attempt to prevent the contact boundary from fully forming either at awareness or to hasten its dissolution without contact or satisfaction.
  • desensitization: as the stimulus does not commence to become figural and does not register an organismic response such as pain, the boundary, if it can be said to exist at this pre-awareness stage, remains in whatever after-state existing after the preceding gestalt.

Clarkson, P. (1989) Gestalt Counselling in Action. London: Sage.

Mann, D. (2010) Gestalt Therapy: 100 Points & Techniques. New York: Routledge.

Perls, F., Hefferline, R., Goodman, P. (1951) Gestalt Therapy. New York: Bantam.

Polster, E. & M. (1973) Gestalt Therapy Integrated. New York: Vintage Books.