Heinrich Bartuska, Manfred Buchsbaumer,
Gerda Mehta, Gerhard Pawlowsky,
Stefan Wiesnagrotzki (eds.)
Psychotherapeutic Diagnostics
Guidelines for the New Standard
SpringerWienNewYork

Dr. Heinrich Bartuska
PO Manfred Buchsbaumer
Dr. Gerda Mehta
Dr. Gerhard Pawlowsky
Ass.-Prof. Dr. Stefan Wiesnagrotzki
Vienna, Austria
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ISBN 978-3-211-77309-3 SpringerWienNewYork

Forewords from Various Perspectives
Translated from the German by Luna Gertrud Steiner


World Council for Psychotherapy
This book contributes to the clarification of two fundamental questions of
psychotherapy:
1) how can we describe diagnostic processes in psychotherapy? and
2) can we solve the problem that there are different ways of diagnosing in
different psychotherapeutic schools, and will our answers transcend the
idiosyncratic1 self-conceptions of the pertaining theories and set the stage
for a conjoint diagnostic practice?
A study group within the Advisory Board of the Austrian Ministry of Health
and Women's Issues concerned itself with these fundamental questions, thus
preparing the ground for the book you are holding in your hands.
Historically, the specific psychotherapeutic way of diagnosing has often
been experienced as insufficient, particularly when compared to medical
diagnostics. Treatment without accurate diagnoses to start from seems im-
practicable to most medical professionals. Psychotherapeutic diagnoses pur-
sue an entirely different way, in that it is embedded in the process or occur-
rence of people interacting, and we might term it 'thera-gnostics', thus denot-
ing diagnoses that emerge in the course of therapy. Psychotherapy addresses
the subjectivity of a patient or a client, and not objectifiable biochemical
parameters. Nevertheless, we need to bear in mind that a patient's subjectiv-
ity does not stand by itself but meets with the psychotherapist's perspectives,
which also constitute subjectivity, however screened they may appear by
experience and knowledge. Hence, an interactive process of jointly elaborat-
ing diagnostic aspects of the patient's personality is facilitated, including the
awareness of oneself and others, action competence, and emotional dimen-
sions. The diagnostic proceeding of psychotherapy is, therefore, a multi-
layered one which, apart from the individual dimension, is determined by
cultural and sociological parameters and traditions, which have to be taken
1 Structural or characteristic behavioral peculiarity of an individual or a group

VIII
Foreword
into account in particular respect of an intercultural and increasingly glo-
balized world. For what is experienced as painful, deviant, or troublesome is
not only subject to individual perception but also to collective states of un-
consciousness.
The diagnostic process may be understood as a form of translation in so
far as a patient's utterances, be they verbal or nonverbal, are transferred to a
new code of understanding, a process every communicator is involved in
because, as we all know, there is no such thing as non-communication. If in
an empathic relational field we manage to decode a patient's subjective lan-
guage including that of her symptoms and distress, a new language will crop
up which will finally explain the text the patient originally came up with. Dif-
ferent visions entail different actions. At best, translating widens the scope of
options of the affected individual and, precedingly, her scope of decision-
making.
Just as translating from other languages is judged successful only if the
hermeneutic depth dimension of a notion has been embraced and con-
veyed, the psychotherapeutic process calls for the same prudence: only if we
have grasped most of the meaning and the content may we adequately inter-
pret psychological occurrences and bestow meaning to them.
The present volume approaches the problem from two different angles:
on the one hand, it is in search of a language that lies 'underneath' the par-
lance of the psychotherapeutic schools, so to speak, and on the other, of one
that lies 'between' them.
'Underneath' the schools means finding a language that is comprehen-
sible to everyone, an Esperanto of psychotherapy, as it were. It is this lan-
guage's most delicate duty to find general acceptance - otherwise it would
not deserve the name 'universal' - by leaving the usual space of interaction
behind and by defining a new one. Its benefit will be a common understand-
ing of basic diagnostic criteria.
The language 'between' psychotherapeutic schools will facilitate a learn-
ing process in reference to differing perspectives and traditions which, for
one part, promotes diversity of descriptions of various diagnostic phenome-
na, thus enriching the other viewpoints, and which, for the other, is apt to
identify the sameness of features which appear different at first sight.
From this perspective, the book on hand provides the basis for psycho-
therapeutic diagnostics to rise from the Procrustean bed 2 of an all too narrow
view, yet without abandoning the essence, the specificity, and the vantage
points each individual school has to offer.
Alfred Pritz
President of the World Council for Psychotherapy
2 From the ancient Greek myth, denoting a situation that tends to produce conformity
by violent or arbitrary means (Random House Webster's Unabridged Dictionary)

European Certificate for Psychotherapy
On a fine evening in June 1995, at the annual conference of the European
Association for Psychotherapy in Zurich, Heiner Bartuska convinced Digby
Tantam and myself that it would be a good idea to create a European Cer-
tificate for Psychotherapy.
It was his vision to have wide ranging discussions with all the national
representatives in the Association in order to arrive at a jointly agreed mini-
mum standard for European Psychotherapy training. Digby and I agreed to
co-chair the committee that was established as a result. Its task was to
come up with the European Certificate of Psychotherapy over the next
years and in the summer of 1997, in Rome, the first draft was agreed by all.
In 1998 in Paris the Certificate was launched and awarded for the first time.
The European Commission commended the ECP as an example of a profes-
sional qualification, capable of recognizing equivalence of standards across
Europe.
The work that went into achieving this agreement was a marvellous,
though also arduous process of collaborative work. It required that each of
the country representatives on the committee, as well as each of the repre-
sentatives of the different modalities of psychotherapy learnt to listen to each
other. We all had to become masterful at compromise and negotiation until
we finally arrived at a jointly agreed document. It was a good example of the
spirit of the European Association for Psychotherapy, which has always stood
for inclusiveness, openness and tolerance on the one hand, and high profes-
sional standards on the other. The common objective was to define, develop
and protect a European wide profession of psychotherapy. This objective
continues to be valid.
It is very telling that after the ECP process was completed Heiner Bartuska
should have gone on to write this book, since this represents the follow-up
to the process of the creation of the European Certificate. Here is a book,
which sets out the fundamental principles of psychotherapy in a systematic
fashion. It fleshes out the standards agreed in ECP with the concrete realities
of psychotherapy training and practice. It aims to remind psychotherapists of

x
Foreword
the need to consider the basic parameters of their trade and formulate these
clearly and explicitly from a trans-theoretical position.
Like with the European Certificate for Psychotherapy: once such a text is
written it seems obvious, but the writing of it can be extremely complex and
problematic. This book should provide an excellent complement to the bare
bones of the ECP. May many generations of trainee therapists benefit from
these structures, which give them access to the profession of psychotherapy,
which we still had to define and consolidate. To have such an edifice to
dwell in should in time allow trainees to feel secure enough within the pro-
fession to dare and be able to challenge it. In that sense it is my hope that
this book will stimulate the generation of new ideas, which in turn will affect
and alter the world of psychotherapy, keeping it in continuous movement.
Emmy van Deurzen

Austrian Federal Association for Psychotherapy
By 1990, psychotherapy had been established as an independent scientific
discipline and treatment modality, regulated by law through the Austrian
Psychotherapy Act (PthG). The definition and the circumscription of psycho-
therapy tie psychotherapeutic practice to a comprehensive, conscious and
planned treatment (91 PthG). The formulation implied that psychotherapists
were obliged as well as authorized to set up diagnoses and indications self-
reliantly and autonomously. The explicit definition reflected an understand-
ing of the psychotherapeutic profession which, by then, the accredited and
old-established schools had partly been implementing for years. They had,
moreover, advanced their lore continuously and taught it in their school-spe-
cific ways.
The discussion and the recurrent controversy as to whether psychothera-
py was an independent science or not, necessitated the elaboration of those
superordinate components which are inherent in all psychotherapeutic mo-
dalities and orientations. The challenge was to find those intermodal and
interdisciplinary factors which could be considered as the core of a specific
psychotherapeutic, science-based form of diagnostics and thus of this par-
ticular profession altogether.
The Research Committee of the Advisory Board for Psychotherapy of the
Federal Ministry of Health and Women's Affairs concerned itself with this
delicate task of elaborating the present Guideline for Psychotherapeutic Dia-
gnostics; it is closely linked to the psychotherapeutic practice and thus ori-
ented towards the Austrian Psychotherapy Act. Clearly and distinctly differ-
ent from the medical-psychiatric and clinical-psychological diagnoses, the
psychotherapeutic ones are described as process-oriented, intrinsic to the
psychotherapeutic procedure and as comprehension- and approximation
processes; these are thought to constantly accompany the therapeutic course
and to appraise the clinical pictures, conditions, or statuses within the frame-
work of psychotherapeutic treatment, as opposed to a diagnostic mode that
classifies and is status-oriented. The Guideline describes the three crucial
pillars on which diagnostic cognition characteristically rests: (1) the 'Symp-

XII
Foreword
toms in Relation to Personality Aspects', (2) the 'Psychotherapeutic Relation-
ship' and (3) the 'Critical Potential'.
Just as the psychotherapeutic procedure itself, the present Guideline is the
result of a joint developmental process within our specification, which will
be by no means terminated when this book is released, nor could it be; it
should be carried further and it will. Basing ourselves on these jointly elabo-
rated and relevant cornerstones, which are so significant for the specific
structuring and the reflection of the psychotherapeutic relationship, it is es-
sential to reconnect these to their methodological conception and to imple-
ment them with the support thereof.
With the compilation and the publication of this book, another important
step will have been taken to firmly anchor psychotherapy in the health care
system and to help establish an emancipative approach towards cognition
and treatment.
All colleagues who have contributed their methodological know-how and
their commitment to the discourse within the Research Committee of the
Advisory Board for Psychotherapy while compiling the Guideline deserve
our sincere recognition. We extend our thanks to those representatives of
orientations who, by their commentaries, have made essential contributions
to the professional discussions of the Guideline, which will, therefore, con-
tinue to be vibrant and open-minded.
For all these reasons, the present book reaches far beyond the sheer pres-
entation of a self-regulating diagnostic approach. It is a demonstration that
the legal foundation of psychotherapy in general and of the school-specific
approaches in particular lays the groundwork for a promising further devel-
opment in Austria and beyond its borders.
Vienna, January 2005
Margret Au/!, President of the OEBVP
Eva Mueckstein, Vice President

Contents
Biographical Notes
XVII
Introduction
Heiner Bartuska, Stefan Wiesnagrotzki: History of the Origin
of Psychotherapeutic Diagnostics
3
1. Diagnostic Guideline for Psychotherapists
Preamble 11
A. Psychotherapeutic Diagnostics 15
A. I. Establishing a Diagnosis 18
1. Symptomatology in Relation to Personality Aspects 18
2. The Psychotherapeutic Relationship 19
3. Risk Level 26
A.II. Indications 28
1. Indications of Psychotherapeutic Treatment 28
2. Indications of Additional Diagnostic Clarification 29
3. Indications of a Specific Psychotherapeutic Treatment Option 29
4. Contraindications 31
B. Psychotherapeutic Guidelines 33
B.1. Guidelines for Establishing a Diagnosis 33
1. Guideline for the Symptomatological Dimension in Relation
to Personality Aspects 33
2. Guideline for the Dimension 'Psychotherapeutic Relationship' 33
3. Guideline for Assessing the Risk Level 35
B.II. Guidelines for Indication 36
1. Guideline for the Indication of Psychotherapeutic Treatment 36
2. Guideline for the Indication of Further Diagnostic Investigation 37

XIV Contents
3. Guideline for the Indication of Specific Psychotherapeutic
Options 37
Appendix 38
Appendix 1: Official Expert Opinion (1991) 38
Appendix 2: Supreme Court Decisions 43
Manfred Buchsbaumer & Eds.: Explanatory Notes and Definitions 47
2. Management and Application of Diagnostics from the Different
Methodological Perspectives
Benedikt Lesniewicz: Analytical Psychology (AP) 59
Franz Sedlak: Autogenic Psychotherapy (A TP) 67
Augustinus Karl Wucherer-Huldenfeld, Hans-Dieter Foerster:
Daseinsanalysis (DA) 73
Friederike Goldmann, Lilli Lehner: Dynamic Group Psychotherapy
(DG) 77
Alfried Langle: The Process of Diagnosis in Existential Analysis (EA) 83
Otmar Wiesmeyr: Existential Analysis and Logotherapy (EL) 91
Gerhard Sternberger: Gestalt Theoretical Psychotherapy (GTP) 97
Hans Kanitschar: Hypnopsychotherapy (HY) 109
Kathleen HolI: I ntegrative Gestalt Psychotherapy (I G) 119
Markus Hochgerner: Concentrative Movement Therapy (CMT) 123
Marianne Martin, Franz Sedlak: Guided Affective Imagery
Psychotherapy (GAl) 129
August Ruhs: Psychoanalysis (PA) 137
Michael Wieser: Psychodrama (PO) 143
Robert Hutterer: Person- and Client-Centered Psychotherapy
(PP & CP) 151
Gerda Mehta: Diagnostic Guidelines for Systemic Family
Therapists (SF). It is Time for Integration 157
Amanda Berghold-Straka: Transactional Diagnosis (T A) 167
Erwin Parfy: Behavior Therapy (BT) 175
3. Diagnostics in Different Professions
Stefan Wiesnagrotzki: Diagnostics in Medicine, Psychiatry, and
Psychosomatics 181
Elisabeth Wagner: Psychotherapeutic Diagnostics in Forensics 185
Anton-Rupert Laireiter: Clinical-Psychological and Psychotherapeutic
Diagnostics 195

Contents
Marion Bauer-Lehrner, Ursula Margreiter: Significance of
Diagnostics for Psychotherapy - A Survey
4. On the Meaning of the Fundamental Terms
Manfred Buchsbaumer: Suffering - Disorder, Illness - Illness Status
Gerhard Pawlowsky: Personality - Personality Structure -
Personality Disorders
Gerhard pawlowsky: Notes on the Psychotherapeutic Relationship
Gerda Mehta: The Psychotherapeutic Relationship - an Explosive
Power in Principle
Heiner Bartuska: Crises and the Risk Potential
Heiner Bartuska: Reflection - Self-Reflection - Self-Awareness
5. Psychotherapeutic Status Based on the Diagnostic Guideline
for Psychotherapists
xv
223
237
241
243
251
263
265
281

Biographical Notes
Aull, Margret, Ph. D.
Psychotherapist (PA), President of the Austrian Federal Association for Psychotherapy
(OEBVP) from May 2000 to June 2007
Bartuska, Heinrich, Ph.D.
Clinical and health psychologist, psychotherapist (DG, GP), ECP, teaching therapist in the
Austrian Association for Group Psychotherapy and Group Dynamics (OEAGG)/dpt Group
Dynamics and Dynamic Group Psychotherapy (DG), member of the Advisory Board of
Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs (BMFG)l
Bauer-Lehmer, Marion, M.Sc.
Clinical and health psychologist, psychotherapist in training under supervision (BT)
Berghold-Straka, Amanda, M.A.
Psychotherapist (TA), teaching therapist in the ARGE TA (consortium for transactional
analysis)
Buchsbaumer, Manfred F., BA.pth.sc.
Psychotherapist (PO); psychotherapeutic consultant: supervisor; member of the Vienna
National (Austrian) Ombudsman Association for Psychotherapy and president of the
alumni-club of the Sigmund Freud Private University; certified in Dance and Movement
Pedagogy
Foerster, Hans-Dieter, M. D.
Psychotherapist (DA), Teaching Therapist for Daseinsanalysis and President of the Aus-
trian Daseinsanalytic Institute for Psychotherapy, Psychosomatics and Basic Research
(ODAI), deputy head of outpatient clinics in the Governing Board for Psychosocial Serv-
ices (PSD) in Vienna, member of the Advisory Board for Psychotherapy in the BMGFJ
(Federal Ministry of Health, Family and Youth)
Goldmann, Friederike, M.A., Ph. 0.
Psychotherapist (DG) and supervisor, teaching therapist and training director for Dynamic
Group Psychotherapy in the Austrian Association for Group Psychotherapy and Group
Dynamics (OEAGG)/dpt Group Dynamics and Dynamic Group Psychotherapy (DG)
1 Since 2007 Austrian Federal Ministry of Health and Women's Affairs and Youth (BMGFJ)

XVIII
Biographical Notes
Hochgemer, Markus, M.5c. (psychosocial counseling)
Psychotherapist (lG, CMT), teaching therapist for Integrative Gestalt Therapy in the Aus-
trian Association for Group Psychotherapy and Group Dynamics (OEAGG)/dpt Integra-
tive Gestalt Therapy (I G) and for Concentrative Movement Therapy in the Austrian As-
sociation for Concentrative Movement Therapy (OEAKBT), member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs
(BMFG)
Hoell, Kathleen, M.A.
Psychotherapist (lG), teaching therapist for Integrative Gestalt Therapy in the Austrian
Association for Group Psychotherapy and Group Dynamics (OEAGG)/dpt Integrative
Gestalt Therapy (lG)
H utterer, Robert, Ph. D.
Associate professor, psychotherapist (PP), teaching therapist of person-centered psycho-
therapy in the Association for Rogerian Psychotherapy (ARP), member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs
(BMFG)
Kanitschar, Hans, Ph.D.
Clinical and health psychologist, psychotherapist (HY, GAl), teaching therapist for hyp-
nopsychotherapy and for Guided Affective Imagery in the Austrian Society for Applied
Depth Psychology and General Psychotherapy (OEGATAP), member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs
(BMFG)
Laireiter, Anton-Rupert, Ph.D.
Associate professor, clinical and health psychologist, psychotherapist (BT), teaching ther-
apist for Behavioral Therapy in the Group for Behavioral Modification (AVM), member of
the Advisory Board of Psychotherapy in the Austrian Federal Ministry of Health and
Women's Affairs (BMFG)
Uingle, Alfried, M.D., Ph. D.
Clinical and health psychologist, psychotherapist (EA), psychotherapy trainer in the
Society of Logotherapy and Existential Analysis, Vienna (GLE), vice president of the Inter-
national Federation of Psychotherapy (I FP), president of the International Society of
Logotherapy and Existential Analysis, Vienna (GLE-International)
Lehner, Lilli
Psychotherapist (DG), teaching therapist in the Austrian Association for Group Psycho-
therapy and Group Dynamics (OEAGG)/dpt Group Dynamics and Dynamic Group
Psychotherapy (DG)
Lesniewicz, Benedikt
Psychotherapist (AP), training analyst in the Austrian Society for Analytical Psychology
(OEGAP)
Margreiter, Ursula, Ph.D.
Clinical and health psychologist, psychotherapist (DG, CP, PD), teaching therapist in
the Austrian Association for Group Psychotherapy and Group Dynamics (OEAGG)/dpt
Group Dynamics and Dynamic Group Psychotherapy (DG), mediator, research director
of the propaedeutic curriculum in the OEAGG, member of the Advisory Board of Psy-
chotherapy in the Austrian Federal Ministry of Health and Women's Affairs (BMFG)

Biographical Notes
XIX
Martin, Marianne, Ph. D.
Clinical and health psychologist, psychotherapist (ATP, HY, GAl), teaching therapist for
Guided Affective Imagery Psychotherapy in the Austrian Society for Applied Depth Psy-
chology and General Psychotherapy (OEGATAP), coopted research director of the ad-
vanced training curricula in medical hypnosis and communication, vice president of the
International Society of Research and Education in Communication-Cooperation-Liai-
son-Strategies (lSOREC)
Mehta, Gerda, Ph. D.
Clinical and health psychologist, systemic family therapist (SF), teaching therapist for
systemic family therapy at the Austrian Society for Systemic Therapy and Studies (OEAS),
lecturer at the Sigmund Freud University, ARGE Bildungsmanagement (i.e., study group
for the management of educational affairs). Mediator. Member of the Advisory Board of
psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs (BMFG)
Muckstein, Eva, Ph.D.
Clinical and health psychologist, psychotherapist (PP), former vice president, now presi-
dent of the Austrian Federal Association for Psychotherapy (OEBVP)
Parfy, Erwin, M.A., Ph.D.
Clinical psychologist, psychotherapist (BT), board member and teaching therapist for
Behavior Therapy in the Austrian Association for Behavior Therapy (OGVT), member of
the Advisory Board of Psychotherapy in the Austrian Federal Ministry of Health and
Women's Affairs (BMFG)
pawlowsky, Gerhard, Ph. 0-
Clinical and health psychologist, psychotherapist (PA, PP), teacher and supervisor in the
Association for Rogerian Psychotherapy (ARP) and teacher and training analyst in the
Viennese Circle for Psychoanalysis and Selfpsychology (WKPS), member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health, Family and Youth
(BMGFJ)
Pritz, Alfred, Ph. D.
University professor, rector of the Sigmund Freud Private University Vienna, Psycho-
therapist (ATP,DG,GP,CP,PA), teaching therapist for group psychoanalysis in the Austrian
Association for Group Psychotherapy and Group Dynamics (OEAGG)/dpt Group Psy-
choanalysis (GP), president of the World Council for Psychotherapy
Ruhs, August, M. D.
University professor, teaching at the Medical University Hospital, department for Depth
Psychology and Psychotherapy, psychiatrist and neurologist, psychotherapist (GP, PA,
PD), training analyst (PA) in the Viennese Association for Psychoanalysis (WAP), teaching
therapist for Psychodrama and Group Psychoanalysis in the Austrian Association for
Group Psychotherapy and Group Dynamics (OEAGG)/dpt Psychodrama, Sociometry
and Role Play (PD) and Group Psychoanalysis (GP), deputy director of the University
Clinic, department for Depth Psychology and Psychotherapy, member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs
(BMFG)
Sedlak, Franz, M. Th., Th. 0., Ph. D.
Ministerialrat [head of division V/4 - school psychology - education counseling & psy-
chological student counseling in the Austrian Federal Ministry of Education, Arts, and
Culture (BMBWK)], studied theology, psychology and sociology; qualified as clinical and

xx
Biographical Notes
health psychologist and psychotherapist (ATP, EL, IP, GAl, Cp, BT), teaching therapist for
Autogenic Psychotherapy and Guided Affective Imagery Psychotherapy in the Austrian
Society for Applied Depth Psychology and General Psychotherapy (OEGATAP), super-
visor
Stemberger, Gerhard, Ph. D.
Psychotherapist (GTP), teaching therapist for Gestalt Theoretical Psychotherapy in the
Austrian Association for Gestalt Theoretical Psychotherapy (OEAGP); representative for
psychotherapy and health sciences of the Vienna Chamber of Labor, chairman of the
International Society for Gestalt Theory and its Applications (GTA), executive editor of
"Gestalt Theory - An International Multidisciplinary Journal", member of the Advisory
Board of Psychotherapy in the Austrian Federal Ministry of Health and Women's Affairs
(BMFG)
van Deurzen, Emmy, M.A., M.Psy., Ph.D.
Prof., FBPSs, FBACP, UKCP and ECP member. Director of Dilemma Consultancy Ltd.,
director of NSPC-London, co-director of the Center for Study of Conflict and Reconcili-
ation at the University of Sheffield
Wagner, Elisabeth, M.D.
Psychiatrist and neurologist, psychotherapist (SF), presently qualifying as a teaching
therapist at the School of Systemic Family Therapy, psychiatric director of the penal in-
stitution at Favoriten, Vienna
Wieser, Michael, M.A., Ph. D.
Assistant professor, teaching in the Department of Psychology of the University of Kla-
genfurt, Austria, psychotherapist (PO), teaching therapist with a partial teaching authority,
research coordinator for psychodrama in the Austrian Association for Group Psycho-
therapy and Group Dynamics (OEAGG)/dpt Psychodrama Sociometry and Role Play
(PD), respondent of the Advisory Board of Psychotherapy in the Austrian Federal Minis-
try of Health and Women's Affairs (BMFG), subeditor of the journal 'Psychotherapie
Forum', Chair of Research Committee and council member within FEPTO (Federation of
European Psychodrama Training Organizations), coordinator of the psychodrama re-
search group in IAGP (International Association of Group Therapy)
Wiesmeyr, Otmar, Ph. D.
Clinical and health psychologist, psychotherapist, teaching therapist and chairman of the
Austrian Training Institute for Logotherapy and Existential Analysis (ABILE), acting mem-
ber of the Psychotherapy Committee of the Federal Ministry of Health and Women's
Affairs in Austria
Wiesnagrotzki, Stefan, M.o.
Assistant professor, medical specialist in psychiatry and psychotherapy, member of the
Advisory Board of Psychotherapy in the Austrian Federal Ministry of Health and Wom-
en's Affairs (BMFGJ), email: stefan.wiesnagrotzki@meduniwien.ac.at
Wucherer-Huldenfeld, Augustinus Karl, Ph.D.
Habilitated as university lecturer at the philosophical faculty of the University of Vienna,
was professor in ordinary of philosophy and member of the governing board of the Insti-
tute for Philosophy at Vienna University from 1974 to 1997, from 1990 to 2002 President
of the Austrian Society for Daseinsanalysis (OGDA), and from 1997 to 2001 President of
the Ferdinand-Ebner-Society

Introduction

History of the Origin of Psychotherapeutic
Diagnostics
HEINER BARTUSKA, STEFAN WIESNAGROTZKI
A few months after the Psychotherapy Act (PthG 1990) had taken effect in
Austria, Le., on January 1, 1991, and with the beginning discussions on cost
absorption for psychotherapy by the health insurance scheme, the Medical
Association released a public bulletin asserting that, as per the PthG 1990,
psychotherapists were incapable of diagnosing, since this skill was not men-
tioned in the Psychotherapy Act. For this reason, all patients needed to be
diagnosed by medical doctors first, before being referred to psychothera-
pists. Thus, psychotherapists, like physiotherapists or nurses, depended on
an accurate medical order and on referral (delegation principle). This contra-
venes 9 14 para 2 of PthG, which, at the most, provides for the collaboration
with representatives of other sciences (cooperation principle).
That attitude towards psychotherapy was by no means novel, but another
version of the opinion held by the Medical Association, who claimed that it
was the medical doctors only who were entitled to practice psychotherapy.
Even before the PthG 1990 had come into force, this opinion had neither
been a legal nor an observable fact (Freud, S., The Question of Lay-Analy-
sis, 1927; this article had led to the acquittal of Theodor Reik in 1927; 1987,
in an unpublished legal opinion, T. Oehlinger discussed the issue of who
was entitled to practice psychotherapy in Austria, submitting a rationale
why psychologists were more entitled to do so than physicians). Between
1980 and 1990, legal action was taken against 3 psychologists for "quack-
ery", pursuant to 9 184 of StGB (penal code), for having practiced psycho-
therapy. The three of them were, however, acquitted without reservation. In
1984, therapeutic activity was adjudicated to psychologists as a legal real-
ity, and, in virtue of this, they were privileged by the Purchase Tax Act. In

4
Heiner Bartuska, Stefan Wiesnagrotzki
1988, Jandl-Jager and Stumm supplied evidence that 80% of the psycho-
therapeutic service in Austria was not being performed by medical doctors
but by individuals whose primal profession was that of a psychologist,
educator, social worker, or of others before they had been trained psycho-
therapists.
Various expert opinions (see Strotzka & Schindler in the appendix) as well as
the book published 1994 "Psychotherapie - eine neue Wissenschaft vom
Menschen" - Psychotherapy, a New Science of Humans, edited by A. Pritz,
on one hand submitted rationales which supported the independent scien-
tific status of psychotherapy (thus the definition of psychotherapy in the
Psychotherapy Act, 1990), whereas on the other, they criticized the lack of
definitions and basic principles to constitute an independent psychothera-
peutic diagnostic discipline. This criticism referred to a diagnostic system
which was common to all psychotherapeutic schools. With this insufficiency
persisting, psychotherapy could not yet be fully recognized as an independ-
ent science or profession. If psychotherapists were not able to declare, by
which criteria they established their professional assessments, how could
they, under such circumstances, be acknowledged as an independent
trade?
In 1999, the diagnostic competence of psychological psychotherapists was
formulated explicitly in Germany, but this did not include a definition nor a
description of the specifically psychotherapeutic way of diagnosing.
With these legal resolutions, the daily practice of psychotherapists has wit-
nessed some change insofar, as a diagnosis had become legally mandatory
in Austria when, as from January 1, 1992, the health insurance scheme was
ready to (partly) bear treatment expenses. This led to an area-wide usage of
the psychiatric classification of diseases (lCD 9), and of ICD 10 later (from
2002 onwards). This diagnostic system is still relied on today, and there psy-
chotherapists are involved in handling diagnostic issues to a certain degree,
but they still express a great deal of dissatisfaction with the ICD 10's inade-
quacy, when used for psychotherapeutic purposes, and with the small
amount of autonomy conceded to them. This shortcoming is aggravated by
the fact that there is a complex variety of psychotherapeutic methods with
an even vaster variety of terminologies and cultures, which has assumed
Babylonian proportions. As far as diagnostics is concerned, up to this day
there is no common language, nor a common fundamental concept. At this
stage, we need to commemorate that psychotherapy, particularly its manifold
methodological subdivisions and schools, has grown from different roots
such as medical science, psychology, education science, philosophy, social
work, and theology.

History of the Origin of Psychotherapeutic Diagnostics
5
The increasing recognition of relevant commonalities led to the founding
resolution of psychotherapy (by the Umbrella Organization of Psychothera-
peutic Associations of Austria, a process commenced around 1982). Origi-
nally, psychoanalysis, which emerged around 1900, used to be considered a
branch of medical science, whereas behavioral therapy (dating back to about
1920) rooted in academic psychology, and Gestalt therapy in the 19 th cen-
tury Gestalt psychology.
For all these reasons from 1992 onwards, a number of representatives of
psychotherapy have concerned themselves with the elaboration of a com-
mon basis for psychotherapeutic diagnostics, so that psychotherapy would
eventually be acknowledged as an independent science. In the first stage
and for many years, however, other issues were more prominent: the joint
elaboration of criteria of how psychotherapy trainings as well as their training
institutions would stand the test of scienctificality; the discussion of the
equivalence of training modules and an adequate crediting system; common
guidelines for supervision and for expert opinions to be furnished by psycho-
therapists. Because of these priorities, it was not before 1999, that the issue
of psychotherapeutic diagnostics could be duly attended to.
The Various Participating Psychotherapeutic Methods and
Professional Fields
The extraordinary situation of the study group, who had come forward with
the definitions, the basic principles and the descriptions as well as the expert
guidelines for psychotherapeutic diagnostics, can be guessed by the fact that
the representatives of various psychotherapeutic methods and schools, and
those from various professional domains had been working at it continu-
ously for more than 62 three-hour sessions. Representatives of psychoanaly-
sis, client-centered therapy, behavioral therapy, systemic family therapy, ge-
stalt, dynamic group psychotherapy, and psychodrama have been working
together. The different professional fields were: private practices, psychoso-
matic hospitals, psychiatric wards, universities, public welfare agents, pro-
paedeutic training institutions, professional associations of psychotherapists,
of psychologists, and the Austrian Federation of Trade Unions (Gewerk-
schaftsbund) as well as representatives of the competent Austrian Federal
Ministry (of Health and Women's Issues).
It is by the participation and representation of this variety of professional
fields that we successfully realized our idea of developing a language com-
mon to all psychotherapeutic schools, at least where basic principles of
psychotherapeutic diagnostics were concerned.

6
Heiner Bartuska, Stefan Wiesnagrotzki
Conflicting Theories and Metaphors
The beginning of this was overshadowed by conflictual phantasies, one of
them being that the way was being paved for the predominance of one
method over another, or for the introduction of a uniformed version of psy-
chotherapy, or that psychotherapists would coercively be disciplined to one
meter. There were fears that, with this discussion of a psychotherapeutic di-
agnostic system, the independence of diagnostic considerations and diagnos-
tic systems, evolved by the traditions of the various psychotherapeutic
schools, was at stake, and that their scientific, terminological, and cultural
development was in danger.
Initially, these phantasms dominated the scene, to the extent that a sense of
competitiveness prevailed over cooperativeness for many work sessions. Be-
cause of this trying start, the motives of the participants of this study group
needed to be reflected on. In so doing, the collaboration became more flu-
ent and its quality improved.
As for the methodological procedure, a record was submitted to the partici-
pants, which led to an accurate examination and reformulation of the text
worked out thitherto. Each draft was revised, discussed, and queried many
times. Many formulations have been abridged or discarded before this present
condensed text withstood their own critical discussion and examination.
It goes without saying that the study group had to evolve their own work
style also as to the substance of the work. Inter alia this consisted in the us-
age of new metaphors, alienations, and practical case studies, which were
drawn from various professional fields. Thus, a creative and appreciative
style of discussion evolved.
There were many occasions when participants did not fully grasp the mean-
ings or the implications which other group members insinuated when using
their method-specific terms. They could be substantiated by the use of exam-
ples only. In so doing, concepts and their implications underwent redefini-
tions for their first time ever.
Other method-specific notions were altered and extended to become appli-
cable and acceptable to all psychotherapeutic methods. Neologisms, the
general usage of language, and the avoidance of established method-related
expressions allowed for an equitable use of language in diagnostics and pre-
cluded the predominance of one method over others.
One key conflict revolved around the idea that diagnostic reflections were
inappropriate or even detrimental to the therapeutic process and would lead

History of the Origin of Psychotherapeutic Diagnostics
7
to the misuse of power. This risk of misuse was held so important that some
individuals seriously argued, diagnostic considerations should not be under-
taken at all. The opinion was that they were inappropriate in the psychothera-
peutic process because of their ill effect on the patient, given her limited ca-
pacity, caused by her ill condition and her specific developmental state.
In the first stage, no distinction was made whether (or not) the diagnostic
thoughts existed in the psychotherapist's mind only and were withheld, or
expressed in her personal notes only, or were, at best, discussed in supervision.
In this present piece of work, we supply evidence that a carefully reflected
psychotherapeutic diagnostic system is a contribution to the quality standard.
A construct which turned out to be rewarding in the discussion was the meta-
phor of the architect who, depending on his work approach, preferably uses
particular materials and structuring processes but, to an equal extent, has to
consider statics also (stability, carrying capacity and resilience), the details of
which are not communicated to the building owner. Only then will these issues
be discussed explicitly, when, because of special requests of the building
owner, the necessity of discussing this carrying capacity arises, and this is done
with or without the help of a specific stress analyst. Psychotherapists and their
diagnostic thoughts are comparable to this process. Their considerations in-
clude presumptive causes and the previous damage which has constricted the
patient's scope of acting freely. The stability, the stress tolerance and the lee-
way of resources, which is to be expanded (alternatives of acting and experi-
encing, spontaneity and flexibility) have to be assessed simultaneously.
The phantasm of an intended uniformed psychotherapeutic hotchpotch
which would level or planate the method-specific designs of therapeutic
processes and thus ease the way for one training institution to seize the pre-
ponderance over others, has been debated in numberless discussions.
This and other allegations have been made against the initiators of the
study group. One of them was that certain individuals were out for their per-
sonal position of power. Representatives of various methodological institu-
tions voiced their concerns that they were risking to be sabotaged or de-
stroyed, or that their terms were being alienated from them, that others would
incorporate them into their systems and pass them off as their own intellec-
tual property. Despite all difficulties, these imputations turned out to be enor-
mously fruitful as they made the study group immerse in the terminological
riches of psychoanalysis, behavioral therapy, systemic therapy, etc., in order
to find notions which were compatible with all psychotherapeutic schools.
Another apprehension was that the social insurance companies could resort
to one existing diagnostic system and that they, by relying on this informa-

8
Heiner Bartuska, Stefan Wiesnagrotzki
tion, might favor one method to the detriment of others. This and other is-
sues had to be considered continuously during the revision of the text, to
safeguard a reasonable preservation of the manifold possibilities of diagnos-
tic usage, within the framework of collaboration with the social insurance
companies, as it is wished to be.
Furthermore, the question of how other professional groups, particularly
physicians and psychologists would accept the psychotherapeutic diagnostic
system, was discussed and used as a touch-stone. It would not have made
sense to include issues in the psychotherapeutic diagnostic discipline which
had already been developed and applied within medical, psychiatric, or
clinical-psychological diagnostics. Nevertheless the necessity arose, and very
clearly so, that psychotherapists, if (and when) they apply the medical diag-
nostic classification of ICD at all, had to define, by which principles and in
which way they were doing so. It was the study group's major task to accu-
rately describe in which areas the psychotherapist contributed to a compe-
tent diagnosis of mental illnesses, as defined by the lCD, and where, more
importantly, the psychotherapists' own authority of establishing psychothera-
peutic diagnoses was.
The study group members frequently uttered their doubts whether an inde-
pendent psychotherapeutic diagnostic system could be envisioned at all. With
the elaboration and the contents progressing, these doubts lost momentum.
The applicability of the diagnostic guidelines, particularly of their summary,
was checked and evaluated by the members of the study group under prac-
tice conditions.
One last question was the teachability of psychotherapeutic diagnostics. This
question also withstood critical examination.
References
Freud S (1927) Die Frage der Laienanalyse. In: Studienausgabe, Erganzungsband: Schriften
zur Behandlungstechnik (1982). Fischer, Frankfurt a. M.
Jandl-Jager E, Stumm G (eds) (1988) Psychotherapie in Osterreich. Deuticke, Vienna
Pritz A (ed) (1996) Psychotherapie, eine neue Wissenschaft vom Menschen. Springer,
Vienna
Kierein M, Pritz A, Sonnek G (1991) Psychologengesetz, Psychotherapiegesetz, Kurz-
kommentar. Orac, Vienna
Translated from the German by Luna Gertrud Steiner

1. Diagnostic Guideline for Psychotherapists
Provided by the Federal Ministry of Health and Women's Affairs
on the Basis of an Expert Opinion
by the Advisory Board for Psychotherapy
15 June 2004
Definitions and Guidelines
for Psychotherapeutic Diagnostics

Preamble
Per resolution of the Advisory Board (AB) in its 44th plenary session (8 June
1999), the Board's Research Committee was consigned to elaborate guide-
lines for psychotherapeutic diagnostics in practice (in the following referred
to as 'psychotherapeutic diagnostics').
Research Committee Assignment
The Research Committee specified the assignment and abstracted the fol-
lowing questions:
- Is there an independent psychotherapeutic diagnostics and if so, how can
it be conceptualized?
Which diagnostic guidelines do practicing psychotherapists A in Austria
abide by, regardless of their specific methodological affiliation, when es-
tablishing an indication' of illness treatment, scilicet of behavioral disor-
ders or of suffering, as per para 1 in 9 1, Psychotherapy Act, Federal Law
Gazette (BGBI.) no. 361/1990 (PthG)?
Which diagnostic guidelines do Austrian psychotherapists abide by, re-
gardless of their specific methodological affiliation, when treating an ill-
ness, scilicet behavioral disorders or suffering, as per para 1 in 9 1, Psy-
chotherapy Act (PthG)?
Which further action is recommended on the basis of the present draft
guideline, concerning psychotherapeutic diagnostics under practice con-
ditions?
Preliminary Notes on Psychotherapeutic Diagnostics
Acting on the basis of the psychiatric classifications of diseases such as the
ICD 10 (International Classification of Diseases, 10 th revision) or similar sys-
A Unless otherwise noted, we mostly use neutral or feminine gender endings and pro-
nouns throughout the text, always understanding the male gender as encompassed.
1 Refer to 'Explanatory Notes and Definitions', p. 47.

12
Diagnostic Guideline for Psychotherapists
tems allows for a description of patients and clients who are engaged in psy-
chotherapy; medical or clinical-psychological diagnostic investigation may
be indicated with some individuals and be of either major or minor relevance
to the psychotherapeutic treatment, the different diagnostic systems always
referring to different aspects of the psychic and the physical state.
According to the Research Committee, additional psychotherapeutic di-
agnostic guidelines are necessary for the psychotherapists to formulate an
appropriate state-of-the-art 2 diagnosis necessary for the treatment of clients
and patients as well as for the efficacy of this treatment in the patients' lives.
On the one hand, the diagnostic procedure is seen as a prerequisite for a
successful implementation of the psychotherapeutic process, while on the
other, the diagnosis will be operant throughout the whole psychotherapeutic
process. 3 The psychotherapeutic diagnostic process practically parallels and
accompanies the complete psychotherapeutic treatment process. The guide-
lines developed herein will flow into the pertinent psychotherapeutic diag-
nostic process and bring to bear their influence, constituting parameters,
which are at work continuously, and which have to be considered without
respite.
In developing standards for a specific psychotherapeutic diagnostics, we
do not nurture claims of omnipotence 4 over the method-bound diagnostic
systems, nor do we attempt to formulate an explicit unitary diagnostic sys-
tem. 5
We value the copiousness and the diversity of diagnostic approaches of
the various psychotherapeutic schools. The variety will do justice to the pa-
tients' manifold ideas of wo/man, 6 to their understanding of psychogenesis?,
to their targets of treatment, etc., much more so than if we endeavored to
construe a uniform terminology. Consequently, the members of the Research
Committee have committed themselves to encouraging each psychothera-
peutic school to abide by its abundance of diagnoses and their therapeutic
language.
It was the Research Committee's goal to draw up guidelines for stating
psychotherapeutic diagnoses under practice conditions, as they are stipulat-
ed in the Austrian Psychotherapy Act (PthG). The phrasing of this goal is to
be understood as a renouncement of those rather exaggerative ideas that
there could be universal answers to psychotherapeutic issues, regardless of
national contexts and the attendant legal and sociocultural parameters.
The present draft is less an outcome of empirical or methodological re-
search than a condensed pragmatic guide. 8 This is in accordance with the
task which the Advisory Board has consigned to the Research Committee, that
is to formulate guidelines for a specific psychotherapeutic diagnostic practice,
as they are already adhered to by practicing Austrian psychotherapists.
To establish a specific indication of psychotherapy, the development of a
method-specific psychotherapeutic diagnosis is required. This includes the

Preamble
13
indication of cooperation with other professionals as well as differential indi-
cation. This entails the need to answer the following questions:
_ whether a psychotherapeutic treatment is indicated with a given patient,
- whether, subsequently, complementary medical, psychiatric and/or clini-
cal-psychological diagnostic clarification is indicated, and
- which psychotherapeutic treatment (psychotherapist, method, setting) is
indicated. 9
Further on, guidelines for psychotherapeutic diagnostics in the context of the
treatment of disorders which are classifiable as diseaseB (understood as be-
havioral disorders and suffering, cpo 9 1 leg. cit.) are explicated.
These guidelines were discussed within the Research Committee and
elaborated by consensus; they are based on the diagnostic experience of
psychotherapists, who are beholden to the terms of either depth-psychologi-
cal-hermeneutic, humanistic, systemic-constructivist or behavior-oriented
approaches. lO
Subsequent to the guidelines for psychotherapeutic diagnostics, the meth-
od-specific psychotherapeutic diagnostic practice 11 will be elucidated.
We, firstly, understand psychotherapeutic diagnostics as a process of dis-
covery.12 In an interactive process between one or more clients, or one or
more psychotherapists, the material emerging on the level of language, emo-
tions, cognitions, and behavior is arranged in descriptive verbal patterns. 13
Consequently, this process of disclosure does not allow to pin-point accurate
prognoses; it may give clues, however, as to the possible development of
such patterns.
We, secondly understand psychotherapeutic diagnostics as an informa-
tion system which, in cooperation with other psychotherapeutic professions
and irrespective of their methodological training and/or other professional
qualifications (i.e., psychotherapists adhering to different approaches or
methods, psychotherapeutically trained medical doctors, psychologists, so-
cial workers, educators, physiotherapists, etc.), offers access to the knowl-
edge of other providers of psychotherapeutic services in illness treatment;
thus, clients, patients, family members, health insurance companies, and
others requesting information on psychotherapeutic services are offered ori-
entation and information. 14
B The German text used the primarily legal terms 'illness' and 'disorder classifiable as
disease'; the latter, being more suitable for psychotherapeutic matters, was defined
anew along psychotherapeutic lines. The 'disorder classifiable as disease' or 'disorder
qualifying as disease' signifies the pathogenic moment as well as the effect thereof in
the sense of an abiding impairment or a deterioration of psychological functions, thus
capturing the meaning of the English word 'disorder' (rather than disturbance), which
had been referred to in the footnote of the German text.

14
Diagnostic Guideline for Psychotherapists
Assumptions of the Research Committee
In elaborating a psychotherapeutic diagnostic system which meets scientific
standards, the findings of other sciences have to be accounted for, particu-
larly the science-theoretic claims of explicit hypotheses, of transparency, and
plausibility (of medical science as to proven findings on disease treatment; of
biology as to biological fundaments; of sociology and psychology as to find-
ings on emotional experience, behavior, development, and the coexistence
of humans; of jurisprudence as to their legal handling of such concepts as
disorder, illness, and illness status or 'valence f15 ).
A psychotherapeutic diagnostic system has to be elaborated as a funda-
ment for the diagnostic practice, as a common basis and point of departure
for the application of method-related diagnostic systems. 16
The psychotherapeutic-diagnostic guidelines should be applicable to psy-
chotherapy in disease treatment, as well as in those areas of psychotherapy
which do not serve the treatment of diseases (couple therapy, facilitation of
development, personal growth, etc.).

A. Psychotherapeutic Diagnostics
Legal Foundation and Definition
The necessity to elaborate a diagnostic system which meets scientific stand-
ards arises from the basic requirements any science has to conform to. A
science cannot be (fully) acknowledged as such, if it lacks clear definitions
and criteria for diagnostic handling, that is, for the specific methodological
assessment of a circumstance, carried out by the holder of a specific profes-
sional qualification. Up to the present day, individual methods have been
using diagnostic systems, which were rather diverse in certain parts, a uni-
versal or global psychotherapeutic diagnostic system that encompasses those
is, however, missing.
The psychotherapists' duty to unfold an independent and responsible di-
agnostic activity is derived from the definition and the delineation of psycho-
therapy as a profession from 9 1 Psychotherapy Act, Federal Law Gazette
(BGBI.) no. 361/1990:
'/The practice of psychotherapy as per this Federal Act is acquired by a
general as well as a specific training in a certain method; it is the comprehen-
sive, conscious, and planned treatment of psychosocial or else psychoso-
matically caused behavioral disorders and of suffering, by scientific-psycho-
therapeutic methods, with one or more treatees interacting with one or more
psychotherapists, with the objective of reducing or removing extant symp-
toms, changing disordered behaviors and attitudes, and fostering the treatee's
maturation, development, and health."
The imposition of offering and conducting a comprehensive form of treat-
ment particularly entails the psychotherapist's authorization and obligation to
establish dear diagnoses.
In the Expert Opinion which Schindler and Strotzka had been commis-
sioned to submit to the former Austrian Federal Ministry of Social Security
and Generations on the issue of the independent diagnostic practice by psy-

16
Diagnostic Guideline for Psychotherapists
chotherapists, the experts assert that the comprehensive treatment has to be
carried out in a 'conscious' and 'planned' manner.
//Hence, this expert opinion points out that, by the legislator's will, the
psychotherapist has to undertake a planning process and this task is under-
stood as inherent in the treatment (see Appendix 1).
Psychotherapeutic diagnostics is an inherent constituent of the psycho-
therapeutic treatment. The diagnosis itself is understood as a snapshot within
a diagnostic process, which has to be perceived and assessed according to
the degree of differentiation. In any case, we distinguish between initial, pro-
cedural and concluding diagnoses.
Achieving psychotherapeutic diagnostic clarification is also suppositional
in the Austrian Social Insurance Law (ASVG). 3 120 of the Social Insurance
Law (ASVG), para. 1, regulates the occurrence of the event insured as fol-
lows.
3 120. (1) Occurrence of event insured:
1. The insured event of an illness occurs with the onset of this illness, that is
of an irregular physical or mental condition necessitating treatment; 17
The wording /irregular mental condition' refers to the identification of ill-
nesses including emotional disorders of illness status."
Motives for Classification
For every patient, usually more than one and up to three or four diagnoses
may be established, depending on the following classification motives:
- Administration: 18 for administrative purposes the systems currently in use
are absolutely sufficient;
- Psychotherapeutic practice: within the framework of the specific thera-
peutic schools, different diagnostic systems have been elaborated; these
are considered to be sufficient for the therapeutic practice. From this
point of view, the development of universal criteria seems unnecessary;
- Communication with affiliated professions: we deem it necessary to make
the process of psychotherapeutic diagnostics transparent and plausible,
particularly to patients, other health professionals, and the public;
- Psychotherapy research: research is preoccupied with finding a common
terminology and a common fundament including distinctions based
thereupon. In this context we point to the above mentioned Expert Opin-
ion, furnished by Schindler and Strotzka.
- Legal, national, and international rulings: at this point we quote the ex-
plicit reference within the German Psychotherapist Act (1999) to the diag-

psychotherapeutic Diagnostics
17
nostic practice undertaken by psychotherapists (as per 9 1 para. 3 Ger-
man Psychotherapist Act, the practice of psychotherapy is ... every action
taken by means of scientifically recognized psychotherapeutic proce-
dures, targeted towards identifying, healing or alleviating disorders of dis-
ease valence, in which psychotherapy is indicated; ... the practice of
psychotherapy does not include psychological activities targeted towards
coming to terms with or overcoming social conflicts or towards other than
curative purposes).
Definition of Mental Disorders of Disease Status
Mental disorders that qualify as diseases are psychosocially or else psycho-
somatically caused behavioral disorders and afflictions (9 1 para. 1 PthG).
They are understood also as an individual's coping endeavors, undertaken
by inadequate means. 19
Definition of the Object of Psychotherapeutic Diagnostics
The object of psychotherapeutic diagnostics is the identification of psycho-
pathological conditions in the sense of subjective suffering of one or more
individuals, under particular cultural and societal norms as well as economic
conditions.
In this context, further sets of rules 20 are of no lesser relevance, namely
those which are, explicitly or implicitly, incorporated in diagnostic clarifica-
tion.
It is essential for the psychotherapeutic diagnosis to be linked to the sub-
jectivity of experiencing and suffering,21 whereas in the medical field the
detection of irregularities is primarily bound to objective criteria.
Definition of Diagnostics
Psychotherapeutic diagnostics is a procedure, during which the following
dimensions 22 of ongoing mutual influence are reflected upon and estimat-
ed:
I. Establishing a Psychotherapeutic Diagnosis
1. Symptomatology in Relation to Personality Aspects
2. Psychotherapeutic Relationship
3. Risk Level
:'/JA.S/.U1YKOVA UNIVfJUJTA
:;'akvi.iE socia!nkh studii --
. GSinva HJ
;(i m \:. P N G <i)

18
Diagnostic Guideline for Psychotherapists
The process of diagnosing results in the indication: 23
II. Psychotherapeutic Indications
1. Indications of Psychotherapeutic Treatment
2. Indications of Further Diagnostic Clarification such as Medical Psychiat-
ric, and/orClinical-Psychological or other Clarifications;
3. Indications of a Specific Psychotherapeutic Method;
4. Contraindications
A. I. Establishing a Diagnosis
The three constituents of a psychotherapeutic diagnosis are:
1. Symptomatology in Relation to Personality Aspects
2. Psychotherapeutic Relationship
3. Risk Level
1. Symptomatology in Relation to Personality Aspects
Psychotherapists classify the dimension of the symptoms in dispute by means
of ICD 10 (International Classification of Diseases, 10 th revision). For classifi-
cation, they can also draw on psychiatric or psychological diagnostic proce-
dures, the results of which may either be at hand or must be requested.
Furthermore, we find significant differences in categorization because of
the variety of psychotherapeutic methods; each scientifically recognized
methodological approach defines 'personality', above all, in its specific way,
be it as a structure, a style, a dynamics, a system, etc. These aspects are
given more or less momentum in the pertinent treatment models.
Over the last years, the phenomenon of co-morbidity has increasingly
been discussed. This term denotes the diagnosis of several simultaneous dis-
turbances, which is found far more often than we would assume at first sight.
In the context of the diagnostic dimension 'Symptoms in Relation to Person-
ality Aspects', we place special emphasis on the lCD's possibilities of diag-
nosing co-morbidities between circumscribed symptom complexes 24 and the
so-called personality disorders.
We consider it beneficial to diagnose explicit personality disorders more
accurately than it has been done so far, in order to trace co-morbidities; we
should, however, tap the full potential of the different schools or modalities
to give diagnostic descriptions of personality characteristics and the corre-
sponding modes of interaction.

psychotherapeutic Diagnostics
19
Additional emphasis on a specific personality structure with merely mon-
osymptomatically25 diagnosed disorders, as it has been practiced to this day,
is regarded indispensable for the psychotherapeutic diagnoses presently un-
der discussion. For this purpose, it is not with explicit personality disorders
only, but also with affective disorders, psychoses, addictive behavior, that we
have to establish an accurate personality diagnosis,26 which is based on dif-
ferential diagnostic criteria. This opens up a number of approaches for psy-
chotherapeutic treatment.
The ICD assesses the degrees of severity within several categories of dis-
orders. We hold this assessment generally necessary, even for those clinical
pictures for which this kind of assessment has not been explicitly provided
for.
The rating in use, ranging from slight via medium to severe, is regarded as
sufficient for clinical purposes, a more accurate description of the qualities
and the degree of severity would, however, be advisable.
In addition, it is vital for the individual treatment scheme to assess the
degree of risk level (see no. 3. Risk level), which is the extent of existential
endangerment. 27 It is quite possible that a major existential crisis may emerge
even from a lesser degree of disturbance, and vice versa. Consequently, it is
a psychotherapeutic issue to set one's priorities of treatment and setting ac-
cordingly.
2. The Psychotherapeutic Relationship
The human being is born into a network of social relations, which she needs
for her development to varying degrees, depending on the phase she is cur-
rently going through. Adequate relational experiences 28 are vital. Inadequate
responding can have adverse effects and lead to symptoms and disturbances
within both, a supportive or a strenuous environment.
To correctly assess the patient-psychotherapist 'relationship' which real-
izes itself on many levels in its interpersonal as well as in its intersubjective
dimensions is defined as the psychotherapist's diagnostic core competence
par excellence.
Those phenomena of the relationship which ease the way to diagnosis are
extensively described in all methodological approaches (as transference, as
actualization of relationship formulae, as relationship patterns, and others).
The mutually realized relationship emerges from a reflective, planned,
and creatively adjusted manner of relating on the psychotherapist's part, and,
on the patient's part, from the very personal relational cues she reveals dur-
ing contacting.
Psychotherapists go through a number of relationship experiences during
their training, and these are reflected upon under the guidance of their train-

20
Diagnostic Guideline for Psychotherapists
ing therapists. This aspect of the training process establishes explicit 29 and
implicit standards for assessing relationship experiences as well as their shap-
ing influence on them.
In principle, psychotherapists are trained to subordinate their diagnostic
and therapeutic thoughts to the therapeutic target, which is to enhance devel-
opment and changing processes to the client's weal. They learn, in particular,
to withhold personal interests and needs, emotions, and thoughts which come
to their minds spontaneously, unless they are relevant and subservient to the
therapeutic process. This specific ability of reflection 3o constitutes an essen-
tial quality criterion, which is acquired during training (e.g., self-awareness
training, theory, supervision) and inherent to the psychotherapeutic task.
A conscious and systematic or planned procedure is common to all psy-
chotherapeutic schools. Hence, the psychotherapist's behavior is such as to
stimulate the process of change and to build up trust (benevolent attention).31
She adopts a neutral position towards values, persons, and changes and cor-
relates them with the patient's relational cues and claims.
According to this process-related approach, the psychotherapeutic atti-
tude is characterized by oscillating between empathy in the patient's ways of
being in the world and a reflective way of 'distancing herself' from them.
This attitude enables her to find the balance between the patient's demands
and her own methodological background, and thus facilitating the process of
change and making helpful and responsible decisions.
In so doing, the psychotherapist repeatedly correlates her findings, per-
ceptions, and cognitions acquired in the psychotherapeutic relationship, and
her experiences with scientific psychotherapeutic insights of her own and
other sciences.
2.1. Establishing and Shaping a Psychotherapeutic Relationship
A psychotherapeutic relationship is brought about by both the psychothera-
pist's and the patient's relational stimuli and demands. The psychotherapist's
encouragement and her requests are defined by reflective action 32 in the
sense of a professional psychotherapeutic attitude, accompanied by em-
pathic interest in the patients and their ailments, leaving aside those issues
which, according to her method, are not needed in the therapeutic space. 33
Furthermore, psychotherapeutic action continuously distinguishes be-
tween the patient's relational endeavors brought into the therapeutic space,
and the responses which she calls forth within the therapist, be it on the
verbal level or on the nonverbal one. These responses are reflected upon
and utilized for therapeutic purposes on the basis of the therapist's concepts
and experiences. Consequently, the psychotherapist complements and am-
plifies the patient's ways of relating in an appropriate manner, so as to facili-

psychotherapeutic Diagnostics
21
tate development. To improve the quality of the relationship, the psycho-
therapist contributes interest, empathy, appreciation and a benevolent atti-
tude, always offering a reflective and conceptualized mode of relating.
Every specific relationship is preceded by expectations and pre-informa-
tion: the diagnostic description sets in, as soon as contact has been made. 34
From the very first session, the way of connecting to another person is an
essential dimension of the therapeutic as well as the diagnostic process, both
of which take place simultaneously.35
From the vast variety of human faculties of expression, and from the vari-
ous fashions of acting out interpersonal behavior, those variables are chosen
which are of psychotherapeutic and of diagnostic relevance. 36 Besides, some
variables are given special emphasis and described from the perspective of
the therapist's method.
Principally, pre-experience 37 of relational patterns 38 do exist on both
sides, on the psychotherapist's as well as the patient's. This pre-experience is
reactivated during the therapeutic relationship; it is either put forth actively,
or resurfaces in the ongoing relationship. The various psychotherapeutic
schools perceive this reactivated pre-experience in different ways. According
to the momentum which is attributed to it,39 it is - more or less - taken up
and made the object of therapeutic work. The common ground of the differ-
ent methodological approaches is the conscious and systematic handling of
this operation.
The psychotherapist evaluates the patient's ideas on the human being (H),
her world-view (W), and her life concept (L) according to the demands of her
particular school of thought.
She will ponder the question, as to what extent the psychogenesis 4o has
to be reflected against the patient's idea of the human being (H), her world-
view (W), and her life concept (L) and to what extent the patient holds these
factors responsible for her ailment or her disorder, and/or on what grounds
her particular ways of presenting conflicts may have arisen. The methodo-
logical procedure will emanate from this. Possibly, the therapist's and the
patient's views of the variables - IJH, W, L" - are differently categorized and
appear as opposed to each other, and a therapeutic relationship may be im-
possible if they fail to connect:4 1 at all. A certain concordance of ideas on the
human being is helpful, but not indispensable.
Before a preliminary diagnosis is established, the patient's abilities to deal
with the boundaries and to relate, or her willingness 42 to engage in a psycho-
therapeutic relationship with the psychotherapist are in the center of atten-
tion and will lessen in importance as work progresses. Subsequently, the
patient's current topics, together with her offers and her requests, will come
to the fore to be dealt with.
The psychotherapist has to decide whether a planned and method-ori-
ented relationship is possible. Different methodological approaches open up

22
Diagnostic Guideline for Psychotherapists
their relational field in steps specific to themselves. At this point, it will be-
come evident whether or not the patient will be able to use this for her ben-
efit.
Diagnosing the dimension 'relationship'43 contributes an answer to the
question whether the psychotherapist will find access to the patient's devel-
opmental potential.
For the completion of the diagnosis, further questions regarding the rela-
tional quality and the severity of the disorder will arise, as compared to the
symptoms in relation to personality aspects and to the risk level.
Framework and Setting
According to the psychotherapist's assessment of the patient's possibilities to
undergo a therapy on a regular basis, timing, frequency, venue, and costs
need to be negotiated. At the same time, the patient will reveal her/his inten-
tions, her/his values, and her/his self-assessment, which are parameters 44 of
importance.
2.2. Target Orientation
The patient's needs, claims and aspirations are the various objectives which
have a different meaning in the psychotherapeutic treatment as opposed to
somatic medicine. 45 Psychotherapy claims to aim at understanding and/or
changing a disorder or an affliction.
First, the psychotherapist takes up the patient's motives (those brought up
as well as the underlying ones yet to be disclosed; they may concern present,
past, and future actions). The patient expresses her goals, e.g., to be helped
with the reduction of her symptoms, with arriving at an understanding of the
meaning of her disorder, with solving her problems, with attaining an under-
standing of the background of her present conflicts, with working out prob-
lem solving strategies, with changing her personality and her quality of expe-
riencing.
The psychotherapist's hypotheses are intertwined with these motives, as
they unfold. At the same time, the psychotherapist invests in establishing an
abiding therapeutic relationship; on the basis of this, the strain inevitably aris-
ing in therapeutic work, e.g., the stress of confrontation and frustration, will
be rendered manageable and integrated to the patient's good.
During this process, a joint orientation towards the goals, which will
eventually become more and more precise, will take hold.
If the patient's self-responsibility is obviously limited, the psychotherapist
may have to seize the initiative and set interim goals in order to connect to
her. 46

psychotherapeutic Diagnostics
23
psychotherapy is principally based on the patient's voluntariness. 47 This
holds true also for critical and constrained initial situations such as coercive
contexts, in which nonetheless specific emphasis will have to be placed on
the voluntariness of the cooperation. This basic assumption rests upon an
emancipatory approach, and the goals deduced therefrom lead to a resource-
and development-oriented way of diagnosing and working on relationships.
Even noncompiiance 4B is of diagnostic relevance in psychotherapy since,
on the relation level, these aspects have to be worked on explicitly.
Potential third party interference (family, finances, media, etc.) has an es-
sential impact on the patient's motivation and her self-assessment: 49
- Supporting the patient (e.g., by questions, by offering orientation, inter-
pretations),
- Contextual, planned proceeding (in an institution or in a private psycho-
therapeutic practice),
- Establishing the relationship on a coequal basis with adopting a coopera-
tive attitude,
- Seizing the patient's linguistic notions and idioms, using a natural lan-
guage, tuning in the patient's words as well as her semantic and emo-
tional implications,
- Establishing correlations to find or bring about sense and meaning, and
- Accurate and detailed observation with special regard to relational as-
pects.
2.3. Process-Oriented Diagnostics
As compared to state- or condition-oriented, psychotherapeutic diagnostics
is defined as process-oriented. This approach implies that the description of
the conditions and statuses always be viewed within the entirety of the
therapeutic process.
The diagnostic process 50 permanently accompanies the therapeutic proc-
ess and feeds back on it continuously. Consequently, questions or tentative
interpretations potentially determine the therapeutic course.
Even if relevant diagnostic pre-information (anamneses, interviews, test
results, etc.) is available, the diagnostic evaluation has to be carried out at the
beginning of the therapy process, or else, a sufficient span of time has to be
reserved for it. Often the psychotherapist is approached at the end of a long-
some search for professional help. It is the psychotherapist's task to place the
patient's current material, be it expressed openly or insinuated, in a wider
context; this means that she takes the patient's cultural, familial, social envi-
ronment into consideration and, if applicable, her/his pre-experience with
former treatment methods. To comprehend these context factors for the di-
agnostic process, she has to handle them with utter therapeutic prudence.

.....
24
Diagnostic Guideline for Psychotherapists
Even if the attitudes, positions, views, or even ideologies are unaccepta-
ble to the psychotherapist and her/his principles, she is advised not to take a
stand right away (unless in those cases, where the therapeutic contract de-
pends on it).
From the various momentary observations, relationship diagnostic sug-
gestions have to be taken into account on their different levels of manifesta-
tion (cognitive, emotional, physical). They may reveal themselves in expres-
sion, self-description, or appearance.
The description of the relational cues may emphasize either disorder-spe-
cific or personality-specific issues; we will concentrate on the former in case
they aggravate. It is the psychotherapist's role to enrich the patient's disorder-
specific aspects by individual and personality-specific relational skills.
To describe further relational aspects, the following concepts are fre-
quently used: degree of motivation, aspiration level, distance versus close-
ness, autonomy versus attachment, self control versus self actualization, sta-
bility versus instability.
Out of these, models of the developmental potential and the necessities
of the therapeutic process may be distilled. The responses and interventions
influenced hereby will start off new perceptions. Thus it is essential to con-
sider as to how the patient currently talks about her experiences, how she
formulates her issue, how she presents herself, how she invites or discour-
ages the therapist to contribute to the conversation, etc., and not only how
she refers to her past experiences.
Personal theories on how a specific disorder came about have to be
pinned down and worked on - in case they are impedimentary to the thera-
peutic process. 51
The therapists' methodological concepts of the formation of a therapeutic
relationship as well as their individual work styles produce different diagnos-
tic specifications, which include the deviations from the required and desir-
able pre-requisites for a constructive therapeutic collaboration. 52
Within the different methodological approaches, different criteria for the
assumption of psychotherapy and the parameters, which accompany or ter-
minate the process, have been formulated. In ongoing psychotherapies, fur-
ther events in relation to the personality structure and/or the process are di-
agnosed separately and gradually integrated in the context.
Due to developmental trends and novel options of life opened up by
them, new aspects are perceived, which may lead to the change or com-
plementation of the initial diagnosis. This is why, frequently, different diag-
noses have to be focused on at different stages of the therapeutic process,
and the initial hypotheses have to be fine-tuned according to the observa-
tions made in the current sessions, and the progress has to be assessed and
evaluated.

psychotherapeutic Diagnostics
25
2.4. Assessment of the Psychotherapeutic Relationship
A minimal consensus on the setting, contents and goal(s) of psychotherapy
(or at least the justified prospect of reaching it/them) is needed for a fruitful
therapeutic relationship.
The first assessment of the therapeutic relationship takes place during the
initial session. It has to be examined whether the therapist's methodological
and individual variables (cp. 'H', see 2.1.) will be helpful for this particular
patient. The question will have to be raised whether interim goals have to be
set in order to build up a therapeutic relationship. Further evaluations will
follow the same principles.
From observing and reflecting on the therapeutic relationship, the psy-
chotherapist judges the avail of the work in progress.
The quality of a therapeutic relationship can be recognized by the useful-
ness and the efficacy achieved by its interventions. The evaluation of the
therapeutic interventions requires continuous adjustment of the diagnostic
comprehension of the relationship relied on hitherto, and this does not have
to be formulated explicitly, but will implicitly guide the further structuring. 53
The change in the patient's self-image, the view of her disorder, and her
expectations concerning psychotherapy and the psychotherapist will turn out
to be diagnostically relevant throughout the therapy.
The continuous reflection on the therapeutic process is the therapist's
indispensable contribution when cooperating with affiliated professions (e.g.,
in coercive contexts, or when psychoses, psychosomatic illnesses, etc. have
to be dealt with). The need of referral will arise when additional diagnostic
clarification or specific treatment is required.
The assessment of the therapeutic relationship is carried out with the in-
clusion of methodological categories and takes the form of a continuous
observation of the treatment process. The gain of insight into the changes of
the client will be communicated to her, which is relevant to healing. In doing
so, it is vital to find an answer to the question which steps have or have not
been beneficial in the healing process or, just as well, whether the present
work leads to an expansion or a limitation of the patient's options. These and
further specifications have meanwhile been termed as 'quality assurance'
and, for more than hundred years now, have been intrinsic to the psycho-
therapeutic work. The form and the emphasis of the assessment of the thera-
peutic relationship is, by definition, task of the different methodologies and
of each individual psychotherapist alike.

...
26
Diagnostic Guideline for Psychotherapists
3. Risk level
Definition of the Term 'Psychic Crisis'
From the psychotherapeutic point of view, a psychic crisis is defined as an
impending loss of the dynamic equilibrium between stabilizing and destabi-
lizing forces, under the impact of external or internal, i.e., psychological,
social, somatic, or other factors. Crises may result in an expansion of options,
as it is the case with the (inevitable) developmental crises, depending on the
coping strategies at hand.
A patient may experience a crisis and go through it consciously or, if such
awareness is amiss, the psychotherapist may diagnose it by virtue of different
indicators. 54
The constriction of options, which usually occurs with crises, challenges
the afflicted person and/or her psychotherapist to look out for alternatives and
to expand the client's scope of experiencing, perceiving, acting, and living.
Crises may be described as disorders of clinical significance (of JJiliness
status or 'valence"', thus the phrasing in the PthG), even with a minor disor-
der of the relationship and of the symptom or structure level. They can also
be experienced as an adequate consequence of realistically assessed events,
either as an illness or not so, and have to be diagnosed accordingly. 55
The degree of severity of a crisis has to be seen as embedded in develop-
mental processes of long standing, or in internal/external traumatizations of
differing currentness, and be assessed accordingly.
Under certain circumstances within the framework of a therapy plan, in-
terventions which elicit crises can be placed purposefully.
Assessment of Risk Level
Psychotherapists regard the dimension 'risk level' as a qualitative and quan-
titative description of the causes of and the criteria for crises. To what extent
the crisis has escalated, will it escalate further or has it already de-escalated,
or else the course which it will take; this is the object of evaluation.
In the course of the necessary change process during the treatment, crises
have to be influenced and worked on towards a constructive ending.
Within the framework of a particular therapy, crises may arise, which
have to be absorbed, mitigated, and worked on. In psychotherapy, a certain
degree of risk level within a given setting is inevitable. Under certain condi-
tions, particularly under stagnation, crises may be called forth intentionally.
Such strategies of treatment are applied against the background of therapeu-
tic intentionality and of the assessment of the patient's endurance, that is, her
ability to deal with crises constructively.

psychotherapeutic Diagnostics
27
The patient's self image as well as the psychotherapist's view of her are
included in the assessment of the risk level, along with all the diagnostic di-
mensions discussed so far. Psychiatric and psychological diagnostic descrip-
tions have to be comprehended in the dimension 'risk level' also.
The degree of risk level is described in a qualitative manner by the follow-
ing criteria: which meaning do the crises have in the context of a particular
patient's life and/or her relationships, for her ability to work, e.g., do we wit-
ness a narrowing of options, excessive demands, existential threat, restricted
access to resources and values, traumatization, bereavement, strokes of fate,
a life passage or threshold situation, such as emigration, displacement, up-
rootedness, etc.
We understand the risk level as a continuum between sound stability, via
increasing instability in various areas of life, up to the outbreak of a severe
existential crisis.
From the assessment of the risk level, various necessities of action will
arise for the psychotherapist (cp. "Indications According to Degree of Risk
level" B.I.1.).
The assessment of a disturbed equilibrium up to a full-blown crisis is
graded into five degrees. The points itemized here are neither exhaustive,
nor do all items have to be extant at once:
Degree one:
- Minor though noticeable irritation of the equilibrium between stabilizing
and de-stabilizing factors.
- Commencing inner inquietude, signs of strain, subjective sense of being
over-strained, increasing exploratory behavior 56 or closing-in, anxiety.
- At the same time, no major restraints are noticeable at work, in training,
or within the family, even if the individual experiences them as such. To
a large extent, the patient is capable of maintaining social functions.
Degree two:
- Considerable perturbation with increasing signs of a critical state, irregu-
lar behavior and/or somatic symptoms become more noticeable, increas-
ing addictive behavior among other forms of disordered conduct, which
are experienced as strenuous but not as serious enough to require hospi-
talization.
- Significant constraint of the capability of acting and of the flexibility, with
the patient still being capable of maintaining social functions, albeit with
considerable effort.
- The patient resorts to sickness leaves, questioning her relationships to her
significant others, her life conditions, etc.

..
28
Diagnostic Guideline for Psychotherapists
Degree three:
- Serious perturbation, in which the symptoms become manifest and key
relations are lost or given up (separation, loss of job, dwelling place at
jeopardy).
Principal endangerment of one's social relations, or even continued and
extreme restriction of social relations. Dangerous and destructive im-
pulses with loss of control.
The cooperation with pertinent institutions should be looked for.
Degree four:
Serious derangement with serious signs of existential and emotional
breakdown, the emotional and mental functions apparently disintegrat-
ing. 57 Patient fails to dissociate herself from the predominant symptoms.
- The structure of a protective institution may be advisable, since it is able
to adopt the responsibility for the patient, particularly if endangerment of
self and/or others is imminent.
Degree five:
- Immediate endangerment of self and/or others.
- The attendant danger-of-life is not necessarily bound to progressive disin-
tegration; the patient may not pass through the degrees 1-4 in a row, but
it can arise acutely also.
- The only psychotherapeutic intervention of choice is the referral to an
adequate in-patient facility.
A. II. Indications
1. Indications of Psychotherapeutic Treatment
Definition
Specific psychotherapeutic treatment is indicated when:
- There is evidence of a person being incapable of living her life in an ex-
tensively satisfying, reasonable or expected way. This incapability may
manifest as psychosocial disorders, as personality development disorders
and/or disorders of disease status 58 and as physical illnesses;59
- These individuals cannot be expected to improve the quality of their lives,
either on their own or with the assistance of their social environments, or
when deterioration is to be feared.

psychotherapeutic Diagnostics
29
Suffering from clinically significant disorders or disorders of disease status, as
it were, or from somatic disturbances commonly puts significant strain on the
individual and/or her social environment. Disorders which are classifiable as
diseases, or somatic disorders manifest in the modes of experiencing, of be-
havior and in relationships, with varying degrees of intensity.
The evolution of disorders and the development of the abilities to shape
one's life lie in one's extant and acquired interaction structures. 60 Disorders
of disease status are also caused by current over-strain in an otherwise
healthy person. Psychotherapeutic treatment is indicated, when the interac-
tion structures do not suffice to cope with physical illness.
The psychotherapeutic methods usually establish an indication right away
and expand it by method-specific criteria.
2. Indications of Additional Diagnostic Clarification
It is essential to determine whether additional diagnostic clarifications, such
as medical, psychiatric, clinical-psychological, or others 61 are necessary.
It is the psychotherapist's responsibility to collaborate with the repre-
sentatives of affiliated professions (as per  14, para. 2 of Psychotherapy Act,
'collaboration with representatives of other sciences'). Even if the psycho-
therapist holds more than one competence, the referral to the analogous
professionals 62 has to be given precedence. This collaboration is carried out
by means of specific questions and requires the exchange of information.
Any kind of automatic referral 63 is unnecessary in most cases and incon-
sistent with the sophisticated professional skills, which psychotherapists have
at their command. In many cases automatic referral would be even contrain-
dicated, since it would perturb the therapeutic process. If the necessity of
referral arises, the patient has to be notified (on informed consent).
3. Indications of a Specific Psychotherapeutic
Treatment Option
The prospective 64 psychotherapeutic treatment of a specific kind should be
checked as to its methodological and economical suitability for a given pa-
tient. In doing so, the specific treatment option should be weighed and com-
pared against other possibilities, as to the benefits which a patient can expect
from it.
The patient's resources and those accessible in her social environment
have to be taken into account for the psychotherapeutic treatment. Thus, all
possible settings, such as individual, group, couple or family therapy should
be considered.

....
30
Diagnostic Guideline for Psychotherapists
The strain which the treatment is expected to impose on the patient must
not exceed acceptable proportions.
All these considerations would result in the allocation of a specific psy-
chotherapeutic method or modality; however, several equivalent modalities
are often available, and the patient's expectations and preferences can also
be taken into consideration.
For referral, the criteria of a relative concordance between the diagnostic
assumption about the patient and the available psychotherapists, as well as
the issues of specific professional experience, age, sex, and the psychothera-
peutic modality should be given due consideration, especially when there is
a choice of equivalent options.
3.1. Indications with Clinically Significant Disorders ('Disease Status')
In this context we point to A.l1.1., where the issue of indication of clinically
significant disorders ('disorders of disease status') has been defined appropri-
ately.
There, the understanding of suffering and of behavioral disorders, which
badly constrain the individual's engagement in her life and her satisfaction of
basic needs, is emphasized.
The more severe a disorder is diagnosed and the further the onset dates
back, the longer and the more intensive the treatment will presumably be.
Specific indications 65 may require a psychotherapeutic treatment at high
frequency, up to several sessions a week, and also over quite a long span of
time.
In treating acute crises, intensive settings such as combined group, family,
couples and individual therapies of high weekly frequency, as it is practiced
in inpatient psychotherapies, may be required.
3.2. Indications According to Degree of Risk Level
Degree 1: Sufficient time is available for planning and taking up psycho-
therapy.
Degree 2: Psychotherapeutic treatment should be initiated and planned. In
an ongoing psychotherapy, change of procedure and of frequency
may be necessary.
Degree 3: Psychotherapy should commence immediately. Cooperation with
the providers of attendant professional services is to be estab-
lished.

psychotherapeutic Diagnostics
31
Degree 4: Referral to an analogous psychotherapeutic inpatient treatment is
to be provided for.
Degree 5: Immediate hospitalization is necessary (see also A.l1.2).
3.3. Indications with Personality Development Disorders Without
Disease Status
Unless illness status is given, the understanding of an ailment and the sense
of dissatisfaction - parameters which do not entail significant restraint on the
individual's day-to-day existence - is paramount.
In these cases, we are confronted with the client's aspiration to solve a
problem or a conflict, to remove some incongruity or difficulty, or to develop
single aspects of her personality more satisfyingly.
These are cases of:
- Prevention, prophylaxis;
- Continuation of psychotherapy after the pathological aspects have been
removed;
- Minor disorders of performance;
- Communication disorders;
- Partner conflicts, family and marriage problems;
- Eating disorders, non-detrimental to health; and
- Divorce and conflict mediation.
4. Contraindications
Even if the 'ideologies' expressed by the patient are incompatible with the
psychotherapist's basic principles, she should avoid to position herself right
away (unless the accomplishment of a psychotherapeutic alliance depends
on this position).
If we consider all these three dimensions, the following criteria should be
taken into account as to possible contraindication against starting or continu-
ing psychotherapy.
Relationship Diagnostic Exclusion Criteria:
- When the patient has taken to using the psychotherapy and the relation-
ship with her therapist solely for the satisfaction of her primary needs.
- When the patient permanently fails to accept the professional mode of
relating, in spite of all therapeutic endeavor to change and to work on
precisely this issue.

32
Diagnostic Guideline for Psychotherapists
- Break-off on the patient's part, or frequent interruptions of therapy by not
observing scheduled appointments, thus revealing a distinct lack of con-
tinuity.
- Intensive acting-out 66 in therapy for long periods of time, without notice-
able willingness to reflect on these histrionic ways of self-actualization.
- Persistent use of psychotherapy for non-therapeutic purposes.
- When the willingness to change ceases to be traceable.
- Breach of or noncompliance with the agreement.
- When the relationship is impaired on the psychotherapist's part by per-
sonal stresses and strains, and/or when unexpected causes for partiality
arise.

B. Psychotherapeutic Guidelines
B. I. Guidelines for Establishing a Diagnosis
1. Guideline for the Symptomatological Dimension in Relation
to Personality Aspects
Here, the psychotherapist conducting a psychotherapeutic treatment will be
guided by the following questions:
- For which ailments does the patient address the psychotherapist, and to
what extent can these be delimited from similar clinical pictures in a fur-
ther differential diagnostic process (see also 'Indications' B.lI.1.)?
Does the ailment (i.e., the behavioral disorder or suffering) have to be
imputed to the character of the individual 67 , or does it become apparent
as a circumscribable complex of symptoms 68 (and, in addition, which cor-
relation do we witness between the two)?
How does the changeability of the ailment have to be assessed, given the
patient's resources?
Does the severity of the behavioral disorders and of suffering have to be
graded as slight, medium, or serious?
2. Guideline for the Dimension 'Psychotherapeutic
Relationship'
Here, the psychotherapeutic-diagnostic approach - as opposed to medical
or psychological diagnostics - is delineated by the following questions.
These will be present throughout the psychotherapeutic process, in which
new answers lead to new diagnostic findings, which will in turn be included
in the psychotherapeutic treatment.

34
Diagnostic Guideline for Psychotherapists
Establishing and Shaping a Relationship (explicated)
- How and in which mode of relating does the patient make contact with
the psychotherapist?
- How does s/he respond to the contact and to the psychotherapist's rela-
tional style?
- Does the patient's relational style encourage the psychotherapist to offer
a high degree of structure, to be judgmental, or to be partial, or which
other relational cues does she offer?
- The patient's possibilities of relating have to be assessed and considered
according to the following dimensions:
- perception, reciprocit y 69, and contact
- degree of suffering and motivation
- needs, expectations, desires, and volitions
- verbal communication and dialogue capability
- (self-) presentation and appearance
- relationship patterns and role behavior (e.g., dominant versus submis-
sive, caring versus rejecting, controlling versus permissive)
- ability to form alliances and to establish cooperation
- ability to sustain a relationship
- other resources such as learning aptitude, social network, etc.
- obstacles
- the effect which the patient has on or evokes in the therapist is in-
cluded in the general diagnostic picture.
It may be desirable to consider the following additional aspects, such as the
general physical condition, biographical circumstances, social relations,
closeness/distance, social class and verbal level, ethnic and religious rela-
tions, non-verbal expression, the patient's self-image, and the psychothera-
pist's perception of her.
Target Orientation (explicated)
- What does the patient need?
- Which meaning does the illness (i.e., disorder or behavioral disorder)
have for the patient?70
- What are her subjective views of the origin, the development, and the
healing of her illness (i.e., disorder or behavioral disorder)?
- Which expectations and targets, including the patient's implicit ones, are
elaborated or agreed upon as the patient's and the psychotherapist's joint
goals within the framework of psychotherapeutic treatment?

psychotherapeutic Guidelines
35
Process-Oriented Diagnostics (explicated)
psychotherapy is understood as a targeted process. The criteria therefore are
growth, increasing freedom of will, self-responsibility, or sustenance of life.
The relationship diagnosis accompanying the process is oriented towards
the following issues:
- Is a psychotherapeutic relationship between patient and psychotherapist
still possible and justifiable?
- Is the subject matter currently worked on still justifiable in psychothera-
peutic terms, given the patient's social environment?
- How does the psychotherapeutic intervention have to be optimized in
accordance with the process?
Assessment of the Psychotherapeutic Relationship (explicated)
The psychotherapeutic process has to be reflected on continually, with the
help of supervision and/or intervision, if need be. Occasionally, the results of
the reflection should be noted down. The assessment has to be directed to-
wards the improvement of the relational quality.
- Which steps turn out to be facilitative or obstructive?
- Does the current psychotherapeutic course lead to an expansion or the
stagnation of the patient's potential?
3. Guideline for the Assessing Risk Level
The treating psychotherapist should assess the severity of the patient's behav-
ioral disorder and/or her suffering in the context of the present situation. This
should be carried out according to the five grades previously delineated (See
also A.1.3.).
Furthermore, it should be assessed whether the psychotherapeutic treat-
ment is sensible and/or necessary, and whether the disorder has assumed the
state of an illness.
- To what extent has the patient's range of options narrowed?
- How acute is the patient's present (state of) suffering, and how restricted
is her ability to assess her coping strategies within her actual life context?
Under which degree of external pressure does the patient find herself?
- How restricted are the patient's coping strategies, which resources are at
her disposal?

..
36
Diagnostic Guideline for Psychotherapists
- Can the suffering be dealt with, or is it excessively strenuous? Is the dan-
ger of a break-down imminent? How does the social environment assess
the crisis?
- Are there any hints of the present situation being an existential risk to the
patient?
- Are there any hints as to active or passive endangerment of self or oth-
ers?
- Is there a mediate or immediate call for action on the psychotherapist's
part?
The risk level is estimated in the same way as the other diagnostic dimen-
sions, i.e., in accordance with the course which the therapy is taking.
B. II. Guidelines for Indication
1. Guideline for the Indication of Psychotherapeutic Treatment
Dimensions of life style, interaction, suffering:
- Are there any suggestions of past or present psychosocial damage which
the patient has been or still is exposed to? How serious are these sugges-
tions?
- Are there any suggestions of the patient's inability to live her life in a sat-
isfying, reasonable, and expected way? Which areas of her life are af-
fected, and to what extent?
- Which personal and social resources are at the patient's command?
The following criteria should be considered:
- the patient's ability for introspection,
- her understanding of psychogenesis,
- her potential resolution approaches,
- her motivation or her willingness to change (as part of these, the extent of
dissatisfaction on the patient's part, and/or the emotional pressure on her
as well as the source of her motivation (intrinsic or extrinsic) have to be
taken into account, before psychotherapy is assumed),
- her ability to form an alliance, and
- her degree of secondary gain from illness.
None of these criteria preclude the indication of psychotherapeutic treat-
ment. The strongest motivation and the best predictor is the willingness to
change which has been clearly articulated and corresponds to the readiness
to work for it.

psychotherapeutic Guidelines
37
Further criteria for deciding on the beginning of a treatment are:
_ Which criteria are relevant for an individual to be able or willing to take
up psychotherapy (e.g., the degree of motivation to undergo psychother-
apy, considerations of accessibility)?
Is psychotherapy economically affordable, or which possibilities are there
for the health insurance companies/relations/other sources of money to
absorb the costs of treatment?
Is even more detailed psychotherapeutic diagnostic clarification indi-
cated?
Summary:
- Is psychotherapeutic treatment indicated, or is there a necessity for fur-
ther psychotherapeutic diagnostic clarification?
2. Guideline for the Indication of Further Diagnostic Investigation
We list medical, psychiatric, clinical-psychological, and other disciplines of
investigation hereunder:
- Does a physical factor have to be suspected at the root of an emotional
ailment, or do physical causes have to be checked for safety reasons?
- Are there any physical symptoms to be diagnostically clarified and treat-
ed in the context of a psychic illness in collaboration with medical doc-
tors?
- Can psychotherapeutic treatment be utilized as a contribution to chang-
ing physical symptoms and/or suffering?
- Are collaboration with psychiatrists and a psychiatric diagnosis indicated
in this context?
- Are there any suggestions of a disorder that needs to be clarified by clini-
cal-psychological testing?
Summary:
- Is additional somatic, psychiatric, and/or clinical-psychological diagnostic
clarification indicated?
3. Guideline for the Indication of Specific Psychotherapeutic
Options
The psychotherapist, the psychotherapeutic method and the setting have to
be checked as to their suitability for a given patient:

38
Diagnostic Guideline for Psychotherapists
- Which resources of the patient and her social environment can be mobi-
lized for the treatment? Which resources of the psychotherapist's person-
ality and the scientific-psychotherapeutic method represented by her can
be utilized for treatment? Do the patient's and the psychotherapist's ideas
on wolman correspond with each other? Are the patient's and the psy-
chotherapist's understandings of psychogenesis in line with each other?
- Which setting is apt to utilize the patient's resources and to make up for
her short-comings?71
- Which financial resources or which possibilities of the (partial) absorption
of the treatment costs by the health insurance companies, relations, or
other sponsors are at the patient's disposal?
Summary:
- Is the psychotherapeutic treatment to be conducted by the psychothera-
pist who established the indication in regard to the method and the set-
ting? Is her particular method or her setting indicated?
If this is not the case:
- Which criteria have to be observed, when referring a patient to another
psychotherapist for treatment?
Appendix
Appendix 1: Official Expert Opinion (1991) of the Former
Federal Ministry of Health, Sports, and Consumerism
Hans Strotzka, MD, University Professor & Raoul Schindler, MD,
Associate Professor
Transcript
Subject: Expert Opinion on the Issue of Independent Diagnostics for the At-
tention of the Federal Ministry of Health, Sports, and Consumerism (as from
autumn 1991)
Preamble: Both undersigned are medical doctors (psychiatrists and neurolo-
gists) as well as psychotherapists (originally trained in psychoanalysis, but
familiar with and teaching experts of a number of psychotherapeutic disci-
plines). Not being jurisprudents, they are, however, closely familiar with the
accruement and the purpose of the Psychotherapy Act (Federal Law Gazette
no. 361/1990), which had been supported by all political parties. Hence, the
two professors engaged in furnishing the Expert Opinion on the issue expli-

psychotherapeutic Guidelines
39
cated above, a matter which had gained importance within the discussion of
the 50 th amendment of the General Social Insurance Law ('ASVG-Novelle').
The issue comprises three areas:
Does the wording laid down in  1 of the Psychotherapy Act, i.e., "compre-
hensive, conscious, and planned treatment of ... behavioral disorders and of
suffering" comprise or preclude an independent form of diagnostics? In case
of the latter, who would be qualified to administer it?
If a therapist assumes treatment independently and on his own account,
does this involve an increased risk to the client's health, by the therapist ei-
ther overlooking or under-diagnosing ailments that should rather be treated
elsewhere, thus delaying the appropriate, non-psychotherapeutic treatment?
This issue can be subdivided as follows:
Does the obligatory general and specific training enable the therapist to
diagnose such dangerous risks, or to develop the suspicion of such complex
ills and reasonably refer the patient to the appropriate specialist? This con-
cern is particularly crucial in cases where the psychotherapist is not a medi-
cal doctor, and the complicating ailment is of physical-organic nature (e.g.,
commencing cancer or brain tumor).
Which legal measures could contribute to a further reduction of such
risks, e.g., mandatory regulations of collaboration between the specialists
involved, or by enhancement of the voluntariness of cooperation?
Do competences overlap in the field of social services, for example in
cases where the justification of sickness leaves has to be examined?
Given the legal situation and the professional experience at hand, the fol-
lowing answers lend themselves:
1. (Explicated). In the Psychotherapy Act, the legislator refers to a "compre-
hensive treatment" without itemizing it. This is in line with the current spirit
which pervades the complete body of laws, i.e., that the professional duties
laid down therein truly have to be conceived of as the patients' rights. This
is frequently pointed to in the accompanying commentary. From the patient's
point of view, the theoretical classification of treatment during examination,
diagnosis, actual treatment, after-care, etc. is irrelevant because it is implied
in the whole treatment issue. The first step relevant to her is her calling on
the therapist. The legislator makes a distinct statement, when elucidating the
goals of the Act: "Whoever consults a psychotherapist is entitled to freely
select a psychotherapist of her own choice." The psychotherapist is, in addi-
tion, obliged to determine the further course of treatment in accordance with
the patient's or her legal representative's ( 14/3) consent. She is instructed to
establish "collaboration with representatives of her or another science" and,
as the commentary annotates, a "model of modern health care for the coop-

....
40
Diagnostic Guideline for Psychotherapists
eration between different occupational groups that are on an equal footing"
is understood hereby. She is interdicted to arbitrarily break off treatment and
has to notify the patient or his legal representative of such intention in due
time, in order for him JJto see for himself to the continuation of the psycho-
therapeutic care" ( 14/6). These regulations are mandatory to the extent that
disregarding them legitimates the injured person to initiate an action for in-
junctive relief. Furthermore, the comprehensive treatment has to be con-
ducted in a JJconscious" and JJplanned" ( 1) manner. The legislator's will
clearly emanates from this formulation, Le., that the psychotherapist assume
a clarifying and planning process which is inherent in the treatment process
and equals the examination and diagnosis in the medical domain.
Since the medical diagnostic concept is based on a physical substrate,
which is deemed the site of any pathological occurrence, the treatment is
conducted accordingly. The diagnostic differentiation of diseases and the
medical specifications are based on this criterion, which fails in the psycho-
logical realm. This is why in the psychotherapeutic field, a separate, func-
tional mode of indication has been developed, which induces treatment,
while an interactive contacting with the patient takes place. The phrasing of
the Act pays tribute to this circumstance. On the other hand, this is the basis
for another fact also, i.e., that psychotherapeutic indication cannot be at-
tained or debarred by sheer medical diagnostic practice. A medical doctor
assists with psychotherapeutic indication only, when she is equipped with
sufficient knowledge of it and an understanding of its characteristics.
2. (explicated) Doing damage to a patient by inexpedient treatment cannot
be precluded either in psychotherapy or in the medical field. Such damage
can result in an irreversible progression of the basic ailment and lead to chro-
nicity or even death. A delayed beginning may also complicate treatment.
Such harms can also occur when a patient avoids consultation as a conse-
quence of justified or unjustified fears and calls neither a doctor nor a psy-
chotherapist. Such damage is well known, and so far it has been recorded
more painstakingly in the medical field, since psychotherapy has hardly been
in effect widely and long enough that it could have been evaluated well sta-
tistically. It is widely known that such damage may involve suicidal action in
cases where psychological strain and suffering have been underestimated, so
that chronicity along with iatrogenic habituation to sedatives, analgesics,
tranquillizers, and even antidepressants are rather common. A study carried
out by Ringel and Kropiunigg (JJDer fehlgeleitete Patient" - The misled pa-
tient, Facultas, Vienna 1983) estimated an average delay of 6.3 years for the
required psychotherapeutic treatment in cases of psychosomatic illnesses.
During this period, an average of 78 contacts with doctors (per person) was
made, and the referrals to the specific technical examinations imposed con-
siderable economic strain on the patient. In the field of psychotherapy, psy-

psychotherapeutic Guidelines
41
chotic crises are noted of which, according to particular follow-up examina-
tions conducted by R. Schindler, only a few can be attributed to psycho-
therapy, whereas a larger amount of clinical outbreaks had apparently been
protracted by psychotherapy, but not prevented. Evidently, the frequently
quoted event of delayed treatment of cancer or brain tumor is extremely rare
and does not at all compare to the figures of those overlooked in the course
of medical routine checkups. (Partly) psychogenic incidences of tonsillitis
and appendicitis as well as the deterioration of ulci do occur within the
framework of psychotherapy, but such cases are referred to medical treat-
ment practically in a hundred percent of cases, unless it parallels and coop-
eratively accompanies psychotherapy anyway. We have to estimate, how-
ever, a larger number of unknown cases, that is, persons who evade medical
services out of pre-conscious fears of the nature of their ailment, and go to
dubious 'biological' cures, as well as a considerable number of patients who
avoid psychiatrists for the fear of (coerced) hospitalization or electric shock
treatment, as a consequence of public campaigns which damage the confi-
dence in medical services. This group of patients is presumably quite willing
to consult a psychotherapist and, once appropriate cooperation has been
established and the unjustified fears have been dissipated, could well be re-
ferred to medical treatment. Summarizing the present state of affairs, the
patient runs a far bigger risk when submitting to the medical routine than
through the concealment of critical conditions by psychotherapy. In future,
these figures could become more balanced when the psychotherapeutic
procedure has become routine, and the non-medical psychotherapists, par-
ticularly, have been desensitized as to the above mentioned issues, or as the
cooperation between doctors and psychotherapists progresses and therefore
attends to a larger number of people seeking help.
2.1. (Explicated). Hence, the legally required training of psychotherapists
provides for a sufficiently distinguished theoretic training in terminology, in
the nature and the achievements of the medical system, particularly where
the two areas overlap, such as in psychosomatic clinical pictures. The future
experience will provide evidence whether these approaches are adequate
enough or have to be expanded by further focal points, etc. Anyhow, a long
period of (compulsory) practical training in medical care facilities ensures
good contact between these complementary fields of work experience. Until
recently, psychotherapy used to be of secondary importance in the training
of an average medical doctor, with the result that the level of experience and
the understanding of the nature, the terminology, and the capacity of psy-
chotherapy with those currently providing medical care had been deplorably
low. On the whole, we may assume that the psychotherapists' average state
of cognition of medical matters is by far higher than vice versa. This is likely
to change within the next few years, a process in which person-to-person

.....
42
Diagnostic Guideline for Psychotherapists
contacts, collaboration, and the exchange of experience have to be priori-
tized over theoretic training.
2.2. (explicated) The material collected by experience so far clearly testifies
that the patient's risk does not lie with the medical or non-medical therapist's
failure to detect rare diseases, but in their routine behavior and also in the
patient's fearful avoidance of articulating her ailments. Statutory regulations
will have to be directed to the furtherance of the cooperation between the
doctors and the (non-)medical psychotherapists, and to easing the patient's
access to help by keeping the procedure as simple and as un-bureaucratic as
possible. With this in mind, coercive regulations have to be judged as coun-
terproductive and annoying.
2.3. (explicated) The assessment of the ability to work and the subsequent
attribution of the social role of a sick person are traditionally carried out by
the family doctor who, in so doing, takes it upon himself to deliver his expert
opinion to the social insurance service. The latter could, however, also draw
on other experts' opinions. In contrast, a psychotherapist can hardly be con-
sidered for such a task, since this would be contradictory to her very spe-
cific position of advocating her patient's viewpoint. The experts' quest for
objective criteria is inconsistent with the attitude of catering to the patient's
subjectivity. In the case of therapeutic cooperation, this concern holds true
for the physician as well, which is the reason why another doctor should be
called upon for that purpose.
Hans Strotzka, MD, Univ. Prof.,
manu propria
Raoul Schindler, MD,
Associate Prof., m.p.
Brief Summary
1. The wording of  1 of the Psychotherapy Act, i.e., the notion "comprehen-
sive treatment" in particular, states that examinations and diagnoses are in-
trinsic to treatment. This is the presupposition for the therapy plan stipulated
in the text. The medical diagnostic concept is applicable to a physical sub-
strate, which is nonexistent in the psychological field. Therefore, psycho-
therapy has developed a functional way of establishing indication. Medical
diagnoses can neither account for nor rule out the indication of psychother-
apy.
2. Detriments to a patient by inappropriate treatment or by delay of the eli-
gible treatment do occur in the medical as well as in the psychotherapeutic
fields. At present, they are more extensively documented in the medical

psychotherapeutic Guidelines
43
profession (e. g., suicides by underestimating the patient's emotional needi-
ness, habituation to medication, misleading of the psychosomatic patients for
an average of 6.3 years).
The fears of overlooking incidences of cancer or brain tumors are obviously
justified in extremely rare cases only; they do occur, but at present they oc-
cur much more frequently so with general practitioners than with psycho-
therapists. The main risk lies with the familiarization of the examination
routine and less so in the lack of training.
The presumably largest vulnerable group consists of patients who, for fear
of their preconsciously perceived illness, shun and avoid doctors and resort
to 'biological' diets and suchlike. We may assume that these patients rather
find their way to a psychotherapist and, after their fears having dissipated, are
referred to the appropriate physician. Every campaign arousing fears of elec-
tric shock therapy, (compulsory) hospitalization or psychotherapy is likely to
increase this group in size.
The triggering of psychotic episodes by psychotherapy is witnessed rarely.
We do have evidence, however, that psychotherapy delays or retards the
outbreak of an evolving psychotic episode, but does not permanently avert
it, and that it may eventually manifest during an ongoing psychotherapy.
2.1. The regulations of the Psychotherapy Act assure a broader knowledge of
medical issues for the psychotherapist than it is presently the case with the
average state of knowledge of a practicing physician, where psychotherapy is
concerned. The future experience will reveal, however, whether amend-
ments or additional focuses are needed. Ample internship periods assure, by
any means, sufficient tangency with the medical reality and are, within a
cooperative exchange, apt to heighten the state of reconnaissance on both
sides.
2.2. Legal regulations safeguarding patients should be targeted towards pro-
moting collaboration between doctors and psychotherapists, and to guaran-
teeing the patient's free access to wherever her trust may tend to. Interrup-
tion of the treatment process, due to external influence, makes the therapist
infringe upon the rulings of the Psychotherapy Act, which stipulate that she
refer the patient to further treatment in cases of interruption or premature
ending.
Appendix 2: Supreme Court Decisions
A Supreme Court Decision of 18 August 1998 reads as follows: with the 50 th
amendment of the General Social Insurance Act (ASVG), psychotherapeutic
treatment conducted by persons who, as per 9 1 of Psychotherapy Act, Fed-

44
Diagnostic Guideline for Psychotherapists
eral Law Gazette (BGBI) 1990/361, are authorized to independently practice
psychotherapy within the framework of disease treatment are put on a par
with the medical professions; ... If thus psychological disorders are of patho-
logical concern (of "illness valence", thus the wording of 9 120 para. 1 fig 1
in correspondence with 9 133 para. 2 of the General Social Insurance Act
(ASVG», the Social Health Insurance Scheme is obliged to bear the expenses
of this treatment and/or the diagnostic action involved in this treatment (see
9 133 para. 2 of ASVG), according to 9 135 para. 1 2 nd sentence lit. 3 (ASVG),
which has been added by the 50 th amendment of ASVG, albeit with the re-
strictions ruled thereabouts.
9 135 para.1 2 nd sentence lit. 3 of ASVG provides that, within the frame-
work of the illness treatment (9 133 para. 2), the psychotherapeutic treatment
conducted by persons who, as per 9 1 Psychotherapy Act, Federal Law Ga-
zette (BGBI) No. 361/1990, are authorized to independently practice psycho-
therapy within the framework of disease treatment, are put on a par with the
medical services, provided that an examination by a medical doctor has
been carried out and confirmed before or after the first, or in any case previ-
ous to the second psychotherapeutic session. As per 9 133 para. 2 the illness
treatment must be satisfactory and appropriate and must not assume undue
proportions. The illness treatment should care for health, the ability to work
and the ability to cater for one's vital needs, i.e., reestablish, stabilize, or
improve them.
The treatment of serious developmental deficits and disordered conduct
of a person under age exhibiting clinically significant disorders, the reduction
of which requires psychotherapeutic treatment, may even then be allocated
to the liability of the Social Insurance Scheme when the behavioral disorders
have been caused by environmental factors (see OGH as from 18 August
1998, 10 Ob S 250/98g).
Concerning psychotic disorders of children, the Supreme Court ruled that
these have to be attributed high illness 'valence' (see OGH 8 September
1993, 9 Ob A 218, 219/93).
Concerning transsexual ism, the Supreme Court (OGH) ascertained that those
cases have to be valued as disease in whom the inner conflict between the
physical sex and the psychological gender identification with the other sex is
distinct to the extent that the symptoms of psychic illness can be removed or
alleviated only by the reduction of this tension. The illness treatment relevant
for the application for cost absorption does not commence as late as with
the transgender surgery, but also includes psychotherapeutic treatment (OGH
12 September 1996, 10 Ob S 2303/96s).
According to the OGH Decision, however, the elimination of the depres-
sive state of a childless woman by medical (in vitro) fertilization does not
constitute indication of treatment in the sense of the ASVG. The issue of cost

psychotherapeutic Guidelines
45
transfer can only pertain to an actually disordered condition of a woman
who is distressed for not having given birth to a child; in cases where merely
the danger of serious damage of her mental condition (i.e., of the potentiality
of falling ill in future in the legal sense of the ASVG) has to be averted, legal
action on the matter would a priori have to be regarded as mistaken: The
sheer possibility of psychological strain turning into an emotional disorder of
illness valence or, in other words, the sheer contingency of psychic illness
does not constitute an illness in the sense of 9 120 para 1 lit. 1 ASVG (see
OGH as from 23 June 1998, 1 0 Ob page 11 5/98d).
In terms of the social purpose of the health insurance, the necessity of
illness treatment is given in the case of permanent conditions even then
when it serves the goal of merely rendering a patient's suffering more toler-
able, and for the purpose of prolonging life (OLG. W. as from 15 March
1963). Principally, the health insurance scheme has to stand for permanent
conditions also, as long as their evolution has not ceased yet and treatment
is still required (OLG. W.5 as from October 1962 and 26 September 1980).
The overall agreement in the negotiation between the Umbrella Associa-
tion of the Austrian Social Insurance Carriers and the Austrian Federal As-
sociation for Psychotherapy still awaits conclusion. In its appendix 1 1 1 ZI,
the concept of psychological illness is defined as follows:
As per 9 120 para. 1 ZI and 133 para. 2, psychological illness is an ir-
regular (pathological) disorder caused by psychic or physical factors, and it
requires treatment; by this treatment, health, the ability to work, and the abil-
ity to cater for one's vital needs shall be reestablished, stabilized, or im-
proved, if procurable. Psychic illnesses are only partly, if at all, accessible to
the patient's volitional control; they are recognizable by psychic, physical
symptoms, or by pathological behavior patterns (disturbed perception, con-
duct, processing of one's experiences, social relations and bodily functions).
It is only when the disordered relationship is associated with an irregularity
or (pathological) alteration of a person's psychological or physical state and
treatment becomes necessary that the disturbed social relations are consid-
ered as the manifestation of psychic illness.
Acknowledgement
For the elaboration of this diagnostic guideline we owe our special thanks to
the following persons:
Heinrich BARTUSKA, Gertrude BAUMGARTNER, Inge BOLEN, Kathleen
HOLL, Robert HUTTERER, Eva GRUBER, Ursula MARGREITER, Gerda
MEHTA, Eva MOCKSTEIN, Erwin PARFY, Gerhard PAWLOWSKY, August
RUHS, Andreas TUCHACEK, Michael WIESER, Stefan WIESNAGROTZKI.


Explanatory Notes and Definitions
MANFRED BUCHSBAUMER & EDS.
1 Distinction between diagnosis and indication
A diagnosis is the professional assessment of a current condition, whereas
indication is the determination and the specification of the necessity of treat-
ment. An indication can only be established subsequent to and as a result of
a professional ascertainment (diagnosis).
2 State of the art
In this context, the expression denotes the present state of a science, or of
the art of healing (see Austrian Psychotherapy Act (PthG 9 14 (1): JJto the best
of one's knowledge and with respect to the development of the cognitions of
the science"). Hence, the psychotherapeutic process is given precedence
over diagnostic practice. The diagnostic process is an accompanying one,
taking place within the psychotherapist's mind.
3 Process
The word denotes the course of treatment and the influence exerted here-
upon by psychotherapy and/or medical attendance. Healing is a process the
physician influences and tries to control by giving medication or by applying
physical means. In psychotherapy, the participation of a competent profes-
sional and, hence, the therapeutic relationship are emphasized, since repeti-
tions will occur in this therapeutic relationship and, therefore, new patterns
of experiencing may be framed.
4 Claims of omnipotence
Claims of omnipotence would entail that all essential psychotherapeutic and
diagnostic considerations are encompassed within psychotherapeutic diag-
nostics. This is definitely not the case.

".....
48
Diagnostic Guideline for Psychotherapists
5 Unitary diagnostic system
Psychotherapeutic diagnostics is not meant to be a unitary system, but a
common basis for method-specific diagnostic elaborations. We rather submit
a guideline for a minimum standard of psychotherapeutic diagnostic investi-
gation.
6 Idea of Wolman
Thus we make allowance for the manifold concepts of the nature of the hu-
man being to be recognized.
7 Understanding of psychogenesis
This is an explanatory hypothesis of the cause of a disorder/suffering.
8 Consolidated, systematized pragmatic guide
The fundament of the present paper rests on the long-standing, palpable,
practical experience gathered by the Research Committee members, on the
basis of their different methodological backgrounds as well as their manifold
professional contexts. During discussion, method-specific concepts were
modified, and new ones were searched for until consensus was reached. In
analogy to the metaphor 'architect - stress analyst' (see also 'History of Ori-
gins'), the working hypothesis was to view the psychotherapeutic relation-
ship and the diagnostic thoughts, which are rarely made explicit, as relating
to each other in a similar way.
9 Why this order?
A logical sequence of routines, which often intertwine in practice, is sensible
since many psychotherapists set certain priorities in their practice and are
accustomed to certain referral modes. Referrals to the representatives of
other methods are practiced only rarely. Usually, a man does not bring along
his wife and his child or has them wait in the anteroom when he sees a psy-
choanalyst for an intake interview. In such a case, referral to a professional
of a different method, for instance family therapy, in which the issue of
boundaries and abstinence is managed differently, should be considered.
10 See Introduction 'History of Origin of Psychotherapeutic Diagnostics'.
11 Method-Specific Diagnostics
The method-specific diagnostics should be based on a common psycho-
therapeutic one, unless the latter is comprised in the former.
12 Process of discovery
The Research Committee based their assumptions on the hypothesis that
there is a common ground to diagnostic thoughts which have, however, not

Explanatory Notes and Definitions
49
been explicitly formulated and defined yet. These similarities between psy-
chotherapists had to be discovered.
13 Descriptive verbal patterns
Putting things into words is the psychotherapist's most important tool, along
with nonverbal modes of communication and enactments, which are both
forms of acting-out what needs to be expressed.
14 Transparency
As a professional group, psychotherapists have to be capable of offering
transparency when collaborating with other professionals, particularly re-
garding the criteria and standards they abide by when establishing their pro-
fessional assessments (see also PthG 'Clarification of Facts and Collaboration
9 14 (2».
15 Of illness status or valence
This term signifies a clinically significant disorder that is legally equivalent to
an 'illness'. For its content see also annotation 58.
16 Method-specific diagnostic systems
See chapter 2, 'Management and Application of Psychotherapeutic Diagnos-
tics from the Different Methodological Perspectives'.
17 Ascertainment of event insured
If the financing of the treatment is left to the health insurance scheme, at
least the treating psychotherapist, by her diagnosis, should have ascertained
the need for it.
18 Administration
This denotes the administration of the health care system (hospitals, out-pa-
tient facilities, health insurance companies, rehabilitation centers, etc.).
19 Inadequate coping strategies and attempts
On principle, inadequate means are appropriate strategies which are, how-
ever, unsuitable for the occasion of decreasing damage, but rather contribute
to the preservation of a present disorder. Thus strategies of self-assertion, for
instance, may make sense in some cases, but are inadequate for winning the
disadvantaged person's sympathy.
20 Sets of rules
This expression points to societal norms: legal, moral, ethnic, familial, reli-
gious, individual, nonverbal norms and those guided by expectations, proph-
ecies, etc.

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50
Diagnostic Guideline for Psychotherapists
21 Subjectivity of experiencing and suffering
A patient describes the following nightmare which horrifies her. Her mother's
head is lying on a judge's table and is still capable of speaking and of forcing
her to do things. The dream is a dreadfui experience for this particular pa-
tient because it illustrates the force she herself puts on her in order to make
herself work, which is experienced as a constant torture (or slavery) as the
mother used to practice it on her. There are no objective criteria for judging
whether she suffers in her work or not.
22 Dimensions
They denote all levels of reflection or all points of view.
23 Establishing an indication
When establishing an indication, clear decisions have to be made. We call
the psychotherapists' attention to the necessity of drawing a clear distinction
between the existence and the absence of an indication, between the neces-
sity or non-necessity of further clarification, and between the selected meth-
od-specific treatment options.
24 Circumscribed symptom clusters
They are the case when a patient who lives in a sound and satisfying (social)
environment develops a phobia.
25 Monosymptomatic diagnostics
To this day, the approach of relying on one symptom only has never been
satisfying to psychotherapists. See 'Motives for Classification' under 'Psycho-
therapeutic Diagnostics.'
26 Personality Diagnosis
When confronted with symptoms, psychotherapists usually find it indispen-
sable to assess the personality (as to its structure and dynamics) and to diag-
nose whether or not the person is able to establish and to sustain relation-
ships (e.g., when s/he exhibits psychotic symptoms); in cases of compulsive
symptoms, such as obsessive washing, it should be determined whether the
symptoms serve as a protection from lapsing into a full-blown psychosis, or
whether they represent the attempt to wash away one's guilt feelings, which
may be the manifestation of hidden evil intentions (JlWhich personality struc-
ture does a symptom of that kind emerge from?JI).
27 Existential endangerment
Can consist in the loss of income, profession, job, dwelling place, or relation-
ships. A precarious divorce situation, for instance, can trigger an acute dan-
ger of suicide in an otherwise well-balanced individual.

Explanatory Notes and Definitions
51
28 See chapter on 'Relationship'
29 Explicit standards
During the introductory ('propaedeutic') studies, general psychotherapeutic
principles are discussed and put to the test, while during the method-spe-
cific training the principles of the particular method are taught.
30 See chapter on 'Reflection and Self-Reflection Requirements'.
31 Benevolent attention
A benevolent, stimulating and trust building attention and a neutral attitude
require sufficient experience in one's self-reflection abilities, particularly
when dealing with issues of aggression, abuse, distrust, betrayal, etc.
32 Reflective proceeding
During training and experience as a professional, a considerable amount of
reflection training is required, since it is imperative to integrate self-aware-
ness, supervision, and theory in these reflective experiences.
33 Unusable topics and contents
These consist in the psychotherapist's personal aspirations and penchants as
well as her problems and private conflicts, which would not only be unfavo-
rable to the therapeutic process but also hamper it significantly.
34 Pre-information
Despite the therapist's dispassionate and matter-of-factly attitude, scheduling
an appointment via telephone or having somebody referred to by a col-
league produces expectations; they constitute a first impression, which has
to be complemented or else revised altogether.
35 Shaping the relationship
A relationship sets in at the very first minute of the contact between the par-
ticipating individuals in the 'here and now'. For instance, it is relevant even
how a person acts when waiting, entering the room, taking her seat, etc.
36 Relevant variables
Depending on the methodological approach, for instance, conflicts, prob-
lems, disorders, excitation, short-comings, moods, intangible material, etc.
are picked up, confirmed, explored, or requested.
37 Pre-experiences
Pre-experiences exist on the psychotherapist's part (see also 'Reflection Re-
quirements'), which stem from her personal history as well as from her pro-

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52
Diagnostic Guideline for Psychotherapists
fessional experience. On the patient's part, pre-experience includes her
strategies of handling social situations, such as making them escalate or de-
escalate. These correspond to different fundamental patterns, which usually
hold a wide scope of possibilities to shape them.
38 Relational patterns
These are well practiced experiences as to how to establish and to shape a
relationship, an activity in which greater importance is attributed to the flex-
ible than to a rigid application of one's relational patterns.
39 Reactivated pre-experience
Various specific methods pick up the reactivated pre-experiences in different
ways and attribute different contexts of meanings to them. This entails that
there is a vast variety of attributions in psychotherapy which, in turn, consti-
tutes a rich repertoire of contexts and understandings as well as possibilities
of development.
40 Psychogenesis
Genesis denotes the history of origins of experiences which contribute to
one's idea of wolman.
41 Impossibility to connect
For example, a patient introduces the conversation by "Unless you are a
Catholic I cannot speak to you."
42 Lack of boundaries, relational ability, and willingness
Examples: a patient declines to switch off her cell phone; a patient goes to
the toilet every ten minutes; a patient keeps emphasizing that she is not in
need to speak to a therapist, and that this consultation is unnecessary and
ridiculous.
43 See guidelines B.1.2
44 Parameters for the choice of a specific therapeutic method
We have to take heed as to which therapeutic method and which setting are
most suitable for a given patient. Information on these parameters is gained
by hands-on training and by further education.
45 See 'Differences in Comparison with Medical and Psychiatric Diagnos-
tics'.
46 Preconditions
These exist for almost all the cases: if a person's responsibility is not limited
in any way, she will not consult a psychotherapist.

Explanatory Notes and Definitions
53
usually, psychotherapists still act on the assumption that their patients come
by their free will and self-responsibility. Within the context of the in-patient-
care facilities, particularly in cases of coercive hospitalization, decisions are
often made against the patient's will, as to whether s/he will undergo psycho-
therapy or not. Often patients are not informed and have no idea as to what
psychotherapy is like. Nevertheless, we have to act on the assumption that
there is a certain voluntariness and expand it.
47 The patient's voluntariness
A minimum freedom of choice always exists for the patient ("Willi talk to the
psychotherapist or not?"), and it is expandable as well.
48 Noncompliance
The translation of the word is: resistance, blockage, fixation, failure to com-
ply with, or even incorrigibility. No matter whether noncompliance manifests
as disobedience or incorrigibility in the face of a medically mandated thera-
py, or as skepticism towards it, or as resistance/skepticism towards psycho-
therapy, thorough work on it is obligatory. From these endeavors, valuable
hints will arise for diagnosis and the therapeutic process.
49 Iatrogenic diseases
Iatrogenic diseases within medical treatment are those accruing on top of the
primary one/s; they are caused by improper treatment and/or errors in the
system. Within the psychotherapeutic context, the specific improper or in-
correct third party influence should be given priority in diagnostics and in
treatment. If, for example, somebody has been told that his manic condition
is a sheer metabolic disorder and has nothing to do with emotional conflicts,
the further psychotherapeutic treatment will be blocked, as long as this
purely biologistic view has not been dealt with and clarified properly. Fur-
thermore, any influences from psychotherapeutically incompetent persons,
who interfere by hampering or misleading the patient by giving explanations
on the emergence and/or the causes or the context of his ill, fall in this cat-
egory.
50 Diagnostic process
The diagnostic process accompanies the therapeutic one and has an impact
on the therapeutic issues and on the tentative interpretations of the therapeu-
tic course.
51 Hampering ideas
Example, "I am suffering from this heart attack and this is my problem, so
what am I doing here with you? I have already had 17 cardiograms and I
have brought the pictures, so please have a look at them!"

.........
54
Diagnostic Guideline for Psychotherapists
52 See chapter on 'Handling and Implementation from a Methodological
Point of View'. For example, a sufficient degree of abstinence in psycho-
analysis.
53 For the metaphor 'architect and stress analyst' also see annotation 8 and
the chapter on 'H istory of Origins'.
54 Lack of awareness
A patient who is partly counterbalancing her problem is not aware of her
problematic emotions. She is in high spirits, and a sense of euphoria prevails,
which is incommensurate with her real life circumstances.
55 Crisis
A person who is stable on her relational and on her symptom level attempts
suicide because of an impending loss or actual deprivation. The situational
component may lead to an acute crisis.
56 Exploratory behavior
This is the increased activity of searching for indefinite improvement strate-
gies, and for supposedly satisfactory solutions in various areas of life.
57 Disintegration of functions
These include disturbed thinking, emotional flooding, misjudgment of reality,
etc.
58 Disorder of disease status ('disease valence')
We make an essential distinction here. Disorders which may be classified as
diseases or bear disease status, as it were, are far more apt as a psychothera-
peutic notion than the concept of disease itself, since it acknowledges the
healthy aspects (resources) and gives the opportunity to regard the underlying
problem or conflict as something plausible and generally human. When we
adopt this attitude, the one-sided dependence on fate and on treating special-
ists is not taken as a fait accompli, but as changeable, whereas the concept
'disease' leads to a sense of passivity and stigmatization, which is adversary
to any active work towards developing coping skills. The demand on the pa-
tient to recognize herself as ill is often experienced as an imposition to submit
to a therapy plan which has been forced on her from outside, regardless of
her will. This is likely to be perceived as humiliation, debasement, or abuse.
If we use the term disorder of disease status (or 'valence'), the condition of
suffering is addressed primarily because the patient is not at ease with his
day-to-day-existence. Not only is this less offensive, but also more accepta-
ble and more comprehensible. The patient is thus addressed as an active
person who has to come to terms with his suffering.

Explanatory Notes and Definitions
55
59 Somatic illnesses
To learn to live with physical illnesses, to plan and to carry out the necessary
adaptation, and to give up the former life style often necessitates psycho-
therapeutic help for a successful reorganization process to take place.
60 Interaction structures
Hereunder, we understand the acquired behavioral and interactive skills in a
given social field (family, significant others, partnerships, work, culture, etc.)
as well as the intrapsychic images of these social interactions which go back
to past experiences and the conclusions drawn therefrom.
61 Other forms of clarification
Are social work, logopedics, physiotherapy, etc. needed also?
62 Differentiation of functions
This is recommended, because the commingling of roles (e.g., when medica-
tion is prescribed first and psychotherapeutic treatment conducted thereafter
by the same person) most probably enhances the dependency of the patient,
for she may easily insinuate this subjective meaning of being dependent. The
psychiatrist's main task is to put forward her opinion by saying "Please take
these drugs". And it is the psychotherapist's main task to question this, "What
made you take these drugs?"
These two functions cannot possibly be carried out within the same session
and still remain distinguishable to the patient (role diffusion).
63 Automatic referral
In some cases, the social insurance companies request a psychiatric or clini-
cal psychological diagnosis as prerequisite to (further) cost absorption. The
delegation principle, which entails that the psychotherapist takes up her
function upon a physician's referral only, does not put the psychotherapist in
the position to carry out an independent, self-reliant treatment of disorders
of disease status.
64 Prospective treatment
It is usually within the first few minutes that the psychotherapist develops a
clear picture if the patient needs psychotherapy. In so doing, the psycho-
therapist thinks of carrying out this therapy herself; this idea should be
closely scrutinized, however.
65 Specific indications
With some patients, three or four sessions a week are required to thoroughly
work through a certain problem. Within the setting of psychotherapeutic in-
patient facilities, between 5-7 sessions of group- and individual therapy are
necessary, in case the disorder takes a critical course.

.....
56
Diagnostic Guideline for Psychotherapists
66 Intense acting-out
To give an example: refusing to leave the therapist's office; to load the psy-
chotherapist with presents; to contact the psychotherapist off-time to discuss
therapy issues; to commit aggressive acts without any endeavors to explain
them, etc.
67 Character of the individual
Each demand is experienced as conflict causing and strenuous.
68 See also annotation 24.
69 Reciprocity
Reciprocity denotes the collaborative interplay between two or more part-
ners. These may make use of the benefits of cooperation along the way and
after. In so doing, mutual correction and amendments will occur, which will
lead to harmony.
70 Subjective meaning
In this context: an extensive abdication of one's personal goals.
71 Setti ng
A gentleman, for instance, brings his wife and child for the intake interview
with a psychoanalyst and wishes them to be present and to participate. This
precondition rather lends itself to the setting of family therapy than to indi-
vidual psychoanalysis.
Translated from the German by Luna Gertrud Steiner

2. Management and Application of
Diagnostics from the Different
Methodological Perspectives

Analytical Psychology (AP)
BENEDIKT LESNIEWICZ
Introduction
Diagnostics in the practice of analytical psychology (AP) has to be viewed in
the context of the image of man, the epistemology, and the basic concepts
of the Jungian school. Its characteristics vary, depending on whether chil-
dren, adolescents or adults are to be diagnosed.
Image of Man and Theoretical Concepts
Analytical psychology traces the cause for mental suffering and symptoms in
the disordered individuation toward psychic maturation which is regulated
by the Self. It is an interactive process between the unconscious and the
conscious, aimed at differentiation and completion towards wholeness. In
this process, the relationship between the ego and the Self is held to be of
major importance. A mental disorder is experienced as 'alienation from the
Self' or 'disunification' with oneself which, nonetheless, bears opportunities
for finding oneself and meaning (cp. Jung, CW 10,  361).
From the very beginning, the human being relies on communication with
significant others in order to develop as an individual and to cope with psy-
chological crises. Therapies of considerable length are sometimes needed to
experience corrective relationships and to finally catch up with the expected
level of maturation. In Jungian analysis, the psychotherapeutic relationship,
the work with dream symbols and images, and also the spiritual dimension
are meaningful. In the creative psychotherapeutic process, neither standard-
ized techniques are used, nor are pre-formulated targets striven for. The fo-
cus of the analytical work is to become aware of, to work through and to
integrate disruptive behavior patterns, internal and social conflicts as well as

....
60
Benedikt Lesniewicz
structural disturbances in a free and protected space. The basic goals are
individual development and the appropriate handling of vital crises, mental
disorders and diseases and, finally, to experience the meaningfulness of life,
well-being and equanimity.
Theory of Cognition and Diagnostics
Jung formulated his epistemological standpoint as follows "That, logically, is
also the principle of my own method: it is, at bottom, a purely experiential
process..." (CW 8,  421).
Diagnostic cognition is basically about the understanding of the individu-
al and personal in the other, with the help of one's own feelings and experi-
ence. When relating to the other, she or he enters our subjective perception
field, leaving traces of their behavior and being. In this 'intersubjective
space', objective, phenomenologically comprehensible and thus diagnostic
experiences are likely to happen by our perceiving the other's appearance,
his or her verbal and non-verbal utterances, and by utilizing our empathy,
the transference and countertransference. Jung held the view that the de-
scription of "the phenomenology of those psychic processes which manifest
themselves in the course of treatment and do not have their counterpart in
medicine" (CW 16,  211) has constituted the psychotherapeutic way of di-
agnosing that was independent from the medical art.
Jung advised against premature diagnostic decision-making, emphasizing
the process-related character of any diagnostic investigation which, in his
view, was a progressing process of understanding - "The content of a neuro-
sis can never be established by a single examination, or even by several. It
manifests itself only in the course of treatment." A diagnosis should be re-
vised and amended over and over: "Hence the paradox that true psycho-
logical diagnosis becomes apparent only at the end" (both quotations CW
XVI,  197).
Basically, the diagnostic clarification in analytical psychology has a phe-
nomenological-descriptive character, which comprises dynamic, nosological
and typological aspects.
For the evaluation of Jungian psychotherapeutic processes, the so-called
operational diagnostics (OPD) approach has proven of value. OPD is a
screening method specific to psychoanalysis and applicable to the theories
of AP. It has been used for the purpose of monitoring the process and of re-
viewing the results of Jungian psychotherapies. Psychodynamic screening
and change measurement, carried out by a research team (Mattanza et al.
2003), were at the core of these studies. The introduction of the process-ori-
ented OPD in diagnostics within AP has proven to be helpful, mainly due to
its psychodynamic variables.

Analytical Psychology (AP)
61
A further diagnostic approach is based on empirical research methods. In
the association experiment (AE - originally due to Falton), auxiliary scientific
measurement methods are utilized for comprehending mental disorders.
Today, AE is still being applied in its original form as it was developed by
Jung himself (Kast 1980). Jung found that retarded responses were indicative
of complexes, Le., of largely unconscious affect-laden constellations, in
which experiential patterns, acquired in the past, were stored as emotions. A
complex can be activated by certain internal and external triggers. Com-
plexes affect our perceptions, our ways of experiencing and our relation-
ships. Complexes have an impact on our personalities, and they cannot be
expunged by therapy. They rather have to be integrated, to the extent that
their inherent developmental potential can be set free. In the course of fur-
ther research and further differentiation, the complex theory has become an
important diagnostic instrument in AP.
Future prospects: The results of infant research are part of the curriculum
of many Jungian training institutes. The relevance of early communication
processes and of attachment theory for analytic work has been duly recog-
nized, whereas in diagnostics, the results, till now, have not been considered
satisfactory (Jacoby 1998).
Handling of Psychotherapeutic Diagnoses in Analytical Psychology
AP does not possess a consistent, nor standardized diagnostic system. The
concept of man, the epistemology, the approach to neuroses/complex theory
and the therapeutic practice of AP are models which have affected psycho-
therapeutic diagnostic action. Models usually structure a subject; they illus-
trate it and facilitate reflection.
Diagnosing is a process. The diagnostic procedure can be discriminated
from the psychotherapeutic process only formally, and by its goals. Hence,
from its very beginning, the goal-oriented therapeutic aspect is interwoven
in the diagnostic operation. The personality of the psychoanalyst and her
subjective experience are interlaced in the diagnostic process. Simultane-
ously, diagnosing is an objective and empirical cognitive process. Jung held
the opinion that, in diagnosing, "the whole human being" had to be per-
ceived in his individuality (cp. CW XVI, 199f).
The symptom-oriented procedure may serve the manageability of a diagno-
sis, but it neglects the assessment of the individual. The point of diagnostics is
to perceive and to understand a person's essential traits as to his developmen-
tal potential and to his conflict solving strategies. The purpose of diagnosis is
to help find the best possible, differentiated and appropriate therapy options.
The analytical psychotherapist has available a whole range of diagnostic
routines such as history taking (exploration), the comprehension of current

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62
Benedikt Lesniewicz
symptoms, her personal impression, complex diagnostics, and projective
material gained from transference and countertransference, or from dreams
or visualizations. Should the standard diagnostic clarification be insufficient,
tests such as the AE, the T A Tl, the Rorschach and/or the Sceno may be ap-
plied. With personal or social-typological conflicts, the MBTF test, based on
Jungian typology (CW VI), can also serve clarification (Myers, Briggs, 1989).
Diagnostics with Children
The diagnostics of children, juveniles and adults differ in character because,
with each group, one has to adhere to different methodological theories. The
disparate life situations and psychodynamics of these patient groups require
fitting diagnostic procedures. The personality structure of children has not
consolidated yet; they are emotionally dependent on their environment to a
large extent.
The psychotherapist's empathetic attitude and her or his ability to engage
in dialogic relationships are highly essential if she or he wants to diagnose
children successfully. From the very beginning, mutual communication will
evolve, on the conscious as well as on the unconscious level. This explains
why, after only a few clarifying sessions in some cases, therapeutic effects
are witnessed. Dialogue implies that the psychotherapist knows her- or him-
self and is also capable of utilizing transference and countertransference-
phenomena for self-reflection.
Symptoms in children have to be viewed against the background of their
life situations and their psychological developmental stage. AP acts on the
assumption that children are usually capable of symbolically processing their
psychic conflicts in the creative processes of playing and shaping. The diag-
noses of children utilize the free and protected encounter space as a medium
through which the quality and the conscious and unconscious dimensions of
the therapeutic relationship may be grasped, and as a space in which sym-
bolic/projective material unfolds. The degree of psychic maturation may be
ascertained gradually, depending on which transitional objects emerge (Win-
nicott). Complex-related phenomena are apprehended in their manifold
qualitative aspects. Diagnostic media are sand play, children's drawings, the
Sceno, the CAT3 and other projective tests. In the subsequent therapy, the
diagnostic process will continue. The symbolic material surfacing in images
or in sand play is continually reflected on under the aegis of both diagnostics
and therapeutics, and incorporated in the work that follows (Rasche J 1992).
The parents are involved in history taking, by which the family dynamics
1 Thematic Apperception Test (translator's note)
2 Myers Briggs Type Indicator (translator's note)
3 Children's Apperception Test (translator's note)

Analytical Psychology (AP)
63
becomes apparent and is noted. The subsequent reflective hypothesizing
involves clarifying the relational abilities, the motivation for psychotherapy,
and the symbolic ability (which in some cases is only developed in the
course of therapy). The clinical diagnosis is usually established along the
lines of ICD-10 classifications. Furthermore, the indication of either an indi-
vidual therapy (which, in analytical work, includes working with the parents),
or other therapy settings (e.g., group or family therapy), or of further exami-
nations has to be established.
The diagnostic process with juveniles is not too dissimilar from that of
adults. The psychotherapist needs specific abilities for associating with young
people, and she has to be aware of their autonomy-detachment conflicts.
Adolescent crises are characterized by particular psychic instability. When
talking with a young person, his or her capabilities of self-observation and
introspection into his own problems are ascertained. Due to the rapid
changeability and development at this age, diagnoses are difficult to make.
When assessing the degree of severity of a psychological disorder, the con-
text of the external reality and of the endopsychic fluctuations between
progressive and regressive tendencies has to be taken into account. At the
beginning, patients tend to dissimulate and to downplay the severity of their
problems. In such situations, countertransference reactions are helpful. No-
ticing and appraising one's physical sensations, feelings and fantasies con-
tribute to assessing the patients' state of mind. In countertransference, the
immature and complex-laden aspects of the patient are reflected. By pro-
ceeding this way, ego development as well as the ability to establish relation-
ships may be estimated (Bovensiepen/Sidoli 1999).
Diagnostics in Adults
The basic material for diagnostic hypothesizing in adults is the patient's ap-
pearance, his or her description of her own problems and their symptoms.
Theses particulars are correlated with the life history and the current life cir-
cumstances of the affected individual. The history is taken in the first ses-
sion. Intuitive impressions may be added to the observation and then veri-
fied as to their validity. Noticing and reflecting countertransference and
complex phenomena, which make themselves felt in the relational space,
point to the particular psychodynamics and to psychopathology. In this con-
text, the ability to attach and to relate as well as the motivation to undergo
analytical psychotherapy have to be examined. The psychoenergetic status
bears diagnostic significance, too. It includes the apperception of the degree
of vitality, exhaustion, flexibility, firmness, regressive versus progressive
tendencies, and the personal access to creativity. The gathering of these
impressions contributes to the formation of hypotheses. They are the pre-

64
Benedikt Lesniewicz
requisites for the formulation of clinical diagnoses and for the preliminary
prognosis. The attribution of psychological disease patterns according to
Jungian theoretical concepts (parts of his or her shadow, complex distur-
bances such as anima and animus complexes, the ego-self-structure and
their respective disturbances, etc.) is now possible. Alternatively, the pa-
tient's mental situation will be diagnosed according io classification manuals
that are utilized internationally (ICD-10 or DSM-IV). An important function
of psychotherapeutic diagnostics is to support the indication of a depth-psy-
chological form of treatment, or, depending on the stability of the patient's
ego-structure, of either a more supportive, or rather analytical/uncovering
form of psychotherapy. Medical records have to be drawn on in the diag-
nostic process to preclude somatic illnesses, or to support the potential indi-
cation of pharmacological treatment.
Diagnostics of Analytical Psychology with Regard to the
Guideline
The Guideline elaborated by the Austrian Ministry of Health and Women's
Issues (BMGF) for psychotherapeutic diagnostics breaks new ground and
indicates a development. It is, however, still necessary to further engage in
the adjustment and in the clarification of the concepts. The inclusion of an
independent psychotherapeutic diagnostic system for children and juveniles,
for instance, would be welcome and recommended, as psychotherapy of
these patient groups follows specific theories and treatment methods. If we
regard the Guideline as a framework for method-oriented diagnostics, the
diagnostic methods of AP fit in smoothly.
The description of Jungian diagnostics, provided in the foregoing, has
made dear that the basic dimensions of psychotherapeutic diagnostics (symp-
toms in relation to personality aspects, psychotherapeutic relationship, criti-
cal potential as well as the guidelines for indication) are being employed by
AP. The specific characteristics of diagnostic methodology rest on the AP
theory and its therapeutic practice, and they can be derived from them.
I want to substantiate this by an example taken from complex diagnostics.
Among all diagnostic methods of AP, this one has been developed the fur-
thest. Diagnosing complexes allow for a differentiated understanding of in-
trapsychic processes and encompass mental disorders, from minor neuroses
up to deep structural personality disorders.
The complex theory is a model of the psychic structure. It describes emo-
tionally recorded response and relationship patterns. Complexes crop up at
any time in the arena where the demands from the environment clash with
painful feelings of inadequacy or failure. Complexes arise from early child-
hood psychological traumata, or from emotionally insufficient social sur-

Analytical Psychology (AP)
65
roundings. At the same time, complexes image conflictual relationship pat-
terns of childhood and adulthood, including the attendant affects and cor-
responding stereotyped behavior patterns. The emergence of complexes
owes itself to a kind of split mechanism. Those personality parts which with-
stand integration continue to exist in the unconscious. Any experience that
impinges on the complex constellates it anew.
Seen from the psychopathological point of view, complexes illuminate
the origin of neuroses and psychoses. The neurosis is understood as an adap-
tive performance of the ego, which is unable to cope with the demands of
the environment and therefore seeks compromises, which then impede psy-
chological development. With more pervasive structural disorders, we find a
dissociation of the personality, which may reach deep into the areas of the
self (cp. Knox J, 2003). The psychological disturbances are described in a
psychogenetic way (in which they are seen in terms of the triggering or
formative situations and of the subsequent psychic development), or in a
psychodynamic way (in which the interdependence of endopsychic forces
and their interactions in relational situations are involved).
In a Jungian psychotherapy, complex constellations are experienced and
comprehended phenomenologically by transference and countertransfer-
ence reactions whereby the developmental potential is also taken into con-
sideration. In the context of symptoms and the structured nature of the ego-
complex or the ego-self-relation, differentiated dynamic diagnoses can be
formulated (Kast V 1998).
The foregoing description of complex diagnostics has shown how en-
dopsychic dynamisms can be accessed via relational experiences and uti-
lized for diagnostic purposes. Basically, diagnostic observations cannot be
explained by a model. Different perspectives correspond to different percep-
tional systems, theories, terminologies and preferences - even within the
Jungian school. The variety of diagnoses as described in this article will aid
the psychotherapist in finding the appropriate therapy method.
References
Briggs KC, Myers I (1989) Jung-Myers-Briggs Type Indicator Test (MBTI). Consulting Psy-
chologists, Palo Alto
Bovensiepen G, Sidoli M (1999) Anmerkungen zur Technik und zur Personlichkeit des
Analytikers. In: Bovensiepen G, Sidoli M (eds) Inzestphantasien und selbstdestrukti-
ves Handeln. Psychoanalytische Therapie von Jugendlichen. Brandes und Apsel,
Frankfurt a.M.
Dieckmann H (1979) Methoden der Analytischen Psychologie. Walter Verlag, Olten
Jacoby M (1998) Grundformen seelischer Austauschprozesse. Jungsche Therapie und
neuere Kleinkindforschung. Walter, Zurich Dusseldorf
Jung CG (1947/1969) On the Nature of the Psyche. In: CW, Vol 8, Bolligen Series XX.
Princeton University Press, Princeton

66
Benedikt Lesniewicz
Jung CG (1934/1970) The State of Psychotherapy Today. CW, Vol X, Bolligen Series XX.
Princeton University Press, Princeton
Jung CG (1945/1966) Medicine and Psychotherapy. In: CW, Vol XVI, Bolligen Series XX,
Princeton University Press, Princeton
Kast V (1980) Das Assoziationsexperiment in der therapeutischen Praxis. Bonz, Fell-
bach
Kast V (1998) Der Zusammenhang zwischen Diagnostik und Psychodynamik. In: e.G.
Jung-Institut Zurich (ed) Handbuch zur Supervision, Psychotherapeutische Super-
vision in der Analytischen Psychologie
Knox J (2003) Archetype, Attachment, Analysis, Jungian Psychology and the Emergent
Mind. Brunner-Routledge, Hove New York
Mattanza G et al (2003) Zur Wirksamkeit Analytischer Psychotherapien - Forschungsbe-
richt. Eine Forschung der Schweizer Gesellschaft fUr Analytische Psychologie und
des e.G. Jung-Institutes in Zurich-Kusnacht in Kooperation mit der Praxisstudie Ana-
Iytische Langzeittherapie (PAL). e.G. Jung-Institut, Zurich
Rasche J (1992) Sandspiel in der Kinderpsychiatrischen Diagnostik. Dissertation at the
Medical Faculty of the Free University Berlin
Translated from the German by Luna Gertrud Steiner

Autogenic Psychotherapy (ATP)
FRANZ SEDLAK
We, first of all, need to note the following: diagnostics in Autogenic Psycho-
therapy (ATP) must not content itself with asserting dystonic states. Autogen-
ic Training as a relaxation technique is only one component of Autogenic
Psychotherapy. As valuable relaxation may be as a preventive measure and
as a means of self-help in the stresses and strains of everyday life, Autogenic
Psychotherapy does reach beyond prevention, once we take note of the
manifold psychological implications latent in the clinical picture of vegetative
imbalance and dystonia. We are, therefore, called to take a diagnostic look
behind the face of the bionomic tension regulation (Le., eutonus understood
as buoyant resilience, and relaxation as a condition that replaces spasmodic
states and atony), and of optimized rhythmicity (which alternates between
active expansion and passive withdrawal), and to grasp and to therapeuti-
cally exploit the early matrices of experience as well as the prospective de-
velopmental potential. In the following we will demonstrate how the impor-
tant diagnostic guidelines intertwine with the diagnostic goals of ATP. The
author has developed a model, the so-called ATP-CUBE, to support the for-
mation of indications, working hypotheses, and the selection of techniques
within Autogenic Psychotherapy. The ATP-CUBE is a three-dimensional
model which interrelates the following therapeutic concepts: the methodical
levels of ATP (such as basic, intermediate and advanced; B, M & A), and
basal therapeutic dimensions such as temperature, rhythm, and constancy,
basal developmental abilities such as regulation, differentiation, and integra-
tion; the fundamental relational topic or stage, Le., the EGO-, YOU-, or
WE-stage. We will, furthermore, attend to the developmental approach: to
sensing, feeling, thinking as the roads of access and their respective struc-
ture levels. This broad diagnostic and therapeutic attitude ensures a com-
prehensive modus operandi, despite the specifications of the numerous
schools (the pertinent statement in the Guideline reads, /leach scientifically

68
Franz Sedlak
recognized methodological approach defines, most of all, personality/ in its
specific way, be it as structure, style, dynamics, system, etc. These aspects
are given more or less momentum in the pertinent treatment models" (Guide-
line A.1.1.).
Figure 1 represents one segment of this model:
SENSING
---
---
y-axis --
relational stage
methodical levels
of ATP
/
/
/
/
x-axis
relational stage
basal developmental abilities
_ - z-axis
--
- relational stage
basal therapeutic
dimensions
Fig. 1
This model encompasses a number of concepts and, hence, excellently
serves diagnostic decision making within ATP; it, moreover, shows a number
of cross-connections with the Diagnostic Guidelines. To give a few exam-
ples: one concept employed by the ATP-CUBE is the psychosocial I-YOU-
WE-model by Sedlak (Sedlak, Chiba 2001). It envelops the I-stage of devel-
opment (the basic build-up of an adequate self-awareness); disturbances in
this area are noticeable by egocentric perceptions, infantile overestimation of
oneself, or auto-aggressive self-denigration. Secondly, the YOU-stage (i.e.,
basic dialogic ability and empathy); if this area is in disorder, empathy will be
wanting. And thirdly, the WE-stage (i.e., the sense of community based on
self-confidence and on the openness to relationships); disturbances in this
area breed, for instance, poor integrative capacities. In this context, an inter-
esting field opens between the dimensions 'Symptomatology in Relation to
Personality Aspects' (Guideline A.1.1) and that of the (psychotherapeutic) re-
lational abilities (Guideline A.1.2). Insufficient regulations (excesses or defi-
cits) may occur at each level, triggering reciprocal effects, and imbalancing
self-apperception and one's ability to form relationships. Disturbances on the
I-stage correlate with guideline 1, those on the YOU- and the WE-stages with
guideline 2. A closer inspection of these three areas (self-perception, forging
one's relationships and integrative abilities) also allows for a comprehensive

Autogenic Psychotherapy (ATP)
69
description of personalities (this is in line with the goals of the Diagnostic
Guideline: "Additional emphasis on a specific personality structure with
merely monosymptomatically diagnosed disorders, as it has been practiced
to this day, is regarded indispensable for psychotherapeutic diagnoses as
presently under discussion" (Diagnostic Guideline A.1.1). Diagnosing these
imbalances takes us straight to the formulation of therapeutic goals, such as
the development of ego functions. For those which have been obviously
disrupted at an early state of structure formation, ATP has specific diagnostic
approaches in store: by tapping the 'organic memory', the basic level of A TP
may reach down to the preverbal realms and thus to the first traces of ego-
formation, thus allowing for a new understanding of the claim voiced in the
Diagnostic Guideline, "Clinically significant disorders are also caused by cur-
rent over-strain in an otherwise healthy person. If the interaction structures
do not suffice for coping with physical illness, psychotherapeutic treatment
is indicated" (A.ll.l). The somatic aspect does not work as an important
therapeutic indicator only. Even with exercises on the basic level, the expres-
siveness of the organic and thus its diagnostic significance become manifest.
Conversely, the ego-functioning of differentiated perception expands to the
same degree, as the therapeutic relationship manages to channel and to re-
duce excessive tension caused by neediness, and to moderate them ade-
quately (as to their proportioning and to their situational adequacy), to the
extent that memory traces of specific stimulus-relaxation-patterns or stimu-
lus-tension patterns may be worked through. If we focus on the YOU-stage,
rhythm is the diagnostic and the therapeutic focus, i.e., the ability to oscillate
between self assertion within a relationship, and elastic adjustment to the
social environment. This, incidentally, is also one of the main goals of the
intermediary level of the ATP-procedure, namely the distinction between
socialization and individuation in a dynamic equilibrium. At this point, the
leading questions of Guideline B.1.1 (Guideline for the Symptomatological
Dimension in Relation to Personality Aspects), which deepen our under-
standing in interesting ways, are
- Does the patient's relational style rather encourage the psychotherapist to
offer much of structure, to be judgmental, or to be partial, or which other
relational cues does she bring in? and
- First, the patient's possibilities of relating have to be assessed and consid-
ered according to the following dimensions: perception, reciprocity, and
contact (Diagnostic Guideline, B.1.2).
Another component of the ATP-CUBE consists of the basal skills of regula-
tion, differentiation, and integration. Regulation is the dominant task of the
ATP basic level, on which the patient is encouraged to find her bionomic
middle and, hence, her ideal regulation pattern. In ATP, the affects associat-
ed with the whole-body tension regulation are made conscious, not only as

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70
Franz Sedlak
innate patterns responding to triggering stimuli, but also as fundamental ori-
entation mechanisms. Emotional autonomy is enhanced by the self-depend-
ent performance of actions (which manifest on each methodical ATP level:
by either self-guided exercises, or - literally - autogenic ones, or by inde-
pendent visualizations on the advanced level, a form of self-reliance or
courage for the autogenic, as it were, is facilitated in and by the therapist's
presence representing the primary care person). The enhancement of au-
tonomy, the development of adequate affect control, and the turning to-
wards mature object relations are all basic to the bionomic, autogenic ATP
approach. The bionomic regulation is the focus of the ATP basic level work.
Psychic inhibitions and repression are usually at the core of irregularities of
tone. The degree of how severely regulation abilities are disturbed affects
the issue of indication also. From the assessment of the risk level, various
necessities of action accrue to the psychotherapist (cp. 'Indications Accord-
ing to Degree of Risk level' B.1.1.). It further states that the degree of the dis-
turbed equilibrium in a person has to be estimated. The therein mentioned
fundamental capability of differentiating disparate behavioral and expressive
modes and their situational appropriateness, e.g., relational patterns and role
behavior (dominant vs. submissive, caring vs. rejecting, controlling vs. per-
missive, ... and needs, expectations, desires and volitions, cpo B.1.2) is the
focus of the ATP intermediary level. On this intermediary level, the self-
induced ('autogenic') focusing and the tranquility are used to observe which
problematic thoughts, feelings, and images surge up from an inner state of
equanimity to thus reduce anxiety and tension caused by specific issues and
problems. The thoughts, feelings, images, and personal ideas likely to come
up more easily in such a relaxed state, are taken up in chiefly supportive,
compensatory, and prospective ways (Sedlak 2000a and b). The focus of the
advanced level, however, is the more thoroughgoing integration, intra- as
well as interpsychically (cp. Diagnostic Guideline, A.ll.l, on psychogenesis,
on the changeability of the idea of the human being, the world-view, and
the life concept).
Another component of the ATP-CUBE is the psycho-ontogenetic ap-
proach of Sensing-Feeling-Thinking by Gerber and Reinelt (Gerber u. Sedlak
1990, Sedlak u. Gerber 1998). It is particularly related to Diagnostic Guide-
line 1, which is about the degree of severity and the interconnection be-
tween ailments and resources (B.1.1). There is also a specific link with the
Diagnostic Guidelines on indication, in particular where the demands (intro-
spection, understanding psychogenesis, potential resolution approaches,
motivation, or the willingness to change, Diagnostic Guideline, B.Ll) are
concerned, in addition to the diagnoses made in accordance with the princi-
ples of the various therapeutic orientations.
If a disorder is rather deep-reaching, we cannot set out from the concep-
tual level (thinking), or from the imaginative level (feeling) only, but we have

Autogenic Psychotherapy (ATP)
71
to look to the (patient's) sensory experiences. In this respect, the "organic
feedback" on A TP basic level which results from one's own body awareness
provides ample diagnostic and therapeutic cues. The more abstract level
(Le., thinking) reached on the advanced training level may be resumed and
fleshed out by sensory apperceptions via certain expedient exercises, to
name only a few in a vast variety of options.
Another thread of activity integrated in the ATP-CUBE is the concept of
warmth, rhythmicity, and constancy by G. Bartl (Bartl 1989, Gerber, Sedlak
1990). By "warmth, rhythmicity, and constancy", we mean 1) the favorable
relationship promoting development, the care for oneself and others 2) the
dynamic oscillation between assimilation and accommodation, or 3) the reli-
ability of a given framework, and the "red thread" apt to create a meaningful
life. These three factors are vital to personal growth and to the promotion of
a sense of community. It, therefore, makes sense to look out for them, while
we obtain ATP diagnoses. When doing so, we realize that there are distinct
foci to each of the three ATP levels.
Warmth Rhythmicity Constancy
Basic level Restori ng Building up confi- Bionomic self-
Goal: Finding one's relationship dence toward one's awareness = trusting
bionomic middle with self own bionomic circuits one's own reliability
Correlation with Focus of basic (whoever learns to
Diagnostic Guideline 1 level let go may rely on
himself)
Intermediary level Improving self- Improving elasticity of Self-assertion in the
Goal: Strengthening and object adjustment between face of intrapersonal
competence over relations assimilation and difficulties and inter-
oneself/self-command accom modation personal resistance
Correlation with passivity, expansion
Diagnostic Guidelines and withdrawal
1 and 2 Focus of intermediary
level
Advanced level Interconnect- Finding oneself and Analytical self-
Goal: Analytical self- edness with one's position awareness till
awareness and the whole between analysis and finding one's
meditative self- synthesis, self- existential values
development immanence, and self- Focus of advanced
Correlation with the transcendence level
concept of man, with
the weltanschauung,
and life concepts
Fig. 2

......
72
Franz Sedlak
According to the Diagnostic Guideline, all goals addressed in Fig. 2 are to be
realized in different settings (depending on whether a patient has reached
the 1-, the YOU-, or the WE-stage), thus following the encouragement of the
Guideline reading /IThe patient's resources and those accessible in her social
environment have to be considered. Thus, all settings possible, such as indi-
vidual, group, couple, or family therapy, should be pondered upon (Diagnos-
tic Guideline, A.11.3). Bischof gives a number of illustrative case vignettes
(Sedlak, 2005).
References
Bartl G (1989) Strukturbildung im therapeutischen Prozess. In: Bartl G, Pesendorfer F
(eds) Strukturbildung im therapeutischen Prozess. Literas, Vienna, pp 15-20
Bischof B (2004) Autogene Psychotherapie. Imagination 2, pp 51-61
Diagnostik-Leitlinie fUr Psychotherapeutinnen und Psychotherapeuten des Bundesminis-
teriums fur Gesundheit und Frauen auf Grundlage eines Gutachtens des Psychothe-
rapiebeirates, as from 15 June 2004
Gerber G, Sedlak F (eds) (1990) Autogenes Training - mehr als Entspannung. Eine ganz-
heitliche Betrachtungsweise des Autogenen Trainings in Ausbildung, Vermittlung,
Supervision. Ernst Reinhardt, Munich
Konig K (1986) Angst und Personlichkeit. Das Konzept vom steuernden Objekt und seine
Anwendungen. Vandenhoeck & Ruprecht, Gottingen
Sedlak, F. (1994) Neue Wege - neue Motive in der Katathym Imaginativen Psychothera-
pie. In: Gerber G, Sedlak F (eds) Katathymes Bilderleben innovativ. Motive und Me-
thoden. Reinhardt, Munich, pp 17-37
Sedlak F Gerber G (eds) (1998) Dimensionen integrativer Psychotherapie. Facultas,
Vienna
Sedlak F (2000a) Die besonderen Moglichkeiten der Mittelstufe der Autogenen Psycho-
therapie. Personlichkeitsentwicklung und Kompetenzsteigerung. Imagination 2000
Sedlak F (2000b) Wie wirkt die Autogene Psychotherapie. In: Hochgerner M, Wildberger
E (eds) Was wirkt in der Psychotherapie. Facultas, Vienna
Sedlak F, Chiba R (2001) Mit Traumen Brucken bauen. Self-published by Sedlak, Vienna
Sedlak F (2005) Die besonderen Chancen der Autogenen Psychotherapie. Published by
Sedlak, Vienna. Stock exhausted; free internet-download shortly
Translated from the German by Luna Gertrud Steiner

Daseinsanalysis (DA)
AUGUSTINUS KARL WUCHERER-HULDENFELD,
HANS-DIETER FOERSTER
The point of reference of the daseinsanalytical understanding of illness is
the human existence. Daseinsanalytical psychotherapy understands mental
distress as variants of unfree existence with regard to the environment and
the social surround rMit-Welt') in question. By exist-ing we do not denote
the sheer being-there (exist-ence) of something real, or the presence of the
sentient human being in his or her free responsibility, but the specific way of
being human (da-sein = being present), which consists in the fact that we are
and are indeed personally present, by each of us keeping open an area of the
world and relating to it and from it (freedom).
With this basic understanding, DA is well suited for the treatment of all men-
tal disorders, provided that the afflicted person is motivated, ready, and ca-
pable of dealing with his/her own existence and the conflicts involved. The
objective of therapy is to achieve an optimal ability to keep oneself open to
the respective segment of the world, to promote free existing by uncovering
the dasein and its dynamics, which revolves around being and not-being, life
and death, but also around being ourselves, caring for ourselves and others
(being-with), for our environment, and for everything animate and inanimate
that we encounter in the openness of the world.
The Daseinsanalyticalldea of Disease
The daseinsanalytical understanding of ill health rests on the idea that there
is well-being. The fundamental essence of good health may be characterized
as the ideal and free ability to dispose of all relational possibilities given to
humans to what appears in a free vis-a-vis, from the openness of his/her

....
74
Augustinus Karl Wucherer-Huldenfeld, Hans-Dieter Foerster
world range. Correspondingly, being ill is being dependent, deficient of
health and, finally, threatened as to the human dasein. Daseinsanalysis rather
speaks of 'being ill' rather than of 'ill-ness' to underline the individual nature
of the human dasein. A sick person is always impaired in his/her whole exist-
ence. The illness does not affect isolated organs only but jeopardizes the
entire dasein.
Being healthy further implies that one is open to disease. It is, in fact, very
impressive to see how the desperate efforts to avoid, circumvent, or fend off
any type of falling or being ill just cause the disease they seek to avoid and
seem pathological in themselves. Anxious avoidance of any contact with sick
people or of visits to hospitalized people, or bacteriophobia, or the disregard
of somatic ailments point to such an uneasy approach towards illness. Every
disease refers the human being to his or her mortality. The possibility of
death seems to draw nearer. Illness points to finality, limitedness, and the
fugaciousness of our existence. The healthy human being is, however, aware
of his/her transience and open to the possibility of being or falling ill. A more
comprehensive definition of health, therefore, has to include the openness to
illness and value it as a sign of health. In so doing, the term 'dis-ease' is
stripped of its derogative meaning, i.e., of deficiency and constriction. It is
extended by the dimension of disease as being a task and by the capacity of
suffering as signs of good health.
Existential Classification of Being III as a Basis of the
Oaseinsanalytical Theory of Neuroses, Psychoses, and
Psychosomatics
DA approaches the state of ill-being systematically by the following three-
pronged key question:
Which possibilities of relating have been restricted or disturbed, and in
what way and with regard to which areas of encounter? Proceeding from
sense and meaning of the disease process, we attempt to render the essence
of the disease more transparent and to understand the causes that led to the
diseased behavior and constricted the human being in his/her relational pos-
sibilities. We analyze in which manner the basic characteristics of the human
dasein (the 'existentialia') are hampered as to their realization. The goal of
Boss's 'classification' of human ill-being is to ascertain the conspicuous and
marked constraint of how the various characters perform their human exist-
ence. Boss subdivides them as follows:
I. Disease with a conspicuous impairment of a person's practicing his/her
openness and freedom of the dasein.

Daseinsanalysis (DA)
75
II. Illness with a marked disturbance of the actualization of the person's es-
sential and characteristic attunement.
III. Illness with a marked impairment of one's being-with-others.
IV. Illness with a marked impairment of allowing him/herself to be and of
realizing her being-in-the-world.
V. Illness with a conspicuous impairment of the corporality of human exist-
ence.
The classification system deliberately refers to conspicuous or marked impair-
ment. Since all the essential features of a dasein form a uniform and indivis-
ible whole, the sick person always finds herself disordered in all ways of
existence, albeit to varying degrees (Condrau 1992).
Referring to the classification of Boss:
- In the fir s t group of individuals, we find psychotics and obsessive-
compulsive neurotics.
- In the s e con d group, we find the bipolar, affective disorders, severe
anxiety neuroses, and neuroses characterized by boredom and senseless-
ness.
- In the t h i r d group, we find schizoid and asocial patterns of behavior
as well as contact and relationship disorders.
- In the f 0 u r t h group, we mainly find disorders such as the so-called
'organic psychoses'; we further subsume progressive paralysis, senile de-
mentia, epilepsy, agoraphobia, and claustrophobia.
- The f i f t h group is made up of the numerous disorders generally re-
ferred to as 'somatopsychic' as well as all those called 'psychosomatic'
disorders in a stricter sense of the word, e.g., stress disorders, abdominal
pain, and others.
Current States of Illness as Access to Motivic Etiology
(Specific Pathogenesis)
The behavior of each human being (from the existential structural variety of
his/her dasein and towards it) comes to maturity as his/her life unfolds. Being
ill always leads to the impairment and the disturbance of the actualization of
the existential characteristics of the individual who displays his/her specific
pathogenesis. If specific psychopathological phenomena can clearly and
unambiguously be attributed to the impaired realization of the individual
existentialia, the special motivic pathogenesis is manifest. Under the guid-
ance of this particular 'existential' (which never exists by itself only!), the
pathogenic causes and the initial answers are quite naturally taken from the
phenomenon itself, in as much as the past manifests in the present.

,
76
Augustinus Karl Wucherer-Huldenfeld, Hans-Dieter Foerster
This position is supported by the International Classification of Mental
Disorders (ICD-l0) of the World Health Organization (WHO) where diag-
nosing is referred to as the description of the phenomena. Thus, the term
'disturbance' largely replaces the 'mental illness'. The attempt is made to do
without terms such as neurosis, psychosis, and endogeneity by following an
'atheoretical' approach, and to replace those by introducing a descriptive
classification oriented towards diagnostic criteria (Dilling 2000, pp 9-23).
References
Condrau G (1992) Sigmund Freud und Martin Heidegger. Daseinsanalytische Neurosen-
lehre und Psychotherapie (p. 100). Universitiitsverlag Freiburg (Switzerland), Huber,
Bern
WHO (2000) Internationale Klassifikation psychischer Storungen, ICD-10, Chapter V (F)
(p. 9-23). Huber, Bern
Text revised by Luna Gertrud Steiner

Dynamic Group Psychotherapy (DG)
FRIEDERIKE GOLDMANN, LILLI LEHNER
Diagnostic Processes in Dynamic Croup Psychotherapy
Dynamic Group Psychotherapy operates on the basic assumption that the
group and its varied options of transference and role-making provide ideal
opportunities within the current relational network. By the individuals re-
enacting the conflict dynamics within the current force field of the group, a
process of psychosocial maturation gets going in a mutual dynamism. The
most important factor is the becoming aware of the resistance and defense
mechanisms, and of the inter- and intrapersonal enactments of conflicts
which have led to those disorders which obstruct the way toward psychic
recovery.
Even in the dyadic settings of Dynamic Group Psychotherapy, the focus is
placed on the way relationships, re-enacted in the presence of the actual
relation with the therapist, are formed and molded. The defense and conflict
constellations reflecting the client's social life and reference groups are, just
as group therapy settings, worked through by analyzing resistance, transfer-
ence, and counter-transference phenomena.
The diagnostic model of Dynamic Group Psychotherapy rests on the per-
sonality concept going back to Kurt Lewin's field theory, which holds that
"person and environment form an interdependent, inextricable systemic
whole, in which the conditions of all components are mutually inter-
dependent" (Lewin quoted in Teutsch/P6lzl 1998, 24). According to this, an
individual's behavior is conceived of as a structured dynamic whole of pre-
conditions which, according to Lewin, is a function of the 'psychological life
space', which is made up of individual and environmental factors, and in
which the historic aspect of one's 'having-become-this-very-person' is repre-
sented in his actions and emotions in the here and now. The formation of a
specific symptom is examined as to the interrelation and interconnectedness

78
Friederike Goldmann, Lilli Lehner
between environment and individual. An individual's utterances are also
manifestations of conflicts, desires, and imaginations of the whole group - an
observation that holds true for the current therapy as well as for one's group
of origin and reference groups.
Accordingly, rather than treating a mental illness as the problem of an
individual, it is thought of as an expression of a perturbed 'field', which is in
turn understood as the sum of all preconditions and factors of the exterior
world and of the intrapsychic situation.
In Dynamic Group Psychotherapy, disorders are thus understood as the
pathological manifestations of the environment, and the relationships and
communication structures prevailing therein. To the individual, these present
themselves as the decline of communicative and relational abilities, and act
as 'barriers' inhibiting development, a condition in which the expansion of
one's life space and the chances of personal evolution are constricted. This
necessarily leads to an understanding of illness as a defined social role,
which - according to 1. Parsons - has grown from the disordered relations
with the environment, and which becomes observable via unsuccessful
adaptive performance or symptoms.
"The therapeutic goal is not the realization of an ideal image of health,
but the (best possible) improvement of the life processes, as opposed to the
constriction and defense figures experienced as illness". Recuperation in-
volves the organization of wholeness on the basis of the extant resources
and, according to Schindler, "the expansion of the individual's free space -
by dealing with inhibition and compulsion - in the context of social com-
munication, and thus the organization of psychic, physical, and social whole-
ness" (both quotations Majce-Egger 1998b, 265).
In individual settings as well as in group settings, the diagnostic processes
commence with the first contact between the therapist and the client, or in
the intake interview, and they are undertaken to form the first hypotheses
and to state clinical ICD-l0 diagnoses. The initial hypothesizing is revised in
the course of the process-oriented diagnostic practice and serves the further
planning and evaluation of therapeutic interventions.
Diagnosing in the Intake Interview
As to the techniques applied in the intake interview, Dynamic Group Psy-
chotherapy favors minimally structured proceedings, thus affording the client
the space to shape the relational situation in which he plays the role of the
'ill', and to thus reenact the basal conflict. The relative unstructuredness of
the interview helps to clarify the interrelation between the presented symp-
toms, the actual dialogic setting, the current life situation, and the history as
reported by the client; it is, therefore, used to comprehend the "interactional

Dynamic Group Psychotherapy (DG)
79
situation between the client and the therapist, [that is] how the client organ-
izes the rather unstructured situation of the intake interview, which role s/he
assumes and which role s/he attributes to the interviewer. From each of these
social reenactments we may infer which conflicts and disturbances the client
has and how s/he deals with them" (Fliedl 1998, 167f).
This opportunity for the patient to actively fashion the interview also im-
plies that she might avoid contents and issues, which have to be addressed
and questioned by the therapist, to whom they become apparent as incon-
gruities or irregularities (be they verbal or nonverbal as facial expressions,
gestures and postures). The way a client responds to questions gives addi-
tional hints as to her introspective abilities, her ego-development and her
defense modalities, to the quality of object relations, and to her reality check;
the therapist's countertransference-induced feelings are further diagnostic
criteria.
"During the conversation, the examiner will either verify or falsify his as-
sumptions by asking, confronting, and interpreting, and thus clarify whether
his way of understanding the client is an expedient one. This is an essential
decision criterion as to whether to accept this person as a client or not. If
fundamental difficulties arise to understand this patient or to convey this
sense to her, collaboration should not be considered" (Flied11998, 167).
Since, from a group therapeutic point of view, the presented disorder is
always contemplated against the background of the patient's group of ori-
gin, the inquiry focuses on the question what the patient, via her symptom,
is expressing on behalf of this group, which position and which roles she
adopts in it and which roles have been attributed to her, which function the
disorder has had in her family of origin, and to what extent the patient's
changes could compromise them. The question is whether "the environ-
ment is able to endorse the patient's change, or whether the reference
group will be destabilized to a degree that it will thwart her efforts to
change" (Fliedl 1998, 166f), how much support the respective reference
groups are able to give in current or future crises, and which resources are
available.
From the attitudes the patient and her environment express toward psy-
chotherapy, diagnostically relevant clues, suggestive of group norms and
group cultures, may be gleaned. Furthermore, relevant pieces of information
on the attitude and on the motives will crop up whether, for instance, the
impetus to undergo psychotherapy arose from dependent, adaptive, opposi-
tional, blaming, or other convictions, and which kind of resistance is to be
reckoned with. The clarification of the actual possibilities and the effort the
patient is ready to make allows for additional prognoses on what may be
expected from psychotherapy and on the degree of the patient's motiva-
tion.

80
Friederike Goldmann, Lilli Lehner
Process-Related Diagnoses in the Croup Setting
The continual analysis of the group process serves the understanding of the
dynamics at work in the group.
"Being part of the group, the individual is a dynamic agent in the build-up
of the dynamics of this particular group and, simultaneously, the object of
the unconscious transference the group is experiencing, processes in which
the transference reactions of the group differ from those of the individuals
concerned. On the one hand, we witness the individual and the unique ex-
pression and action of a certain person and, on the other, unconscious fan-
tasies/issues of the group are expressed and shaped by these individuals
also" (Majce-Egger 1998a, 240f).
"It is the task of the process-oriented diagnosis to understand the meaning
of any ongoing, by observing the interactions of the group members as well
as the dynamics which emerges within and between individuals and sys-
tems, and to view it against the background of group theories and group
models (phase models, rank dynamics, Bion's model of basic assumptions,
etc.), and to determine one's interventions on the basis of hypotheses in or-
der to influence the group's development toward the common objective of
the work" (Majce-Egger 1998b, 267f).
"Aspects of the process analysis are the personal development of the par-
ticipants, the interpersonal relationships of the participants (as to quality,
frequency, and intensity), the progression of the dynamic rank structure, the
role systems, the role structure, and the development of the group via occur-
rences therein (in the group phase: development and defense)" (Majce-Egger
1998a, 251).
Criteria for Diagnosing Within a Croup
(according to Majce-Egger 1998b, 268f)
Situational Analysis of Group
- Identifying critical situations (e.g., imminent group disintegration)
- Rank dynamics
- Group diagnosis as to subsystems of the group (patterns of interaction,
group emotions, norms, targets, values)
- Process analysis (course taken so far, repetitions, incidents of avoidance)
- Group phase
- Group conflicts (desire versus anxiety, effecting compromises)
- Resistance (resistance phenomena)

Dynamic Group Psychotherapy (DG)
81
Interpersonal Situation Analysis
Representation of conflicts (which protagonists stand for desire, anxiety,
compromises)
- Relational level - dynamics of interaction
- Levels of relations and meanings
Interplay of positions of the dynamic rank structure
Personal Situation Analysis
- Personality structure (basal conflict)
Resources
Rank within group
Role (differentiation, flexibility)
Rigidity - permeability - barrier
Developmental approach (skills)
References
Fliedl R (1998) Erstgesprach, Anamnese, Diagnose. In: Majce-Egger M (ed) Gruppenthe-
rapie und Gruppendynamik - Dynamische Gruppenpsychotherapie. Theoretische
Grundlagen, Entwicklungen und Methoden. Facultas, Vienna, pp 166-183
Majce-Egger M (1998a) Methodik der Dynamischen Gruppenpsychotherapie. In: Majce-
Egger M (ed) Gruppentherapie und Gruppendynamik - Dynamische Gruppenpsy-
chotherapie. Theoretische Grundlagen, Entwicklungen und Methoden. Facultas, Vi-
enna, pp 237-254
Majce-Egger M (1998b) Interventionstechniken. In: Majce-Egger M (ed) Gruppentherapie
und Gruppendynamik - Dynamische Gruppenpsychotherapie. Theoretische Grund-
lagen, Entwicklungen und Methoden. Facultas, Vienna, pp 255-270
Teutsch H-R, Polzi G (1998) Sozialpsychologische Wurzeln und Aspekte der Methode.
In: Majce-Egger M (ed) Gruppentherapie und Gruppendynamik - Dynamische Grup-
penpsychotherapie. Theoretische Grundlagen, Entwicklungen und Methoden. Facul-
tas, Vienna, pp 17-34
Translated from the German by Luna Gertrud Steiner

.,

The Process of Diagnosis in Existential Analysis (EA)
ALFRIED LANGLE
Within an existential-analytical framework, diagnosis can be understood as
the process of realizing and coming to an understanding about a disorder.
Diagnosis includes the frequency of appearance, the structure, and the indi-
vidual specifications of the disorder in order to provide an orientation for
treatment. The diagnosis is used at the beginning of the psychotherapy (initial
diagnosis)/ during the process of the treatment (process diagnosis), and as a
reflected assessment at the end of the existential analytic treatment (conclud-
ing diagnosis).
The aim of a given diagnosis is to connect the patienes experience (or
phenomenon) of the disorder to existential analytic theory in such a way that
it facilitates appropriate treatment that is in tune with the patient, the phe-
nomenon, and psychotherapeutic ethics. The purpose of diagnostics is to
assess the phenomenon in regard to the severity of disturbance (necessity of
treatment), in its etiology and connection to other relevant domains (espe-
cially somatic participation, social and existential environment). Diagnostics
is also used to assess the phenomenon in terms of its prognosis (treatment
expectations, obstacles, and dangers during treatment), and to coordinate
these insights with methods that enhance optimal treatment (this includes an
easy communication with other specialists). The diagnosis is built on anam-
nesis, tests, and phenomenology. Its power of evidence is increased by link-
ing these results to general knowledge.
As a phenomenological diagnosis, the existential-analytical diagnosis be-
gins primarily with what actually moves the patient and focuses its attention
on the existential capacities and needs of the patient. Both are ascertained
through a clarification of the prerequisites for a holistic existence (represented
by the existential fundamental motivations), and the ability to encounter one-
self and the world (represented by the method of personal existential analy-

..
84
Alfried Uingle
sis). This sheds further light on the dynamic power of the patient and the
processing capacities for the prevailing psychopathology.
This work is based upon the published results (1999) of a project that was
conducted by Luss, Freitag, Langle A, Tutsch, Langle S, and G6rtz for exis-
tential analysis.
I. Existential-Analytical Cycle of Diagnosis
The existential-analytic process of diagnosis reveals six distinguishable stages
by which the symptoms or problems are objectively investigated, including
the subjective experience the patients made themselves (and the therapist
conducting the diagnosis) (Fig. 1). To provide this necessary information for
existential-analytic therapy, the order of these stages of diagnosis is flexible.
The process of diagnosis generally takes place over the course of several ses-
sions of therapy and remains relevant throughout the entire treatment. In
order to arrive at a holistic picture of diagnosis, all areas of the diagnostic
cycle must be examined at least once.
The goal of an existential-analytic diagnosis is to reveal at least the follow-
Ing:
1. Whether an existential-analytic therapy is necessary or if other help is
needed;
2. Which therapeutic approach is useful and where to apply it;
3. The personal and environmental (Mitwelt, Umwelt) resources available to
the patient that are relevant to therapy;
4. Which problems and dangers are to be taken into account for the patient,
the therapist, and the therapeutic work (prognostic value);
5. The extent and scope of treatment which is justifiable, given a realistic
and responsible assessment of the necessary timeframe for therapy and its
financial implications for the patient;
6. The categorization of symptoms according to international psychiatric
systems of diagnosis. This is necessary in order to facilitate and improve
intra- and interdisciplinary communication, scientific comparative stud-
ies, and provide a rationale for the patient's insurance carrier.
Hence an existential-analytic diagnosis follows two schemas: the methodi-
cal which sheds light on the specific understanding of psychopathology,
anthropology, and the existential understanding of the disorder; as well as
the common diagnostic schema, which spans across various schools of
thought (ICD and DSM). Practically speaking, the diagnosis is a homogenous
process in which there is a fluent transition from each step to the other.

The Process of Diagnosis in Existential Analysis (EA)
85
FM Fundamental Motivations
PEA Personal Existential Analysis
Fig. 1. Existential-Analytical Cycle of Diagnosis: an overview of the essential
elements which are incorporated in a complete, existential-analytical diag-
nostic
Step 1 of Diagnosis: Reference to the Three-dimensional View
of the Human Being
According to Frankl (e.g., 1990, 198f), the three-dimensional view of the hu-
man beings offers a preliminary, general grid to determine whether the cen-
tral emphasis of the disorder lies in the somatic, psychic, or personal (noetic,
existential) domains. This step is a preliminary and general orientation, one
that gives the disorder its appropriate assignment according to the main em-
phasis of the anthropological structures involved. It clarifies whether other
methods of treatment should be employed (e.g., referral to other disciplines
and further examinations) in addition to existential-analytic psychotherapy.
Step 2 of Diagnosis: Existentiality - the Dialogical Exchange
between the Individual and His or Her Situation
This next step of diagnosis attempts to locate the individual in his or her ex-
istentiality. The dialogical openness can generally be disturbed on three lev-
els: the level of input, the process level, and the level of output. If there are
blocks on any of these three levels, an individual becomes existentially im-

.,
86
Alfried Langle
poverished. These blocks, or hindrances, are the breeding ground for psy-
chopathology. The diagnosis of the patient's ability for relationship and en-
counter can be ascertained from how s/he reports on handling various life
situations. Additionally, the therapeutic relationship also mirrors the patient's
relational abilities and is thus highly relevant for diagnosis. The degree of
disturbance in the patient's existentiality offers insights into the severity of the
psychological disorder.
Step 3 of Diagnosis: Psychopathology and
Psycho- Pathogenesis
After the existential situation of the patient has been comprehended, the next
step of diagnostics is to clarify the specific suffering of the patient and its
causal connections. The aim of this step is to understand the patient's (con-
scious and unconscious) desire to seek outside help. This step involves a di-
agnosis of the patient's motivation for therapy, and this includes the patient's
subjective understanding of the illness/disorder. The attitudes patients hold
towards the disorder as well as their expectations of psychotherapy (the sub-
jective aim of therapy) are interconnected themes in this third step of diag-
nosis.
In addition to the subjective expectations of the patient, professional as-
sessments regarding the specific elements of disorder and its causes are also
required. On the one hand, such an assessment demands a phenomenologi-
cal and sensitive approach. On the other hand, it necessitates knowledge of
the specific existential-analytic psychopathology in order to find explana-
tions for the disorder based on an accurate anamnesis.
Step 4 of Diagnosis: Personal Resources "What can the
Patient do?"
In this fourth step (and this extends to the fifth step) the disturbed experience,
the experience of pain, and the pathological behavior of the patient are seen
within the contexts of both the theory of the person and the theory of exist-
ence. The main focus in existential analysis is on the personal resources of
the patient. Therefore, the patient's own abilities to solve or improve his/her
condition must be recognized at the outset. This facilitates and improves the
patient's existentiality. In addition, the psychological, somatic, social, eco-
nomic, and professional resources of the patient must also be addressed.
Inquiry into the resources and personal abilities of the patient provides
the specific groundwork for existential-analytic psychotherapy. In some cases
(e.g., with children) an indirect anamnesis is helpful or even necessary.

The process of Diagnosis in Existential Analysis (EA)
87
The structural model of existential analysis and the personal fundamental
motivations (Langle 1997, 2002; engl. 2003) are the schematic background
for determining the patient's personal resources. This model allows for a
systematic exploration of the fundamental conditions of existence in order to
reveal which conditions are well-developed and which are blocked. The
main "substance" for the existential abilities is elaborated. Several psycho-
logical assessments employ specific methods to achieve this purpose (Langle,
Orgler, Kundi 2000; engl. 2003; Langle, Eckhard 2001).
In addition, the patient's ability regarding her personal dynamics is also
assessed using the personal existential analysis. In order to handle present
situations, an individual has four dynamic forms of behavior. These are de-
scribed in the personal existential analysis (Langle 1993, 2000; engl. 1995)
and may also be called /Ipersonal process variables".
Step 5 of Diagnosis: Analysis of Needs of the Patient
Closely connected to the previous step is the analysis of the patient's needs.
In step 5 the therapist evaluates, on the basis of his or her professional
knowledge and observations, the imminent needs required to improve the
actual life-situation of the patient. This professional assessment also requires
that the therapist use the same abilities of personal existential analysis.
This fifth step of diagnosis leads to the establishment of a therapeutic plan
based on a summary of the gathered information from the previous steps.
The overview of the patient's dialogical blocks may also lead to the realiza-
tion that the disturbance may lie more predominantly at a systemic level, or
at the pathology of the patient's partner rather than within the patient him- or
herself. In addition, this general diagnostic picture also facilitates a prognos-
tic assessment.
Step 6 of Diagnosis: Self-Assessment of the Therapist
In order to round off the psychotherapeutic diagnostic within the framework
of a phenomenologically oriented approach, the therapist also needs to as-
sess his or her own competence, motivation, personal sense of responsibility,
and the sensibleness (meaning and purpose) of therapy. A diagnosis of the
therapist's own personality, mirrored by the personality, symptoms and prob-
lems of the patient, is important in order to protect the patient and to ensure
an efficient progress in the therapy as well as for the therapist's own protec-
tion and psychological hygiene.
This self-assessment can be made in theoretical conformity with the four
fundamental motivations of human existence.

"'II
88
Alfried Langle
After the initial existential-analytic diagnosis is undertaken (or while this is
being done), a second diagnosis that is extrinsic to the existential-analytical
theory is made. This diagnosis is conducted according to the current diag-
nostic schemata, which have been established by the various international
commissions. The aim is to serve as a corrective for specific methodical
diagnosis, to reveal possible "blind spots" on the basis of anthropology and
methodology, and to make use of the wide experiential range within the
discipline. On account of its standardized and schematic structure, the diag-
nosis of psychopathology becomes more precise. Employing an interdiscipli-
nary diagnostic system facilitates and improves communication with repre-
sentatives from other disciplines who use alternative methods for arriving at
a diagnosis.
II. An Overview of the Process of Diagnosis
Figure 2, in the shape of a cone, represents the process of diagnosis. It is
based on the theoretically specific diagnostic process. As abstraction in-
creases, a uniform picture forms. In the figure, the peak of the cone sym-
bolizes this uniformity. It is at this point, at the most abstract level, that the
Coordination with
theoretically extrinsic
diagnostic schemes
(lCD, DSM)
]
Diagnostic of
Phenomenon
z
o

u
«

l-
V)
CQ
«
Diagnosis in Conformity to Theory
] Diagnostic
of therapeut.
Approach
z
o

UoI

U
Z
o
U
Fig. 2 An Overview of the Existential-Analytical Process of Diagnosis
(Luss et al. 1999)

The Process of Diagnosis in Existential Analysis (EA)
89
connection with the theoretically extrinsic diagnosis is established. The re-
sults achieved supply the basis of practical treatment. This, in fact, is the
main task of diagnostics. The insights gained become practical. What moves
the patient is now reflected by his or her needs to find his/her way out of
suffering and to solve the problem. For this, the same tools are used as in
the initial phase of diagnosis: Anthropology, the structural elements of exist-
ence, and the process dynamics. The insights gained become increasingly
tangible in this step. Silvia Langle proposed the double-cone shape to
illustrate these complex processes and provide a clear overview of them
(d. Fig. 2). The double-cone clarifies the epistemological steps of diagnos-
tics. At first, the steps are increasingly abstract. However, as these steps
progress in the opposite way, they become more and more concrete. In
terms of content and method, this model summarizes the process of diag-
nosis in existential analysis.
References
Frankl V (1990) Der leidende Mensch. Anthropologische Grundlagen der Psychothera-
pie, Neuausgabe. Piper, MClnchen
Frankl V (1955/1986) The doctor and the soul. From psychotherapy to logotherapy. Vin-
tage Books, New York
Frankl V (1967/1985) Psychotherapy and Existentialism. Selected Papers on Logotherapy.
Simon & Schuster, New York
Langle A (1992) Existenzanalyse und Logotherapie. In: Pritz A, Petzhold H (eds) Der
Krankheitsbegriff in der modernen Psychotherapie. Junfermann, Paderborn, pp 355-
369
Langle A (1993) Personale Existenzanalyse. In: Langle A (ed) Wertbegegnung. Phano-
mene und methodische Zugange. Tagungsbericht der GLE 1+2, 7. GLE, Wien,
pp 133-160
Langle A (1995) Personal Existential Analysis. In: Psychotherapy East and West. Integra-
tion of Psychotherapies. Korean Acadamy of Psychotherapists, Seoul, pp 348-364
Langle A (1997) Modell einer existenzanalytischen Gruppentherapie fUr die Suchtbe-
handlung. In: Langle A, Probst C (eds) Suchtig sein. Entstehung, Formen und Behand-
lung von Abhangigkeiten. Facultas, Wien, pp 149-169
Langle A (2003) The Search for Meaning in Life and the Fundamental Existential Motiva-
tions. Psychotherapy in Australia 10, 1: 22-27
Langle A (ed) (2000) Praxis der Personalen Existenzanalyse. Facultas, Wien
Langle A (2002) Die Grundmotivationen menschlicher Existenz als Wirkstruktur exis-
tenzanalytischer Psychotherapie. Fundamenta Psychiatrica 16, 1: 1-8
Langle A, Eckhard P (2001) Skalen zur Erfassung von existentieller Motivation, Selbstwert
und Sinnerleben. Existenzanalyse 18, 1: 35-39 (an English version is available from
the author)
Luss K, Freitag P, Langle A, Tutsch L, Langle S, Gortz A (1999) Diagnostik in Existenz-
analyse und Logotherapie. In: Laireiter H (Ed) Diagnostik in der Psychotherapie.
Springer, Wien
Langle A, Orgler C, Kundi M (2000) Existenzskala ESK. Hogrefe-Beltz, Gottingen

...
90
Alfried Lingle
Langle A, Orgler C, Kundi M (2003) The Existence Scale. A new approach to assess the
ability to find personal meaning in life and to reach existential fulfilment. European
Psychotherapy 4, 1: 135-151
Simhandl C (1997) Diagnostik psychischer Storungen in der Praxis. Existenzanalyse 14, 1:
33-37
My thanks to Britt-Mari Sykes (Ottawa) and Derrick Klaassen (Vancouver) for
the revision of the English translation.

Existential Analysis and Logotherapy (EL)
OTMAR WIESMEYR
The definition and the detailed illustration of a basic diagnostic practice con-
form to the description of the psychotherapeutic profession as a comprehen-
sive treatment, as it is stated in the Psychotherapy Act (PthG). This very fact
brought those training contents that are common to all orientations closer to
a psychotherapeutic specification of diagnostics; this and the elaboration of
general standards for psychotherapeutic treatments have contributed a good
deal to the quality assurance of psychotherapy.
The emphasis of the method-specific abundance and thus variety and
diversity of diagnostic approaches confirm the autonomy of the manifold
psychotherapeutic orientations.
Describing psychotherapeutic diagnostics as a discovery procedure re-
veals the similarities with the diagnostic approach of the meaning-centered
psychotherapy in which, via the interaction with the clients, new and more
complex perspectives are developed on the verbal, emotional, cognitive,
and behavioral levels. The Existential Analysis expands this diagnostic frame-
work by offering additional insight and perspective onto man's freedom and
responsibility.
With the various psychotherapeutic professions collaborating, great atten-
tion has been paid to mutually accept and respect each other to provide
comprehensive and accurate information material on the psychotherapeutic
modalities.
The formulation of an illness being "an irregular bodily and mental state"
in the Austrian Social Insurance Law and the definition of "mental disorders
that qualify as diseases" and represent "coping efforts with inadequate
means" is presently put through a necessary revaluation within EL's image of
man, which holds that the human being possesses "unconditional dignity".
The classification of psychotherapeutic diagnoses in the 3 dimensions -
'symptomatology in relation to personality aspects', 'psychotherapeutic rela-

92
Otmar Wiesmeyr
tionship', and 'critical potential' - is complemented by a fourth component
in the diagnostics of Existential Analysis and Logotherapy, namely by 're-
source-oriented diagnostics', which pays tribute to the healthy parts of a
personality and his/her environment as well as to her meaning and values.
Keywords: Definition of the psychotherapeutic treatment in the Psychother-
apy Act; general diagnostic standards; quality assurance of psychotherapy
training and psychotherapy; autonomy of the psychotherapeutic method;
diagnostics as discovery procedure and information processing; establishing
psychotherapeutic diagnoses and indications.
Method-specific addenda: diagnosis as insight and perspective onto man's
freedom and responsibility; revaluation of the illness concept by adding the
idea of human dignity grounded in EL's image of man; additional dimension
of 'resource-oriented diagnostics' in view of the healthy aspects of a person
and his/her environment as well as of her meaning and values.
Establishing Diagnoses
Symptomatology in Relation to Personality Aspects
We do see parallels in the application of ICD 10, the consideration of the
phenomenon of co-morbidity, and in the advancement of personality diag-
nostics by means of careful differential diagnoses. The "ascription of the
clinical-diagnostic guidelines of the ICD 10 to the terminology of Existential
Analysis and Logotherapy" (Lukas 1998) points in the same direction. By
means of this ascription, method-specific differences which are based upon
the concepts of man and personhood including the noetic level - a specific
human feature - become apparent. This also applies to the 'symptomatology
in relation to personality aspects', whereby mental conflicts that contributed
to the origination of psychosocially or psychosomatically caused behavioral
disorders and states of suffering, constitute a focal point within method-spe-
cific diagnostics. In this context, Victor E. Frankl describes the different proc-
esses going on between the "somatic, the mental, and the spiritual, or noetic"
(quoted from 1983, 48; 2004) realms by means of "effects, triggers, and re-
percussions". Hereby, Frankl puts forward a rather differentiated etiology of
the origination of illnesses. When faced with noogenic neuroses, with neu-
roses that arise from the spiritual dimension, it is important that they elicit a
psychotherapy that takes its starting point in the spiritual dimension" (Frankl,
Dubois 2004, 154).
Keywords: application of IDC 10, consideration of the phenomenon of co-
morbidities, careful differential diagnosis in personality diagnostics.

Existential Analysis and Logotherapy (EL)
93
Method-specific addenda: inclusion of the noetic level - a specific human
feature; differentiated etiology with regard to effects, triggers, and repercus-
sions on the psychological, somatic, and noetic levels; noogenic neuroses
and depressions, i.e., those which arise from spiritual conflicts.
Psychotherapeutic Relationship
We find another concordance in the description of the psychotherapeutic
relationship which is to enhance development and change processes to the
patients' benefit. There is a method-specific addendum, namely the empha-
sis on the ethics involved in the person-to-person encounter. The responsibil-
ity described in unison in the professional code of conduct characterizes the
psychotherapeutic attitude of a meaning-centered psychotherapy. "The re-
sponsibility of the psychotherapists includes her respect for the dignity and
responsibility of the individual as well as for her attitudes and values" (Firlei
et al. 2005, 161).
Taking-up and devising the psychotherapeutic relationship and negotiat-
ing the basic conditions, setting, and the purpose of psychotherapy exhibit
an extensive concurrence between the Guideline and EL; from all interven-
tions defined, the generation of correlations for finding and constituting
meaning (sense) must be accentuated. In Existential Analysis and Logothera-
py (EL), process-oriented diagnostics is practiced by way of 'alternate diag-
nostics', which demonstrates the effort of carefully integrating diagnostic
processes in the psychotherapeutic treatment along with safeguarding a
good psychotherapeutic relationship throughout. Psycho-diagnostic proce-
dures are increasingly being applied also. "Over the last years, psychothera-
py has witnessed various tendencies towards the conceptualization and de-
velopment of new techniques" (Stieglitz 2003, 114). Diagnostic procedures
could gain in importance particularly where indication needs to be deter-
mined. "This refers to the selection of one of various therapeutic treatment
options with the aim of an optimum accordance between patient, therapist,
and treatment modality" (Brahler et al. 2002, 114).
This corresponds to Viktor E. Frankl's intentions. "The determination of
the 'method of choice' in a given case is analogous to two unknowns:
\f' = x + y, where x stands for the unrepeatability and uniqueness of the pa-
tient's personality and y for the no less unrepeatable and unique personality
of the therapist. In other words, a given therapy does not allow itself to be
applied in every case with the same expectation of success, nor can every
therapist use all methods equally effectively" (1979, 118; Frankl, Dubois
2004, 3).
In addition to the evaluation of the therapeutic relationship, in which ob-
servable progresses and regresses are discussed, de-reflective aspects are

....
94
Otmar Wiesmeyr
brought into play by Existential Analysis and Logotherapy in order to avoid
"hyper-reflection" and to tie the therapeutic proceeding to the being-in-the-
world and the bearing-an-effect-on-the-world. A lot of effort is also put into
documenting diagnostic data properly and accurately. For this purpose, a
databank has been set up so as to support the entrant psychotherapists and
to help ascertain comparative data.
Keywords: therapeutic relationship to further processes of change and de-
velopment; taking-up and devising the psychotherapeutic relationship; nego-
tiating basic conditions, setting as well as purpose-orientation; process diag-
nostics.
Method specific addenda: ethical focalization by emphasizing the person-to-
person encounter which comprises the therapist's attitude of accountability;
careful inclusion of diagnostic processes by means of 'alternate diagnostics';
using evaluative diagnostics to improve the determination of indication; de-
reflective aspects to evaluate the psychotherapeutic relationship; careful and
exact documentation.
Critical Potential
The term 'critical potential' in psychotherapeutic diagnostics comes close to
the concept of crisis in meaning-oriented psychotherapy. Correspondingly,
Existential Analysis and Logotherapy dispose of an ample tradition - well
expressed by the illustrative terminology such as 'existential frustration, exis-
tential vacuum, and loss of the orientation towards meaning'. Thus the extant
definition of what characterizes a crisis is expanded by the 'critical potential',
which is accompanied by the frustrated will to meaning and thus renders the
term ('critical potential') and its diverse and manifold aspects more compre-
hensible. Furthermore, crisis is not only viewed as a pathological state but as
a challenge to cope with the given circumstances. The critical potential as
ascertained by the psychotherapist corresponds to the thought that the client
may exhibit different degrees of severity which necessitate different actions
on the psychotherapist's part.
Keywords: general critical potential; evaluation of the crisis according to
various degrees of severity; necessities of action consequently arising for the
psychotherapist.
Method-specific addenda: crises which stem from the frustrated will to
meaning, crises as challenge and opportunity.

Existential Analysis and Logotherapy (EL)
95
Resource-Oriented Diagnostics
In Existential Analysis and Logotherapy, the comprehensive description of
the healthy aspects of man and their significance for the healing process
have given rise to a specific resource-oriented form of diagnostics which, in
its specific way, focuses on increasing and decreasing the processes of per-
ceiving and finding meaning. This proceeding includes paradox interventions
and therapeutic humor. JJ... the patient must be brought to and encouraged
to objectify the processes of the illness and to distance him or herself from
them. In other words, the patient should learn to stare into the face of things
like fear and compulsions ... and laugh in their face" (Frankl, Dubois 2004,
64).
Psychotherapeutic Indication
The definition of an indication of psychotherapeutic treatment corresponds
to certain criteria in Existential Analysis and Logotherapy. Additional criteria
refer to the existential crises which are rooted in the spiritual as well as in
those issues and problem areas that are tied to meaning and values.
A further focal point is constituted by the psychotherapeutic treatment of
seriously ill or even dying patients. The necessity of referral and collabora-
tion, after having informed the patient and secured his consent, the compila-
tion of an adequate treatment offer that seeks to understand the affliction
and the behavioral disorders by considering the degree of severity corre-
spond to the current standard. If the personality development is disturbed
without bearing the quality or status of an illness, EL possesses an additional
tool that contributes to the cultural integration of immigrants and marginal
groups. There is a consensus also where contraindications and exclusion
criteria are concerned.
Keywords: definition of the indication of psychotherapeutic treatment, as-
signment, and collaboration; adequate treatment offers; understanding of
affliction and behavioral disorders by considering the degree of severity,
contra-indications, and exclusion criteria.
Method-specific addenda: existential crises and conflicts which are rooted in
the spiritual: issues and problem concepts related to meaning and values;
psychotherapeutic treatment of seriously ill or dying patients; contributions
towards cultural integration of immigrants and marginal groups.

96
Otmar Wiesmeyr
Summary (by Keywords)
Psychotherapeutic diagnostics is a good reference basis for Existential Analy-
sis and Logotherapy; particularly the crisis concepts of both shows great af-
finity. Complementary fields refer to a resource-oriented form of diagnostics,
scilicet, of the healthy aspects of a personality and her environment as well
as with regard to meaning and values. Great attention is paid to a careful and
precise documentation of diagnostic findings. Method-specific addenda refer
to the diagnosis as an insight and perspective onto man's freedom and re-
sponsibility, the revaluation of the illness concept, the inclusion of the noetic
level, a differentiated etiology, the description of noogenic neuroses and
depressions due to irresolvable spiritual conflicts; emphasizing ethical view-
point by demanding a responsible attitude of the psychotherapist; careful
inclusion of diagnostic processes by way of the 'alternate diagnostics', evalu-
ative diagnostics; de-reflective aspects when evaluating the psychotherapeu-
tic relationship; crises arising from the frustrated will to meaning; crises are
viewed as challenge and opportunity; resource-oriented diagnostics when
the processes of perceiving and finding meaning are described; inclusion of
paradox interventions and therapeutic humor; psychotherapeutic treatment
of seriously ill and dying patients; approaches to further the cultural integra-
tion of immigrants and marginal groups.
References
Brahler E, Schuhmacher J, Straurs B (2002) Einleitung: Psychodiagnostik in der Psycho-
therapie. In: Brahler E, Schuhmacher J, Straurs B (eds) Diagnostische Verfahren in der
Psychotherapie. Hogrefe, G6ttingen Bern Toronto Seattle, pp 9-15
Firlei K, Kierein M, Kletecka-Pulker M (2002) Berufskodex fUr Psychotherapeutinnen und
Psychotherapeuten. In: Firlei K, Kierein M, Kletecka-Pulker M (eds) Jahrbuch fUr Psy-
chotherapie und Recht II. Facultas, Wien, pp 159-169
Frankl VE (1979) Theorie und Therapie der Neurosen. In: Der Mensch vor der Frage nach
dem Sinn. Piper, Munchen, pp 118-140
Frankl VE (1983) Theorie und Therapie der Neurosen. Reinhardt, Munchen
Lukas E (1998) Lehrbuch der Logotherapie. Profit, Munchen Wien, pp 215-230
Stieglitz R-D (2003) 4 Psychodiagnostische Verfahren. In: Harter M, Linster H W, Stieg-
litz R-D (eds) Qualitatsmanagement in der Psychotherapie. Hogrefe, G6ttinger Bern
Toronto Seattle, pp 97-117
Text revised by Luna Gertrud Steiner

Gestalt Theoretical Psychotherapy (GTP)
GERHARD STEMBERGER
All the colleagues who worked for the elaboration of the Diagnostic Guide-
line by the Advisory Board for Psychotherapy and contributed to it by engag-
ing in an interdisciplinary dialogue deserve thanks and acknowledgement.
We, first and foremost, need to appreciate their courage as well as their ab-
stinence: their courage to expose themselves to the criticism, by submitting a
- necessarily provisional - result, Le., the formulation of the interdisciplinary
principles of psychotherapeutic diagnostics, and to thus make a tangible pro-
posal to base our discussion and inspection thereon; they, moreover, with-
stood the temptation to prematurely elevate this draft to the rank of a manda-
tory directive.
The Guideline is part of this fine tradition in Austria, which appreciates
the richness of the manifold methodic approaches of psychotherapy, as they
developed over time, instead of sacrificing them for a few, allegedly 'excep-
tionally economical', or 'only effective' ones. We neither take their conver-
gence as the evidence that the psychotherapeutic schools be outdated, nor
do we overhastily throw them into the melting pot of one big unifying thera-
py. Instead, a way of gently and respectfully sounding the developmental
potential has taken hold, which lies in the advancement of the specific per-
spectives and commonalities of the different schools, and in the inclusion of
results and viewpoints from adjoining sciences. As exemplary studies which
had anticipated this approach and dealt with these topics in a narrower or
wider sense I would like to mention the following essay collections a) on the
nosological concepts within psychotherapy (pritz & Petzold 1992), b) on
psychotherapy as a science (Pritz 1996), c) on ethical issues of psychotherapy
(Hutterer-Krisch 1996), d) on diagnostics in psychotherapy (Laireiter 2000),
and e) on the very specific domain of psychotherapeutic report writing
(Lanske & Pritz 2002).

98
Gerhard Stemberger
To my mind, it is this Guideline's most essential strength to not bypass the
question as to which explicit and implicit presumptions guide the diagnostic
activities of psychotherapists and, most importantly, which concept of man
they adhere to. A glance at the historical evolution of the diagnostic guide-
lines of ICD reveals that such a debate is by no means customary.
There, the fact that psychiatry also (as much as clinical psychology) is split
into different schools and theoretical approaches had been countered to the
effect that a completely 'atheoretical' approach toward the diagnostic guide-
lines has been opted for (after implicitly adhering to a psychoanalytic ap-
proach in earlier versions of the ICD). The ICD guidelines seem to confine
themselves to the rules of inclusion and exclusion, according to which a
'case' should be allocated to one category or another. The internationally
raised critical discussions around the evolution of ICD and DSM (cf., e.g., the
collection of papers by Beutler & Malik 2002, published by the American
Psychological Association), unfortunately barely apprehended in the psycho-
therapeutic circles of Austria, have been a lasting testimony that neither
these greatly arbitrary classification rules nor these classification systems
themselves are exempt from theoretical presumptions. The extensive re-
moval of the semantic, and the systematic references to particular theoretical
models in these classification systems (such as the depth-psychological ones)
has not resulted in 'freedom from theories'. Instead, other theoretical models
quietly slipped in and gained predominance, which were characterized by
an elementarism that tended to isolate variables, "so that the psyche could be
thought of as an aggregation of single data, regardless of any holistic integra-
tion or of how individuals were composed and structured; basically, an ele-
mentaristic 'catalogue of disorders' had been assembled" (plaum 2000,
154).
By contrast, the authors of the Guideline chose to explicitly state a gen-
eral interdisciplinary and common anthropological basic position to psycho-
therapeutic diagnostics which, despite all differentiations of the individual
schools, is agreed upon to be committed to a holistic perspective: the human
being should be conceived of as a physical-psychological entity within his or
her social relations, and not as a bundle of segregated shortcomings and
derailments.
This holistic perspective which, incidentally, emphasizes the relational
nature also of the diagnostic process in psychotherapy moreover manifests in
the proposed practical routines and in the explanatory and illustrative state-
ments of the Guideline.
On this premise and in my judgment, Gestalt Theoretical psychothera-
pists will, by all means, be able to identify with the essentials of the present
Diagnostic Guideline. In the following, I will delve into the details of these
accordances before once again discussing the relationship of the Guideline
with the issues of classifying and of classification systems.

Gestalt Theoretical Psychotherapy (GTP)
99
The Diagnostic Understanding of Gestalt Theoretical
Psychotherapy
In accordance with the basic thoughts of the Guideline, Gestalt Theoretical
Psychotherapy acts on the conviction that diagnostic revelations and thera-
peutic change processes are inseparable. Even if each of them is related to
different functions and thus particular demands, an efficient patient support
requires the professional and proper interplay of discovery and change proc-
esses throughout therapy.
Each new discovery is per se related to a change and may set off a series
of further changes, which may again trigger off new discoveries. As widely
known, this may also happen when this whole process and this cause-and-
effect-relation are neither intended, nor planned, nor insightfully adminis-
tered, or understood. The authors of the Guideline are, therefore, right not
only to ascertain the fact that discovering and changing in psychotherapy are
joint and intertwining processes, but also to postulate that the psychothera-
pist has to work on this intertwining process consciously and deliberately,
guided by and in accordance with her particular scientific-methodological
approach.
Even in the diagnostic strand of psychotherapeutic work, Gestalt Theo-
retical psychotherapists let themselves be guided by the "characteristics of
working at the living", as they were elaborated by Wolfgang Metzger (1962)
and transferred to psychotherapeutic applications by Hans-Jurgen P. Walter
(1977). Simultaneously, essential anthropological, epistemological and ethi-
cal home positions of Gestalt theory are concisely expressed therein.' I am
going to mention them briefly, reformulating them in reference to the diag-
nostic remit. By doing so, the accordance with the major viewpoints of the
Guideline in the description of diagnostic processes in psychotherapy should
become apparent.
Mutuality of Influence within the Psychotherapeutic
Diagnosing Process
In psychotherapeutic diagnostics we do not have an impersonal or non-in-
volved diagnosing 'subject' standing vis a vis a passive, diagnosed object.
1 The "characteristics of working at the living" mentioned in this paper find increasing
recognition outside Gestalt Theoretical Psychotherapy, due to their interdisciplinary
relevance. In his well known compendium "Grundkonzepte der Psychotherapie" -
"Basic Concepts of Psychotherapy", Jurgen Kriz argues "that each practitioner must
and will heed them" (Kriz 1985; d. also Kriz 1996). For the observation of these
characteristics for diagnostic purposes within clinical-psychological diagnostics d.
also Soff 1990, within the neurological practice Berger-Knecht 2000.

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100
Gerhard Stemberger
This diagnostic activity is rather a joint process of discovery within a vital
relational situation occurring between two humans. Although geared to-
wards the clarification of a situation, of the developmental potential and the
need of support by one certain person, with the professional help of the
othe/ both do affect each other, opening themselves to this interaction and
adopting an egalitarian attitude, which they use mindfully and consciously
for the clarifications to be achieved. 2
Shaping the Process by Using the Forces Inherent to
the Patient
Diagnostic clarification will only succeed when it is founded on the acting
forces inherent to the patient. The aspiration and the ability to arrive at such
a clarification as well as its counter-forces essentially spring from the patient
herself. Even the smartest and the most experienced psychotherapist will
fight a losing battle, if she fails to effectively and constructively support the
patient in becoming her own diagnostician.
Non-Exchangeability of Forms
Nothing may be sustainably imposed on a living creature that is contradictory
to his or her nature. Similarly, only those potentials can be brought to matu-
rity which are intrinsic to a person. Hence, each form of diagnostic explora-
tion needs to be adjusted to the individual possibilities and abilities of both
parties in each situation, in an interactive process between the psychothera-
pist and the patient. Any procedures executed along a standardized pattern,
irrespective of the individual and the situational needs, are out of place. The
psychotherapist rather has to stay in close touch with a given situation and
with her own as well as the patient's skills or faculties in order to - in con-
junction with her patient - find those paths of discovery which are innate in
this individual and, therefore, appropriate, however novel, unusual or contra-
dictory to prevailing rules or third party claims they may seem or be.
2 In more general terms, we find this perspective in the definition of psychotherapy in
the Austrian Psychotherapy Act, where the psychotherapeutic issue as a whole is
characterized as an interactive process. Gestalt Theoretical Psychotherapy specifies
this general interactive understanding to that effect that any occurrence be compre-
hended as a field process that complies with the rules of the psychic field. The psy-
chotherapist becomes part of the patient's life space and vice versa. This cognition is
the basis for building a social field that encompasses both partners. Thus, experience
and behavior of both relate to each other in the context of the same field and this,
naturally, is no less true for diagnostic situations.

Gestalt Theoretical Psychotherapy (GTP)
101
Non-Exchangeability of Working Times
As every human being has his own time and moments which are particu-
larly fruitful for change, the diagnostic discovery processes also have their
preferred moments; not any given time or moment is apt for every procedure
and every step taken thereafter. Planned diagnostic proceedings do not im-
ply that the psychotherapist conforms to a rigid pattern or schedule when
doing her explorations without questioning whether the time is ripe for the
patient to take certain steps, or to undergo certain procedures.
Non-Exchangeability of Work Speed
The speed of going about this diagnostic discovery process is not the same
with all humans, nor can it be accelerated or slowed down ad libitum.
Accepting Detours
Not all diagnostically relevant questions can be addressed directly. We will
often have to tolerate diversions or to even make provisions for them delib-
erately when we have realized that they are indispensable intermediary steps
in the unfolding discovery process.
As to the application of methods, the "Force Field Analysis" of Gestalt theo-
rist Kurt Lewin is central to this practical approach which pays regard to the
oneness (interrelatedness) of discovering and changing, as claimed by Gestalt
Theoretical Psychotherapy (cp. Lewin 1963). It is part of his comprehensive
field theoretical (system-theoretical) approach. Human experience and be-
havior are understood as functions of the person and the environment (in-
cluding the other individuals therein) in a psychic field (life space) which
encompasses both of these mutually dependent factors (cp. Soff, Ruh & Za-
bransky 2004).
The anthropological model of this approach is, hence, not monopersonal
but, a priori, structural and relational in nature. It does not one-sidedly focus
on the 'inner components' of a person, but on the interrelation of the indi-
vidual and a given environment, which affects experience as well as behav-
ior (cp. Galli 1999, 29ff). The personality constructs, elaborated on this
premise by Lewin and his associates and surveyed in the "Iife-space"-model,
have been systematically incorporated and made fruitful for psychotherapy
by Hans-Jurgen P. Walter (1977) in his outline of a Gestalt theory of the per-
son, by inclusion of the psycho-physical presumptions and the critical-realis-
tic home position of Gestalt theory. As a "Change-Process-Activating Force

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102
Gerhard Stemberger
Field Analysis" the force-field-analysis, which had originally been developed
and experimentally tested for other application areas by Lewin et aI., was
transferred to the psychotherapeutic work field and integrated in Gestalt
Theoretical Psychotherapy. 3
The Force Field Analysis is a phenomenologically-oriented procedure in
which the psychotherapist, along with the patient, looks for the specific and
situationally appropriate routes of exploring the specific properties of the
patient's life space and the presently attracting and repulsing forces, the bar-
riers, the inaccessible realms, and other dynamic factors operant there. This
may be facilitated by a kind of dialogue in psychotherapy which encourages
'experiencing while speaking', and equally addresses and activates the pa-
tient's thinking, feeling, sensing, intuiting, and acting. The therapist may also
propose appropriate and specific 'experiments' or jointly 'contrive' new ones
which are apt to illuminate the patient's life space to her and no less to the
attending therapist, and to thus render it immediately palpable and experi-
enceable.
The Force Field Analysis (or in more general terms, 'life space analysis') is
not geared toward classifying the patient along the lines of one or another
constellation of symptoms in a certain phenotypical 'category of disorders',
but to grasping the dynamic properties of the psychological situation in
which the patient finds herself at a given point in time. Such analysis will af-
ford pointers the situation holds, as to what is needed for the changes due.
Instead of a phenotypical, a genotypical analysis will be undertaken, one that
concurs with the epistemological posit voiced by Lewin, which postulates
that the transition from the Aristotelian to the Galileian way of thinking
should finally be made in the social sciences (Lewin 1931).
This thinking tradition, for instance, does not look for a congruous inven-
tory of traits of a depressive patient, but it inquires for the dynamic properties
of the psychological situation in which a person conducts himself depres-
sively, and tries to find out the function which interconnects the depressive
demeanor and the life space. Or, in Lewins's words, "to progress from purely
symptomatological concepts to ascertaining psychological realities, replacing
the sheer classification-based conceptualization by a constructive one. ...
The psychotherapist ... does not only seek to cognize a patient/s inner life,
but to also have an impact on it ... she has to be aware of how the actual
behavior depends on the respective inner and outer situation, and which
concrete changes of a situation may result in the desired modification of
3 Cf. also Ruh 1999. In the psycho-diagnostic field, the Life Space Analysis as a holistic
approach to clinical-psychological diagnostics looks back on decades of research
and practice traditions which we merely mention and cannot discuss further in this
context. Cf., e.g., the studies by Plaum 1989, 1992, 1996, 2000; Maibaum 2001 and
Stemberger 2001 for further references.

Gestalt Theoretical Psychotherapy (GTP)
103
conduct. This cannot be revealed by the classificatory statements ... but by
the identification of the dynamic principles only, the essential function of
which, accurately speaking, is ... not to pass from concrete to abstract gen-
eralities, but, despite their universal validity, to fully maintain their relation-
ship with the reality of the individual case and of the individual situation (cp.
Lewin 1970, 24f). In the therapeutic situation, the correct apprehension of
what 'is' does, therefore, not only 'explain' what is happening at present but
also points to what can and should happen.
Our conviction that the root of the distinction between phenotypical and
genotypical classifications 4 is not some aloof epistemological sophistry ir-
relevant to the clinical practitioner gets supported daily when psychothera-
pists deal with the available classification systems ICD and DSM, which, as
a rule and for good reasons, are held immaterial because they do not provide
instructive principles apt to guide therapeutic (and diagnostic) practice.
Diagnosing and Classifying
As is widely known, diagnosing and classifying are related but are not identi-
cal. The psychotherapist does not want to file her patient in an index of dis-
orders, but to explore and understand with her what her situation is like,
what her suffering is made up of, what is at the bottom of it, which possi-
bilities there are to cope with it, where the self-recuperative forces have been
impaired (to the degree that the patient finds herself ensnared in a vicious
circle which she cannot break up by herself), which resources are still there
and intact for the psychotherapist and the patient to rely on in the coping
process, what has to be done next, which further steps are feasible and ap-
propriate in therapy, etc.
Even in the diagnostic process, as outlined in this paper in accord with
the Guideline, concordances between the individual and other cases can
and will become apparent, which means that classifications will become
possible that differ, however, fundamentally from those of ICD and DSM.
They will not primarily be oriented toward finding symptoms or other exter-
nal concurrences, but toward the congruence between the qualities of each
happening, its preconditions, its patterns and regularities, from which con-
clusions on therapeutic options and on the prognosis may be drawn. The
classification with one of the lCD-categories is usually meaningless to the
therapist and the patient when such joint diagnostic proceedings are under-
taken. At worst, it is even obstructive or misleading, for it does not render
4 For the relation between phenotypical and genotypical classifications in the realm of
mental disorders and for the possibilities how both approaches may be interrelated
d. Stemberger 2001.

...
104
Gerhard Stemberger
clarity. Precisely for this reason, attributions to categories play such a mar-
ginal role in the psychotherapeutic practice, and not only there, but psychia-
trists and clinical psychologists usually also feel similarly, as the long-stand-
ing critical discussion of these taxonomies demonstrates. Practicing clinical
psychiatrists and psychologists, as much as psychotherapists, have difficulties
with the extant psychiatric systems and the deplorable state they are in.
As measured by the classification standards in other sciences, these sys-
tems lag behind other disciplines by decades, regarding their basic approach
as well as their methodology. No physicist, chemist, zoologist, or botanist
would still classify in this manner which has been largely abandoned in
most other medical specifications decades ago. Even Kraepelin who is con-
sidered the founder of this line of categorization in the psychiatric field re-
garded this abstracting subsumption under taxons of identifiable symptoms
and syndromes as provisional, or as the "second line of defense", which
should be given up as soon as possible (cp. Kihlstrom 2002). Little would be
his enthusiasm if he, today and so many decades later, found ICD and DSM
still loitering at this provisional defense line, which is rightfully held the low-
est and most primitive stage of taxonomy also in medical science (cp. Houts
2002). He would, supposedly, rather join those critics who, like Carson
(1996) for instance, with reference to the classical contribution of the Gestalt
theorist Kurt Lewin (1931 I), postulate that we should finally get serious about
the transition from the Aristotelian to the Galileian way of thinking 5 , also
where analyzing and cataloguing mental disorders are concerned, rather
than contenting ourselves with "re-arranging the deck chairs on the Titanic",
as Kihlstrom sneeringly characterizes the 'progress' of the more recent ver-
sions of those systems (2002, 290).
Under these circumstances and for a number of other reasons, I would
appreciate the Guideline to take a clearer stance on its relationship with
those systems. If I interpret the Guideline correctly, the authors propose
'non-interference' and 'pragmatic adjustment' in this issue. They suggest
'non-interference', as the classification systems of other sciences refer to
other subjects and competence areas ("different aspects of mental and phys-
5 Cf. lewin's description of the problem well known to psychotherapeutic, psychiatric,
and clinical-psychological practitioners, namely of the abstracting, symptom-sup-
ported classifications of the Aristotelian kind: "If one 'abstracts from individual differ-
ences,' there is no logical way back from these generalities to the individual case.
Such a generalization... leads from a psychopathic individual to similar pathological
types, and from there to the general category 'abnormal person.' However, there is
no logical way back from the concept ... 'abnormal person' to the individual case.
What is the value of general concepts if they do not permit predictions for the indi-
vidual case? Certainly, such a procedure is of little avail for the... psychotherapist"
(1951, 60; German: 1963, 102). This criticism determines today's critical dispute over
the present psychiatric taxonomies, d., e.g., Beutler & Malik 2002).

Gestalt Theoretical Psychotherapy (GTP)
105
ical conditions"). They advocate 'pragmatic adjustment' in the sense that
psychotherapists should abide by these systems also, however inept they are
for their therapeutic purposes since, firstly, the institutions want it (health
insurance companies, etc.) and, secondly, communication with other profes-
sional groups (and with psychotherapists with other methodological orienta-
tions) is essential.
In my opinion, the scope of validity of both viewpoints is restricted.
Apart from some specific areas where it is, of course, justified to speak of
engagement in "different aspects of mental and physical clinical pictures or
conditions", clinical psychology, psychiatry, and psychotherapy deal with the
same basic issues, particularly with regard to the diagnostic tools relevant to
the therapeutic practice, and controversies and concordances usually do not
occur between these disciplines of science, but right through them. This is
true for the quest for procedures of the diagnostic process, which should be
appropriate for the humans as well as for the classification issue. There, it is
not non-interference that is called for, but the communication over the com-
mon subject, and a firm stand on the major yet-to-be-answered and contro-
versial questions. In my opinion, the psychotherapeutic science has much to
offer in this area, and it will find many ways to connect to various currents
within those two other disciplines.
Similar restrictions hold true for the 'pragmatic adjustment'. Doubtlessly,
the Austrian psychotherapists who are currently being remunerated by the
health insurance companies, usually and necessarily, 'label' their patients, or
'tag' them with lCD-code numbers. We disbelieve, however, that these en-
codings meaningfully contribute to the interdisciplinary exchange between
psychotherapists, psychiatrist, and psychologists or, among the members of
these professional groups, over common patients, and this skepticism is well
supported by the practical experience as well as by a large body of pertinent
research findings. 6 For all these reasons, these encodings, at the most, play
an underpart in all those areas which are engaged in fruitful interdisciplinary
communication and collaboration, and the endeavors of setting up interdis-
ciplinary classification systems in psychotherapy take a completely different
direction (e.g., OPD7).
A clearer positioning of the Guideline on ICD and similar systems is,
therefore, not only academically relevant but, more immediately, to psycho-
therapeutic practice also. It is most obvious that internationally as well as in
Austria, there are politically and economically motivated tendencies to di-
6 For the same reasons, applying these categories in research raises problems, a topic
we cannot dwell on in this context. Cf. also, e.g., Beutler & Malik 2002
7 'Operationalized Psychodynamic Diagnostics', d. Arbeitskreis OPD 1996 (German
ed.), OPD-Task-Force 2000 (English ed.)

..,..
106
Gerhard Stemberger
rectly tie ICD-'diagnoses' to 'state-of-the-art treatments'. In the face of this, a
guideline of psychotherapeutic diagnostics should, to my mind, unmistakably
state that from the point of view of the psychotherapeutic science (by anal-
ogy with the critical discussions of these diagnostic systems in psychiatry and
clinical psychology) and from the pertaining research perspectives, the
present state of these systems does not permit such link-ups. Not because of
their derivation from other sciences but because of their fundamental scien-
tific deficits, the existing taxonomies do not provide a qualified foundation
for deducing psychotherapeutic indications, fitting psychotherapeutic meth-
ods, particular psychotherapeutic routines or intervention strategies from a
particular lCD-category. If a future version of the Guideline will take a clear-
er position vis-a.-vis ICD and DSM, I still anticipate that the representatives of
psychiatry and clinical psychology will eventually take a joint position, at
least where the basic principles are concerned.
There is a good reason why the Guideline in its present form does not
refer to any classification systems when dealing with the practical decisions
reviewed there (e.g., indication of psychotherapy, consultation with other
health professionals, etc.), but proposes other selection procedures and crite-
ria. The few references to ICD remain marginal, but they should be voiced
less ambiguously for the reason I discussed above. The same holds true for
the references to the Potemkin village 8 of the so called 'definition of illness
by the terms of the social insurance law'.
The procedures proposed in the Guideline for practical diagnostic deci-
sion processes as well as the concepts, constructs, and dimensions devel-
oped for that purpose deserve a more detailed discussion, be it approving or
critical. This would, however, exceed the compass of this commentary and
is reserved to future stages of critical reception, discussion, and revision of
these proposals within the working group of the Advisory Board for Psycho-
therapy. To my Gestalt Theoretical-psychotherapeutic mind, the basic orien-
tation of the submitted Guideline is, in any case, positive and promising for
the further advancement of the project.
References
Arbeitskreis OPD (1996) Operationalisierte Psychodynamische Diagnostik: Grundlagen
und Manual. Hans Huber, Bern. English edition: OPD-Task-Force (2000) Operational
Psychodynamic Diagnostics. Foundations and Manual. Hogrefe & Huber, Seattle
Tortonto G6ttingen Bern
8 The myth that this was a clearly circumscribed concept that met the general criteria
of a definition will be dispelled after reading Mazal's thorough and astute analysis of
the concept of illness within the Austrian health insurance scheme - d. Maza11992.

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Berger-Knecht R (2000) Gestalttheoretische Psychotherapie unter besonderer Beruck-
sichtigung meiner Arbeit in einer nervenarztlichen Praxis. OAGP-Informationen 9 (2):
1-16
Beutler LE, Malik ML (eds) (2002) Rethinking the DSM - a Psychological Perspective.
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Carson RC (1996) Aristotle, Galileo, and the DSM Taxonomy: The Case of Schizophre-
nia. Journal of Consulting and Clinical Psychology 64: 1133-1139
Galli G (1999) Psychologie der sozialen Tugenden. B6hlau, Vienna
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DSM - a Psychological Perspective. American Psychological Association, Washing-
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Hutterer-Krisch R (ed) (1996) Fragen der Ethik in der Psychotherapie (2nd edn 2001).
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Kriz J (1985) Grundkonzepte der Psychotherapie (5th edn 2001). PVU, Weinheim
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Laireiter A-R (ed) (2000) Diagnostik in der Psychotherapie. Springer, Vienna New York
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Lewin K (1931) Der Obergang von der aristotelischen zur galileischen Denkweise in Bio-
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Bern Stuttgart).
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Plaum E (1989) Psychodiagnostik in der Tradition der Lewin-Schule. Gestalt Theory 11
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Translated from the German by Luna Gertrud Steiner

Hypnopsychotherapy (HY)
HANS KANITSCHAR
Hypnopsychotherapy is a depth-psychology based method which employs
depth psychological and hypnosis-specific diagnostic models. The diagnosis
of symptoms as well as of personalities and relationships, and the assessment
of critical potentials are developed and based upon structural and psycho-
dynamic, resource- and prospect-related considerations.
The formation of diagnoses is inherent in the hypnotherapeutic process;
these may be classified as initial, process-related, and concluding structural
diagnoses. In diagnosing, we start out from the preliminary diagnostic work
hypotheses, which will be modified and refined to differential diagnoses in
the process of therapy.
The hypnotherapeutic diagnosis proceeds from the subjectivity of experi-
encing and suffering, relating this subjective matter to objectively verifiable
facts.
The sources of information for establishing diagnoses are:
1. Personal history
a) Anamnesis including all treatments undergone hitherto
b) Current life situation
c) Life history
2. Observation within the therapeutic situation
Behavior during first contact, patterns of communication and interaction,
congruity/incongruity, transference offers and reactions on the client's
part.
3. Ways of reacting to specific hypnotherapeutic interventions, which make
for the assessment of a client's personal variables such as his ability to
enter trance, the suggestibility, the ability of dissociation, etc.

110
Hans Kanitschar
a) Responses to hypnotherapeutic verbal interventions such as indirect
or interspersed suggestions, or facilitation (Erickson & Rossi 2001).
b) Responses to different forms of trance induction
c) Individual trance patterns of the client
d) Autosuggestive patterns of the client
4. Hypnotherapeutic interventions arousing unconscious matter
a) Problem- or resource-related trances
b) Trances for the purpose of hypermnesia
c) Ideomotor questioning, and others
5. Countertransference reactions of the therapist
Establishing Psychotherapeutic Diagnoses
Symptoms in Relation to Personality Aspects
The symptoms are classified by means of the descriptive diagnostic procedure
of ICD 10. Pieces of information are collected on the onset of symptoms, the
triggering situations, the duration and the frequency of their occurrence, on
the factors which either favor, elicit, or thwart the appearance of those symp-
toms, the responses from the environment, and how symptoms affect the
client's day-to-day living, the secondary gain from illness, and many others.
In case of a personality disorder, the diagnosis is also stated along the
lines of ICD 10. But this descriptive diagnostic proceeding is viewed against
the background of the depth psychological structural diagnosis and related to
it. The structural diagnosis rests on developmental diagnostic, psychoana-
lytical, and hypnotherapeutic criteria.
Ermann (1997) distinguishes three levels of neurotic structure and does so
by developmental-diagnostic and psychoanalytical criteria. With their sup-
port, the degree of maturity of the ego and the stability of the self structure
are described, according to the observable and deducible criteria as listed
below. Due to the limitation of space, I can merely outline them briefly:
Relatively high structural level: Mature neurotic structure, characterized
by object constancy, self coherence, realistic perception of others, mature
relational abilities, mature defense mechanisms (repression, suppression and
auxiliary mechanisms), and others.
Intermediary structural level: Narcissistic basic structure with a coherent
ego, characterized by repression and splitting as defense mechanisms, de-
pendency on objects, narcissistic relational style, fundamental lack of self-
confidence and self-esteem.
Low structural level: borderline personality structure, characterized by
ego-weakness, deficient distinction between self and object, identity diffu-

Hypnopsychotherapy (HY)
111
sion, and the key defense mechanisms of splitting and projective identifica-
tion. The object relations are dyadic, and there is a strong dependency on
objects. We distinguish between borderline personality pathology, border-
line personality disorder, and borderline syndrome.
On the psychotic level, we have a gradually disintegrating ego with un-
derlying partial self and partial object representations. The defense mecha-
nisms supposed to ward off the dangers of fusion are splitting, primitive de-
nial, and projective identification.
To further specify the personality, we also include the processing modes
(hysteric, schizoid, depressive, obsessive-compulsive, narcissistic, and others
(Mentzos 1998).
Resources
To establish a hypnotherapeutic diagnosis, it is indispensable to familiarize
oneself with the client's resources and to correlate them with the character-
istics of the structural levels.
The skills of the conscious and the unconscious ego as well as the stabil-
ity of the structure of self, in other words, the healthy aspects of a personal-
ity, constitute those endopsychic resources which may be utilized in the
therapeutic process (Frederick & McNeal 1999).
Those abilities of the unconscious ego which, for instance, manifest as
defense mechanisms are considered resources. They can be employed in
various contexts. We may, therefore, assume that if differentiated defense
mechanisms exist, the accordant resources may usually be actualized also.
These abilities, along with the integrated self and object representations,
form those structures which are to be addressed as the healthy and creative
unconscious in the sense as Milton Erickson understood it (Erickson & Rossi
2001; Gilligan 2005). Concrete pieces of information concerning these un-
conscious resources hold valuable prognostic clues.
By resources we further understand abilities innate in a person such as the
capabilities of introspection, reflection, imagination, dissociation, the degree
of suggestibility, autosuggestive abilities, memory, access to dreams, etc.;
furthermore, gifts, talents, extended expressive faculties such as musicality,
artistic/literary/poetic gifts, and similar need to be mentioned.
Fundamental personal attitudes such as openness, willingness to learn,
perseverance, optimism, curiosity, humor, etc. are resources as much as a
person's level of education, his communicative skills and qualities, his psy-
chological or philosophical background, to name only a few.
Pre-experience in imaginative or body-oriented procedures, in Autogenic
Psychotherapy, or in various relaxation methods are valuable coping ap-
proaches to build the hypnopsychotherapeutic work on.

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Hans Kanitschar
Besides, external supportive circumstances, such as a sound relationship,
a meaningful occupation, a supportive circle of friends, material safety and
mobility should be taken note of.
The availability of the above mentioned or other resources, or their ab-
sence, offers valuable clues as to what could be helpful for the client to suc-
cessfully build her therapy and to settle her problems. The correspondence
between problems and personal and environmental resources provides prog-
nostic markers.
Whether the client's ailments are to be subsumed under the characteris-
tics of her personality or have to be regarded as definable symptoms in the
narrower sense of the word has to be clarified in the initial stage of hypno-
psychotherapy.
On principle, personalities that are more highly structured tend to exhibit
symptoms or problems which are rather easily definable. These problems are
often treatable within a short term therapy setting. The more unstable the
ego or self structure, the higher the likeliness of comorbidities, and the more
intricately the symptoms and problematic issues will be intertwined with
personality deficits or disorders.
An essential differential diagnostic distinction concerns the potentiality of
a structural collapse and whether its duration is terminable. The ascertained
structural level describes the highest stability and maturity level ever reached
by a particular individual. The stability of the ego can, however, dwindle
due to neurotic maldevelopment, or unpleasant external conditions such as
adversariallife circumstances or events, particularly traumatic ones; the self-
assuredness will be shaken and the structural level will drop. Under extreme
conditions (e.g., torture), a person may regress from a relatively high, fully
integrated structural level to a psychotic one. In the case of serious life crises
which a person is unable to cope with we often witness a temporary and
terminable sag of the structural level. This reduced picture may be called
functional level. When the structural level slumps to a lower functional level,
comorbidities are more likely to occur, which may, in turn, cause further,
secondary symptoms. A hypnotherapist, aware of these coherences, will fo-
cus on the restoration of the former structure and stability, which are both
resources, rather than on the symptoms only.
A method-specific technique to obtain information, apart from those al-
ready named, is the ideomotor questioning. It consists of open-ended, non-
suggestive yes-no-questions, to which the client, in a hypnotic trance, reacts
non-verbally by involuntary finger twitches. The client may, in addition, re-
port upcoming thoughts, images, and reminiscences (Cheek 1994, Kaiser-
Rekkas 1998). The information gained from this ideomotor questioning
technique provides the therapist with insights into the client's unconscious
imaginative world and contributes to the illumination of psychodynamic co-
herences.

Hypnopsychotherapy (HY)
113
The Psychotherapeutic Relationship
Initiating and Shaping the Psychotherapeutic Relationship
The psychotherapeutic relationship starts with the (potential) recommenda-
tion of a certain therapist which includes statements about her and arouses
expectations. The very first contact via telephone, letter, or email sets off an
interaction, geared toward the joint and intensive collaboration which is to
change the client's life for the better.
The beginning of hypnotherapy is characterized by the expectations con-
cerning the techniques as well as the therapist. After the client has outlined
his problem and been informed on the possibilities and limitations of psy-
chotherapy in general, and on the method of hypnotherapy in particular,
both jointly sound the possibilities and targets of this particular therapy. In so
doing, the attitudes and propensities of the client, such as a passive attitude
toward therapy, idealization, competitiveness, seductiveness, and over-ad-
justment become translucent, and a certain transference offer will shine
through. Simultaneously, countertransference reactions to this implicit rela-
tional offer will emerge in the therapist, too. Personality variables, the char-
acter structure and the communication style essentially influence contacting
and relating (Mende 1998; Revenstorf 2001). From the moment they first
meet, the therapist will register all these processes and include them in her
first diagnostic considerations.
By adopting an empathic, interested and attentive attitude which oscillates
between receptivity and activity, the hypnotherapist eases the way for the cli-
ent to speak about her issues and to formulate various coherences. The thera-
pist attends to the client's language, her verbal images and metaphors, her
frame of reference, and her world view. The therapist tries to understand and
to empathize, and plays her own understanding back by pacing. Hypnothera-
pists call this style of interacting, when managed successfully, a good rapport
(Gilligan 2005). When the therapist relies on it, her responses will be authentic
while she proceeds with occasional questions and comments, without imply-
ing personal judgments. The therapeutic attitude conveys fundamental ac-
ceptance and appreciation, and it is the basal moment of shaping the relation-
ship in hypnotherapy. Frederick & McNeal (1999) mention the following fac-
tors a hypnotherapist brings to the therapeutic relationship: respect and inter-
est, interpersonal safety, reliability, empathy, and responsiveness. Eisen &
Fromm (1983) proved that trust grows with the hypnotherapist's capability of
creating an atmosphere, in which the major part of the experience accrues
from the client's inner resources (quoted from Brown & Fromm 1986).
Checking the motivation for therapy is important. The client may be
driven by the rather pragmatic request to simply get rid of a symptom or a
painful condition, or there may be something more to it. The client may al-

114
Hans Kanitschar
ready have conceived and expressed some ideas about the background of
his problems and, possibly, even on how to solve them. The therapist surveys
these coherences for herself, but does not let herself get entrapped in prema-
turely and uncritically translating the client's ideas on how his problem
should be solved into hypnotherpapeutic interventions. Reserving the com-
petence to diagnose to herself she, conjointly with the client, draws up a
therapy plan, before employing a more deep-going intervention. This may
call forth the first (moment of) frustration in the client, and the way it is re-
solved is highly significant for the transference relationship.
The course and the success of previous treatments, particularly of those
applying psychotherapeutic means, as well as the questions of the treatabil-
ity of the symptoms and disorders by hypnotherapy, its presumptive dura-
tion, the required frequency of therapy sessions, and others are also indica-
tive of how the client is going to structure the relationship on his part. He is
particularly expected to willingly and actively contribute to his therapy, an
attitude which may not be present at the outset, given the passive and magi-
cal expectations that are often fostered of the healing powers of hypnosis.
The way a client relates to himself affects the transference offer. When he
describes himself and his problems from an objectified perspective only,
e.g., in pathological terms, he implicitly addresses his expectations from the
psychotherapist, which she, no less implicitly, corrects. She will direct the
client to speak from his own experience, or at least to get close to it.
Likewise, we will attend to how a client relates to his body. The degree of
dissociation from, or ambivalence towards his own body or body parts often
corresponds to the unrealistic expectances of the instant, 'technical' healing
to be achieved by hypnotic means. In such a case, the therapist will provide
realistic information and point out possible ways how to deal with ambiva-
lence, deficits, and unconscious dynamics.
By observing the above mentioned and similar features, and by gaining an
overall impression of the client, the hypnotherapist starts to assess the client's
willingness to collaborate, his ability to ally, and the sustainability of the
evolving therapeutic relationship.
Target Orientation
Besides the generally valid therapeutic goal of restoring health on the psy-
chological, physical, and social levels, goals that may be paraphrased as the
abilities to relate, to work, to enjoy, and to find one's own meaning or pur-
pose, the hypnotherapist and the client jointly set themselves specific thera-
peutic targets.
At the start, the client is usually instructed to replace her wishful and
usually unreflected ideas about her symptoms or disorder disappearing by

Hypnopsychotherapy (HY)
115
affirmatively formulated targets, i.e., to phrase what she wants to achieve by
this therapy. These personal goal statements should possibly be operational-
ized and thus made objectively verifiable. The main question should be, 'By
which criteria will you realize that the therapy has been completed success-
fully?' (Gerl 2001).
The handling of this question may ease the access to deeper issues and
concerns. Whether concrete answers to these questions come easily or re-
luctantly serves as a diagnostic indicator of the definability of the problem
and of the factors which either stabilize the problem or signal the client's
willingness to change.
After one or more therapeutic targets have been negotiated, partial goals
may be formulated which serve as some sort of markers on the way toward
the therapeutic target.
Besides these explicitly formulated goals, the hypnotherapist tries to con-
trive concrete procedures and techniques by which to achieve them.
Process Diagnostics
Diagnosing the relationship which accompanies the process enables the hyp-
notherapist to further differentiate and refine her diagnostic hypotheses and
to thus respond to the client's needs more and more adequately. Diamond
(1973) distinguishes four levels of the hypnotherapeutic relationship: transfer-
ence (1), working bond (2), symbiotic level (3), and reality level (4).
Hypnotherapists continuously keep an eye on the working bond (mature
level), while in the transference relationship and on the symbiotic level (early)
childhood rudiments either mature silently and incidentally or, if need be,
are picked up and worked over explicitly.
The observation of transference is an important source of information for
establishing diagnoses (Brown & Fromm 1986). Irrespective of the presenting
problem or symptom, the client's transference offers pointers as to his level
of ego maturation, to the quality of self structure, to his attachment pattern
(Brisch 1999), to the predominant defense mechanisms, and to many other
Issues.
When reflecting her countertransference, the therapist identifies her own
personal problem areas, thus capacitating herself to use her countertransfer-
ence responses to empathize her client's way of shaping his relationships. She
may, for instance, become aware of the client's split-off affects within herself
and 'contain' them (Bion 1962), or witness her own fantasies which portend
the transference structure such as of parent-, twin-, sibling transferences and
others (Brown & Fromm 1986), or she may locate projective identifications
which point to a deficient self/object discrimination (Kernberg 1988). From
these data we may draw further differential diagnostic conclusions.

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Hans Kanitschar
One hypnotherapeutic technique, i.e., the work with personality parts or
ego-states (Watkins & Watkins 2003), offers specific diagnostic insights into
the interrelatedness of mature and immature, integrated and less integrated,
or split-off personality parts. The client's growing ego-strength and autonomy
indicate the shift of the interior balance toward the more integrated personal-
ity components.
Assessing the Psychotherapeutic Relationship
The psychotherapeutic relationship is the agent as well as the space for the
client to learn to experience himself in contrast to others (in case of border-
line personality structures), to discover, to accept, and to extend his emo-
tional realms and to thus gain confidence in himself and others (in the case
of narcissistic neuroses), and to face his conflicts repressed hitherto (in cases
of mature neuroses).
The hypnotherapist continually monitors the evolvement of therapy and
regularly communicates her thoughts on the therapeutic relationship, on the
course the work is taking, and on the hypnotherapeutic strategies and tech-
niques used. Every now and then, she will write down the most important
results of her reflections.
Critical Potential
How do we influence and manage the crises necessarily arising in the hypno-
therapeutic change process?
By getting to know the client in the continual psychotherapeutic process
and by orienting ourselves to the structural level and to our awareness of the
client's resources, we will usually manage to a priori assess the degree of
severity of an imminent crisis in hypnotherapy, and we will take provisional
safety measures. These may, for instance, consist in the acquisition of an-
choring or self-hypnotic techniques which will activate the client's resources,
or in the tentative anticipation of problems, and in the application of sup-
portive posthypnotic suggestions, and many others.
If a crisis occurs due to unexpected external or internal factors, diagnostic
cognitions as those mentioned increase our alertness to steer the crisis into a
more constructive direction. By hypnotherapeutic pacing (Gilligan 2005), we
build rapport with the client, which in turn reinforces the supportive charac-
ter of the therapeutic relationship. Ascribing a meaning to the crisis, e.g., that
it could be the opportunity for personal learning, may be helpful in the con-
fidential therapeutic context. The usage of appropriate metaphors and stories
may open new perspectives, and the relaxation, the switching-off, the recov-

Hypnopsychotherapy (HY)
117
ery of energy by trance, and the activation of fundamental unconscious re-
sources may further facilitate the process.
Psychotherapeutic Indication
1. Indication of Psychotherapeutic Treatment:
Hypnopsychotherapy is indicated in all disorders listed in ICD 10 under
Fl up to F9.
2. Indication of Additional Diagnostic Clarification (Somatic-Medical,
Psychiatric, Clinical-Psychological, or Others):
as described in general terms in the Guideline
3. Indication of a Specific Psychotherapeutic Treatment Option:
Hypnopsychotherapy is highly suitable for supporting medical treatment
and other healing processes, and for the treatment of psychosomatic dis-
orders (Erickson 1997, Revenstorf 2001).
Furthermore, hypnotherapy is particularly effective in building and actualiz-
ing resources and in making them available in critical situations outside the
therapy, e.g., with behavioral or anxiety disorders (Revenstorf 2001). More-
over, hypnotherapy is particularly effective in the short-term treatment of
those symptoms and issues which are clearly definable. Another specific
field of application lies in the basal re-maturation of early disturbed person-
alities (Zindel 2001).
References
Bion W (1962) Lernen durch Erfahrung. Suhrkamp, Frankfurt/M
Brown D, Fromm E (1986) Hypnotherapy and Hypnoanalysis. Lawrence Erlbaum, Hills-
dale London
Cheek D (1994) Hypnosis. The Application of Ideomotor Techniques. Allyn and Bacon,
Boston
Diamond M (1993) Die interaktionelle Basis der hypnotischen Erfahrung - i..iber die Be-
ziehungsdimension der Hypnose. Imagination 15 (2): 5-32
Eisen M, Fromm E (1983) The clinical use of self-hypnosis in hypnotherapy: tapping the
functions of imagery and adaptive regression. International Journal of Clinical and
Experimental Hypnosis 31: 243-245
Erickson M H (1997) Gesammelte Schriften von Milton H. Erickson. Band III. Special
edition for M.E.G. Carl Auer Systeme, Heidelberg, pp 202-301
Erickson M, Rossi E (2001) Hypnotherapie. Klett-Cotta, Stuttgart
Ermann M (1997) Psychotherapeutische und Psychosomatische Medizin. Kohlhammer,
Stuttgart
Frederick C, McNeal S (1999) Inner Strengths. Contemporary Psychotherapy and Hypno-
sis for Ego-Strenghthening. Lawrence Erlbaum, Mahwah London, pp 5-21

118
Hans Kanitschar
Gerl W (2001) Resourcen- und Zielorientierung. In: Revenstorf D, Peter B (2001) Hypno-
se in Psychotherapie, Psychosomatik und Medizin. Springer, Berlin Heidelberg New
York Tokyo, pp 75-82
Gilligan S (2005) Therapeutische Trance. Das Prinzip Kooperation in der Ericksonschen
Hypnotherapie. Carl Auer, Heidelberg, pp 129-150 (127-128)
Kaiser-Rekkas A (1998) Klinische Hypnose und Hypnotherapie. Carl-Auer-Systeme, Hei-
delberg, pp 96-115
Kernberg 0 (1988) Schwere Personlichkeitsstorungen. Klett-Cotta, Stuttgart
Mende M (1998) Hypnotherapeutic responses to transference in the face of therapeutic
change. In: Hypnos, Vol XXV, No 3-1998, pp 134-144
Mentzos S (1998) Neurotische Konfliktverarbeitung. Fischer, Frankfurt/Main
Phillips M, Frederick C (2003) Handbuch der Hypnotherapie bei posttraumatischen und
dissoziativen Storungen. Carl Auer-Systeme, Heidelberg
Revenstorf D (2001) Nutzung der Beziehung in der Hypnotherapie. In: Revenstorf D,
Peter B (2001) Hypnose in Psychotherapie, Psychosomatik und Medizin. Springer,
Vienna New York, pp 53-75
Stumm G, Pritz A (2000) Worterbuch der Psychotherapie. Springer, Vienna New York
Vas J (1993) Hypnose bei Psychosen. Quintessenz, Munich
Watkins J, Watkins H (2003) Ego-States. Theorie und Therapie. Carl Auer-Systeme, Hei-
delberg
Zindel J (2001) Hypnose mit frLlhgestorten und Borderline-Patienten. In: Revenstorf D,
Peter B (2001) Hypnose in Psychotherapie, Psychosomatik und Medizin. Springer,
Vienna New York, pp 488-498
Translated from the German by Luna Gertrud Steiner

Integrative Gestalt Psychotherapy (IG)
KATHLEEN HOll
Diagnostics in Integrative Gestalt Therapy
Categorizing or classifying human beings is per se contradictory to the basic
theoretic approach of gestalt therapy (cp. Perls 1988, Staemmler 1989). Ge-
stalt therapy emphasizes the uniqueness of each individual. With that in
mind, gestalt therapists used to be skeptical about any form of diagnostic ac-
tion, also because of the apprehension that a 'nosological' perspective (which
can hardly be adopted without emotionally distancing oneself) would render
the psychotherapist emotionally unavailable already in the intake interview,
and lessen her ability to encounter her client with empathy and attentiveness
- qualities that help the client bear her fears that her hurts and shortcomings
will be revealed.
The process-related concept of self (understood as engagement in the
environment at the contact boundary, cpo Perls, Hefferline, Goodman 1951)
consequently evolved into the gestalt understanding of the diagnoses being
momentary working hypotheses which refer to certain experiential and be-
havioral aspects of the way humans form or deform their contacts with
themselves and the environment. We regard the client's suffering as disor-
dered or - in certain cases - dysfunctional ways of perceiving, experiencing,
and comporting, which at some stage used to be creative solutions under
difficult life circumstances. As fixed gestalts they have become inappropriate
under current conditions.
Proceeding from these assumptions, gestalt therapeutic diagnostics is re-
garded to be a phenomenological and structural way of analyzing: starting
points are the phenomena and anything immediately accessible to observa-
tion. We try to comprehend the client's appearance as thoroughly as possi-
ble, including her body language, the pitch of her voice, her attire, the at-
mosphere she emanates, as well as her way of contacting. Gestalt therapists

120
Kathleen Hall
are particularly trained to notice minute motor activities, lingual characteris-
tics, and the atmospheric tuning in their vis a vis, as well as their own subtle
reactions to all these details. They lay special emphasis on the skill of distin-
guishing perceptions from fantasies and interpretations.
We may thus ascertain that, at the beginning of the therapeutic/diagnostic
contact, gestalt therapists leave all diagnostic hypotheses aside to remain
open to a - possibly - completely new constellation of individual and social
factors, every human is - potentially - endowed with.
Each of these individual constellations along with the history of one's hav-
ing-become-this-very-person may be deduced increasingly accurately and
comprehensively as therapy proceeds: from the physical presence of the hu-
man being, from her utterances on the image of herself and of the world,
from her social relations as explored by role-play, from her imaginative
manifestations (paintings, texts, tunes, dreams), from her values and her ac-
tual demeanor.
The medium in which this contact process between the patient and the
therapist occurs is the awareness continuum, which is the mutual becoming
and remaining aware of everything in the client that strives for expression
and actualization. The more regardful the therapist is of all aspects of any
occurrence, including his own corporality, his emotionality, and his history,
the more open he is for all shades and facets of his dialogue partner.
In Integrative Gestalt therapy, diagnostics is conceived of as an interactive
process taking place between two people with their current potentials and
limitations, which makes it a mutual learning process. The process of two
partners contacting each other hence flows into diagnosis. In this process,
preconceived diagnostic categories, seemingly meaningful at present, are
used as auxiliary constructs, to bundle single individual traits, to derive hy-
potheses therefrom, and to work out further questions.
The chosen diagnostic category may give way to another when the thera-
peutic process moves on. Whether this is so, depends on the therapy progress
and thus on the level of profundity fathomed (suppression layer). In any case,
we have to look to the totality of the phenomena and to the quest for the
best, i.e., the most meaningful 'diagnosis', in order to assess the picture of a
disorder as fairly and as sensibly as possible.
Gestalt therapy, hence, has to press for a form of diagnostics which, ac-
cording to Lewin's assertions in the thirties, abstains from classifications ac-
cording to symptoms (or symptom clusters), but rather seeks to apprehend
those actual psychological situations in which the disorders arise, including
the laws at work in them. It was Wertheimer who postulated in 1918 already
that pathological demeanor was ordered demeanor following the same rules
as the healthy one (cp. Stemberger 2002).
According to the tradition of Gestalt therapy, we start out from the ex-
plored phenomena and, together with the client, we draw conclusions on

Integrative Gestalt Psychotherapy (lG)
121
the underlying structures which have lent meaning to the hitherto dysfunc-
tional ways of experiencing and behaving. These structures in turn offer clues
as to how the diagnosis in use needs to be reviewed and adjusted. A sensible
diagnosis has to deliver clues for interventions; if unrelated to underlying
structures, a diagnostic category will not provide any help for finding psy-
chotherapeutically reasonable interventions.
The following questions are useful for diagnoses to provide clues for
therapeutic action, whether guised in a category or not
- Which parts of a client function well, which resources and abilities are
available and supportive of the self-regeneration process?
- What are the deficits, what is missing, and what has to be nurtured/social-
ized to compensate for them?
- Which disorders do we witness, which functions are perturbed and,
therefore, have to be restructured?
- Which potential do we realize: in which direction does the person strive,
which steps of growth has s/he been avoiding hitherto?
References
Perls L (1989) Leben an der Grenze. Essays und Anmerkungen zur Gestalttherapie. Edi-
tion Humanistische Psychologie, Cologne
Peds F, Hefferline RF, Goodman P (1951) Gestalt Therapy. Excitement and Growth in the
Human Personality. Julian Press, New York
Stemberger G (ed) (2002) Psychische Storungen im Ich-Welt-Verhaltnis. Gestalttheorie
und psychotherapeutische Krankheitslehre. Krammer, Vienna
Translated from the German by Luna Gertrud Steiner

Concentrative Movement Therapy (CMT)
MARKUS HOCHGERNER
According to 9 1 of the Austrian Psychotherapy Act, administering psycho-
therapy to an ill person requires the "conscious and planned treatment of
psychosocially or psychosomatically caused behavioral disorders and condi-
tions of suffering with scientific-psychotherapeutic means".
In 2000, Concentrative Movement Therapy was acknowledged as an inde-
pendent psychotherapeutic method, applicable to individual and group ther-
apy.
"CMT understands the body as the venue of the entire mental and psy-
chic occurrences. By its psychotherapeutic offers which refer to perception
and movement, it creates a concentrative (i.e., a balanced, equally inward
and outward bound perception, M. H.) experiential space in the here and
now. During the interaction with the... therapist... or with the group mem-
bers, the individual ... fashions his or her inner world. Whatever is expressed
this way is symbolized experience. One's own apperception, movement and
relationship patterns become tangible experiences, and former coping and
problem solving strategies become conscious. Deficits as well as resources
are actualized. New possibilities of experiencing and acting may be gener-
ated and rehearsed. The experience and action levels are the foundation of
any therapeutic occurrence in CMT" (OAKBTl 2004).
In CMT, describing, classifying, and identifying clinically significant ways
of experiencing and behaving are usually realized along the lines of clinical-
psychiatric diagnostics (diagnostic systems and manuals - ICD 10, DSM IV)
or, if need be, of medical-somatic diagnostics (in the case of somatoform
disorders), occasionally along those of psychological diagnostics (evaluative
1 Osterreichischer Arbeitskreis fUr Konzentrative Bewegungstherapie - Austrian Study
Group for Concentrative Movement Therapy (translator's note)

124
Markus Hochgerner
diagnostics, course and process diagnostics) and, within the psychotherapeu-
tic procedure itself, as JJorientation or theory-based diagnostics" (Laireiter
2000).
During the intake interview or in diagnostic sessions, CMT, which is a
depth-psychological and interactional therapeutic method, refers to the psy-
chodynamic-structural diagnoses of the personality, with special regard to
the conflicts beneath the current symptoms, on the background of the indi-
vidual personality structure which manifests in the patient's attitude towards
herself and in her behavior towards the environment (Mentzos 1984).
Stating diagnoses in the intake interview may be regarded as the incep-
tion of a JJcircular process"(Wiesnagrotzki et aI., 2004), which remains in
abeyance between diagnosing and clarifying possible indications of psycho-
therapy, and reveals the life context and the qualities of relating on the cor-
poral, emotional, and physical levels.
In order to establish a diagnosis, we firstly have to assess the symptom
profile in relation to the personality, secondly, the psychotherapeutic rela-
tionship, and, thirdly, the patient's susceptibility to crises; we, furthermore,
have to arrive at a psychotherapy-relevant indication (Wiesnagrotzki, ibid.).
The formulation of the initial diagnosis should consider the following is-
sues:
Situational Assessment by Classification of Disorders
According to ICD 10
The goal is to give an account of the surveyed symptom profiles and their
extensions by identifying co-morbidities. References to the classification of
DSM IV (Diagnostic and Statistical Manual of Mental Disorders), particularly
to the dimension of the narcissistic personality dynamics and to the concepts
of personality disorders, give a differentiated picture of the severity of the
illness.
Diagnosing Personalities
CMT refers to depth-psychological developmental and disorder theories,
which have been enriched by infant research findings.
Hence, in the framework of the theory-based diagnostics of the relational
dimensions, the following key aspects should be heeded:
- description and classification of defense mechanisms within the frame-
work of ego-psychological considerations (A. Freud, 1936) as the first
comprehensive diagnostic system on the background of stage-specific
ego-development and its impairment; and

Concentrative Movement Therapy (CMT)
125
- orientation toward o. Kernberg's (Kernberg 1978) structural approach of
personality organization and personality diagnostics (neurotic/narcissistic/
borderline/psychotic personality organization).
Practice-relevant diagnostics calls on us to bridge the gap between the phe-
nomenological, syndrome-oriented, and categorizing classification (ICD 10)
and the condensed metalingual-theoretical comprehension of the psycho-
dynamic description of the personality by depth-psychological categories.
The Operationalized Psychodynamic Diagnostics (Study Group OPD 2001,
Rudolf and Grande 1996), devised and developed from 1990 onwards, ex-
tends the ICD 10 classification, particularly by the psychodynamic perspec-
tive of how disease, relationships, conflicts, psychic structure, psychological,
and psychosomatic disorders are experienced after ICD 10/DSM IV diag-
noses have been established.
OPD is compatible with the object relational and depth-psychological
theory formations, specifically with the above mentioned theory-based ideas,
since the terminology of OPD ties in with ego-psychology and with the
theories of personality organization (Kernberg 1978), thus providing for a
classification on four structural levels (well/moderately/scarcely integrated/
disintegrated), which are compatible with Kernberg's subdivisions in neurot-
idnarcissistic/borderline, and psychotic personality organizations.
From OPD, a clear basis of how to conduct therapy follows, which makes
it highly relevant for the psychotherapeutic practice: at this point, the thera-
pist has to opt for either a regressive/conflict-focused, or a progressive/ego-
supportive procedure after having cognized and assessed the current func-
tional level on the backdrop of the structural personality levels ascertained
by OPD.
Setting up a developmental map (Stern 1992, Blackwedel 2000, Schwarz-
mann 2000/2003) that is based on the findings of infant research facilitates
the therapeutic orientation: which developmental tasks failed in early self-
development (with particular regard to the enhancement of the scenic under-
standing of relational cues), and which differential procedures need to be
applied to patients with disparate structural levels.
Relational Diagnostics
Diagnosing and fashioning relationships for the purpose of therapy is both,
the core of psychotherapeutic practice, and the medium of diagnostics and
intervention. The therapist's reflected and planned relational offer (as rela-
tional occurrence in the body-dialogue, as symbolic-interactive play and
creation, conversation) is reciprocated by the patient's individual relational
offer and becomes the clarification and explanation model of diagnostics

126
Markus Hochgerner
and treatment. We must focus on the current life situation, the biography,
and the goals the patient has subjectively set for herself on the background
of transference and countertransference occurrences, with special regard to
capturing the nonverbal elements of the communication.
The focal points of diagnosing the relationship are:
- comprehending the current life situation/the lived-in world
- comprehending life history and history of previous learning experiences
- comprehending the patient's subjective rating of her illness and her theo-
ries thereof
- goal and time frame of the patient.
The focal points of comprehending the relational dynamics are:
- the way the individual connects to herself and others,
- transference and countertransference phenomena, and
- body description/patient's own body image!conscious and unconscious
body experience (OPD: 'Intentional body')
The goals of psychotherapeutic diagnostics of CMT hence are:
- instruction on controlled comprehension of saluto- and pathogenesis,
identification of characteristics by means of ICD 10 and complementing
DSM IV perspectives;
- to denominate and preliminarily assess personality structure (Kern berg:
form of personality organization; OPD: structural and functional levels)
against the backdrop of the individual's life and learning histories;
- reference to explanation models of pathological conflict constellations
and conflict management, and formation of theory-based and focus-di-
rected intervention hypotheses with regard to conflict and resource orien-
tation; and
- situational diagnostics as a phenomenological-hermeneutic encounter
approach ('procedural diagnostics'/'from the phenomena towards struc-
ture').
References
Arbeitskreis OPD (2001) Operationalisierte Psychodynamische Diagnostik. Huber, Bern
Bleckwedel J (2000) Menschliche Koordination zwischen Autonomie und Bindung. Psy-
chodrama 18/19, vol 10 (1/2): 91-143
Dilling H, Mombour W, Schmidt MH (1991) Internationale Klassifikation psychischer
Storungen (lCD 10). Huber, Bern
Freud A (1987) Das Ich und die Abwehrmechanismen. Fischer, Frankfurt/Main
Hochgerner M, Schwarzmann M (2004) Psychosomatik in der Integrativen Gestaltthera-
pie. In: Hochgerner M et al (eds) Gestalttherapie. Facultas, Vienna

Concentrative Movement Therapy (CMT)
127
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Kernberg 0 (1988) Schwere Pers6nlichkeitsst6rungen. Klett-Cotta, Stuttgart
Laireiter A (2000) Diagnostik in der Psychotherapie. Springer, Vienna New York
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Osterreichischer Arbeitskreis fUr Konzentrative Bewegungstherapie (2004) Jahrespro-
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Vienna
Translated from the German by Luna Gertrud Steiner

.......

Guided Affective Imagery Psychotherapy (GAil)
MARIANNE MARTIN, FRANZ SEDLAK
Notes on Diagnostics in Guided Affective Imagery
Psychotherapy
Part one: Basic comments on diagnostics and on its relations to
GAl (F. S.)
Freud/s comparison of a symbol being an iceberg that juts out above the
waterline by one tenth only, is particularly meaningful in GAl diagnostics:
from its very onset, any diagnostic undertaking has to address the material
which is accessible to consciousness at the appropriate moment in time.
With certain indications and in the initial stages of psychotherapy, particu-
larly, GAl uses motifs for the guided imagery processes, the meanings of
which remain undisclosed to those patients who are unfamiliar with symbols
and their use. This allows for a gentle and cautious approach toward prob-
lematic issues. Under the protection of the symbol/ conflictual zones and
deficit areas may be diagnosed. This corresponds to the covert part of the
iceberg.
On the other hand, the imaginations are often impressively significant and
meaningful to the patient. The imagined picture casts a sudden light on one's
own problems and encourages processing. This conscious, /confrontational'
part corresponds to the visible section of the iceberg. Finding a balance be-
tween conscious and yet to be disclosed material is vital in the initial diag-
nostic stage when the therapeutic goals and the desire for change are being
negotiated. This dual task of symbolizing (concealing versus expressing)
1 The German uses the acronym 'KIP' - 'Katathym Imaginative Psychotherapie', with
the Ancient Greek word 'katathym' denoting according to one's soul or one's emo-
tionality (translator's note).

130
Marianne Martin, Franz Sedlak
obliges the GAl-therapist to be particularly wary in her choice of motifs. She
must, for instance, avoid motifs, particularly at the beginning, which are
counter-indicated with certain pathological pictures. With narcissistic disor-
ders, for example, those motifs should be put on hold which would confront
the patient all too clearly with his self-worth problems.
The Diagnostic Guideline for Psychotherapists put forward by the Austrian
Federal Ministry of Health and Women's Issues as of 15 June 2004 empha-
sizes in its preamble:
"We value the copiousness and the diversity of the diagnostic approaches
of the various psychotherapeutic schools. The variety will do justice to the
patients' manifold ideas of the human being, to their understanding of psy-
chogenesis, to their targets of treatment, etc., much more than if we en-
deavored to construe a uniform terminology. Consequently, the members of
the Research Committee have committed themselves to encouraging each
psychotherapeutic school to abide by their abundance of diagnoses and their
therapeutic language."
Contrariwise, the conjoint therapeutic discourse requires agreements and
conventions regarding disorders and the criteria for comprehending them.
The Guidelines, as they have been compiled, resolve this double-faced issue
of idiography versus nomothetics by providing formal regulations, which
serve as vessels ready to hold different fillings and contents (target defini-
tions, images of man and what their therapeutic implications are as to the
intended changes, how changes are defined, etc.). Some matter is, however,
usually sensed and felt before it is mentally realized and formulated. There,
the limits of verbalization become obvious.
A significant advantage of GAl is its ability to ease the access to preverbal
material, a benefit that is usually effected by its methodological key tech-
nique, namely the induction of symbols (i.e., the suggestion of motifs around
which the imagination processes crystallize), the comprehension of symbols
(GAl trains comprehensive understanding of symbols which primarily emerge
and form when daydreams are shaped), and the processing of symbols (the
dialogical approach of GAl enables the therapist to "latch into" symbolic
ongoings, and to encourage in-depth engagement, confrontation, and other
processes). This advantage holds equally true for the diagnostic procedures:
in a broader sense, it applies to the symbolism of paraverbal communication
during the first encounter, such as covert or overt expressive posture, ad-
justed or rigid physiognomy, expansive or inhibited psychomotor activity,
controlled or uncontrolled gestures or facial expressions, which all together
compose the overall picture.
The interactional diagnostic aspect (particularly the rating of relational
abilities as described by the Diagnostic Guideline) involves not only the
scenic information gained during the first encounter but also interior per-
ceptions such as empathy, observation, and the consideration of transfer-

Guided Affective Imagery Psychotherapy (GAl)
131
ence and countertransference, which complement the apperception of ex-
terior facets.
The patient's presentation of those symptoms which motivated him to
seek treatment may also be valued as symbolic language (there, the symptom
is valued as the representation of the compromise between desire and de-
fense). In addition and as mentioned above, GAl holds a specific repertory
to ease the way to the understanding and treatment of patients, i.e., the
guided imagery. When committing to the process of guided imagery, the
patient gives a condensed account of his psychic /household his structure,
the state and quality of his conflicts, his personality, object relations and rep-
resentations, etc. This is a particularly valuable access to the integrative com-
prehension of the personality, as ruled under the heading 'Symptomatology
in Relation to Personality Aspects' in the Diagnostic Guideline.
The therapist, too, may undergo an imagery process which pertains to the
situation and the personality of the patient, and then compare her symbolic
picture with that of the patient; she will obtain further information from the
concordances and the differences and thus establish a preliminary work
model. The therapist's imagery may accompany the patient's (in the case of
early disorders, for instance, the patient's imagery will appear in the contain-
ing therapist in a non-distorted and healthy form). The therapist may also
engage in a mental imagery process after the therapeutic session to support
the integration of her own perceptions.
Last but not the least, the imagery technique may be used in the super-
vision. Comparisons between the imageries of the various participants con-
cerning the presented case or problem yield stunning results. Naturally, it is
not before the therapist herself has taken in and surveyed all the information
that she will be safe from diagnostic mistakes which might arise from the
vague formulations in the patient's narrative, or else from self-delusion and
false recollection.
The authors recommend to superimpose the different layers of informa-
tion gained from various sources onto one another (narration, anamnestic
readings; interaction revealing scenic information; transference and counter-
transference; symptom profile; constellation of social relationships; symboli-
zations in the imagination process) to minimize the error which is probably
generated by intrapsychic defense activity, by social-psychological halo-ef-
fects, contrast distortions, or ambiguities which stem from the selective,
punctiform comprehension that often disregards subject, situational, and
observation variances. By this superimposition, the invariant (i.e., the valid)
material will become more articulate, whereas the variant will be obscured.
The imagery of the patient valuably supports the following dimensions:
1. symptoms in relation to personality aspects (there, particularly the inter-
pretation of the subject stage of imagination lends itself) and 2. the therapeu-
tic relationship, the way a patient connects to the therapist and structures the

132
Marianne Martin, Franz Sedlak
therapeutic relationship, the target orientation and, as mentioned above, the
procedural diagnostics (in which a specific segment of the interpretation of
the object stage of imagination becomes visible and must then be embedded
in the overall framework of the patient's way of shaping his relationships in
his lived-in world).
The imagery concerning the critical potential, as it has been dealt with
extensively in the Diagnostic Guideline/ is particularly impressive, since GAl
disposes of an inventory of disorder criteria which are reflected in the im-
agery process; GAl also possesses tools for the assessment of general and
specific indications - as postulated in the Diagnostic Guideline - because,
although imaginative abilities are innate to all humans, the access to analo-
gous thinking may be barred, particularly in people who tend to over-rational-
ize. Far-reaching deficits may make it necessary to first build up the capacity
to symbolize or verbalize, which requires a special set of GAl techniques.
The following examples of one of the authors (M.M.) will further illustrate
the diagnostic access by guided imagery.
Part 2: References to Differentiated Diagnostic Possibilities in
GAl (M.M.)
The diagnostic potential of GAl is mentioned only incidentally in the techni-
cal literature (Klessmann, Eibach 1993; Klessmann 1997; Wilke 1983), save
for a few exceptions (Klessmann 1983; Sedlak 2000a). This is astounding
since it was Hanscarl Leuner, the founder of the method, himself who main-
tained that it was "correct to understand the procedure as a highly sensitive
projective test" (trans/. from Leuner, 1983, 30).
The utilization of the pictorial symbol, i.e., an image or imagination per-
ceived with all senses (e.g., Dieter 2000, 2001), is held specific to GAl "... si-
multaneously the human intersubjective potential is emphasized by GAl
(relationship, transference, interpretation, meaning, etc.) ..." (Dieter 2001, 6).
What is GAl as a projective test able to perform in addition to the general
diagnostic possibilities?
To give an outline: the symbolic illustration is able to point to conflicts
and their defense. The purposeful conduction of imaginative processes on
specific conflict areas provides diagnostic insights, particularly on the dimen-
sion "Symptoms in Relation to Personality Aspects" (Guideline A.I.1). The
transference relationship may not only be deduced from the 'katathymic' -
affective - pictures but also scrutinized systematically by selecting and in-
ducing certain motifs. This method-specific proceeding eases the diagnosing
of the dimension 'psychotherapeutic relationship' as well as the evaluation of
it. Rigid behavioral patterns will manifest in the patient's spontaneous de-

Guided Affective Imagery Psychotherapy (GAl)
133
meanor during the imagination process. The guided affected imagery proce-
dure also allows for an intensive monitoring of the therapeutic course.
According to Leuner (1985), 'fixed images' point to preconscious con-
flicts. These are either "single pictures or scenic sequences which, as to their
contents or underlying expressive structures, remain immovable over a sig-
nificant extent of time, i.e., days, weeks, or even months. If they are repeat-
edly induced at these intervals, they often return unchanged and fixed down
to the tiniest little detail" (104). "When, after getting a general idea of the
patient's katathymic - affective - panorama, we configure a diagnostic mo-
saic of the fixed images of all five standard motifs, and we will get a repre-
sentative picture of the 'conflict pattern' that manifests itself on the precon-
scious level" (110). (For how several diagnostic resources may be intercon-
nected, see also Sedlak 2000a, 98f). The motifs forged and structured by the
patient have to be considered just as the results of any other projective test.
It is quite possible to purposefully 'scan' certain conflict areas by suggest-
ing a certain motif; 'three trees', for instance, or the 'animal family' illustrate
family conflicts or such of oedipal origin. The individual specification of
these motifs figuratively expresses intimacy-distance issues, or else autono-
my-dependence conflicts and others.
Likewise, a GAl-motif may depict the current state of the transference
relationship, such as 'two flowers' or 'two animals', suggested after a topic-
centered intake interview. By using this strategy, more information may be
garnered that refers to the actual transference, due to the diminished defense
(see also the 'doubleganger'-motif, or the principle of splitting up too com-
plex matter Sedlak 1994, 32f).
Another diagnostic approach of GAl is the observation of the patient's
spontaneous behavior while he is involved in an active imagery process. This
"nearly regularly runs in the tracks of unconscious or preconscious behavior
patterns of everyday living. They equally determine the imaginative as well
as the actual behavior" (tr. from Leuner 1985, 167). Leuner calls this observa-
tion "the 'third track' of unconscious structures to be read along with the
katathymic/affective scenery and the accompanying emotional tune ..." (tr.
from Leuner 1985, p. 168). If the therapist interferes as little as possible with
the associatively moving imagery, unconscious behavioral tendencies will
become more discernible to the patient.
GAl has much to offer in terms of a "relatively precise instrument of
monitoring the therapeutic course" (tr. from Leuner 1985, 357). Leuner sug-
gests the usage of a 'sample motif' which is not worked over therapeutically,
for the change is supposed to come about as a 'synchronous metamorpho-
sis', not by the therapeutic elaboration of the motif: iterated induction of the
same motif in the course of therapy makes changes detectable by the varia-
tions this very motif undergoes. When using the motif 'house', for example,
each imagined house reflects the progress made underway, or else the stag-

134
Marianne Martin, Franz Sedlak
nation of the therapeutic process. Leuner explicates this for all standard mo-
tifs. The yield of the motif 'house', particularly, is most impressively evi-
denced by case descriptions and drawings (Joliet, Krippner, Krageloh 1989;
Klessmann, Eibach 1993; Klessmann 1997).
The author (M. M.) prefers the motif "construction of a new house", as
suggested by Leuner (1985, 361), to monitor the therapeutic process. If re-
peated at longer intervals, it clearly illustrates either the progress, or else the
occasional stagnation of therapeutic development (see also Sedlak 2000b,
186f for further details).
GAl offers valuable tools for diagnosing couple relationships and family
structures (Sedlak, Chiba 2001, 44-62).
With all these additional GAl-specific diagnostic instruments, one strictly
has to bear in mind that, just as in the therapeutic process itself, the imagina-
tive contents are multidetermined. If we refrain from simplifications such as
"to impose a fixed casing of meaning on symbols from outside" (pahl 2000,
72), the conception of GAl will contribute much - particularly to diagnostics,
thanks to its specific methodology.
References
Dieter W (2000) Imagination und Symbolisierung bei neurotischen und ich-strukturell
gestorten Patienten. In: Salvisberg H, Stigler M, Maxeiner V (eds) Erfahrung traumend
zur Sprache bringen. Huber, Bern, pp 147-168
Dieter W (2001) Katathym Imaginative Psychotherapie - eine tiefenpsychologische Be-
handlungsmethode. Imagination 23 yr 3: 5-41
Joliet H, Krippner K, Krageloh C (1989) Das KB bei Objektbeziehungsstorungen. In:
Bartl G, Pesendorfer F (eds) Strukturbildung im therapeutischen Prozess. Literas Uni-
versitatsverlag, Vienna, pp 99-108
Klessmann E (1983) Das Katathyme Bilderleben als Spiegel gestorter Familienbeziehun-
gen bei Kindern und Jugendlichen. In: Leuner H (1983) Katathymes Bilderleben.
Ergebnisse in Theorie und Praxis. Huber, Bern Stuttgart Vienna, pp 274-292
Klessmann E (1997) Wege und Irrwege in der Katathym-Imaginativen Psychotherapie. In:
Kottje-Birnbacher L, Sachse U, Wilke E (eds) Imagination in der Psychotherapie. Hu-
ber, Bern Gottingen Toronto Seattle, pp 135-140
Klessmann E, Eibach H (1993) Wo die Seele wohnt: das imaginare Haus als Spiegel
menschlicher Erfahrungen und Entwicklungen. Huber, Bern G6ttingen Toronto
Seattle
Leuner H (1983) Katathymes Bilderleben. Ergebnisse in Theorie und Praxis. Huber, Bern
Stuttgart Vienna
Leuner H (1985) Lehrbuch des Katathymen Bilderlebens. Huber, Bern Stuttgart Toronto
Pahl J (2000) Psychologische Bedingungen der "Vorstellung-Dialog-Struktur" und der
"Imaginationsstruktur". In: Salvisberg H, Stigler M, Maxeiner V (eds) Erfahrung trau-
mend zur Sprache bringen. Huber, Bern, pp 57-72
Sedlak F (1994) Neue Wege - neue Motive in der Katathym Imaginativen Psychothera-
pie. In: Gerber G, Sedlak F (eds) Katathymes BilderIeben innovativ. Motive und
Methoden. E. Reinhardt, Munich, pp 17-37

Guided Affective Imagery Psychotherapy (GAl)
135
Sedlak F (2000a) Die Diagnostik in der Katathym Imaginativen Psychotherapie. In: Lai-
reiter H (ed) Diagnostik in der Psychotherapie. Springer, Berlin Heidelberg New York
Tokyo, pp 95-106
Sedlak F (2000b) Katathym Imaginative Psychotherapie und Gesundheit. In: Hochgerner
M, Wildberger E (eds) Was wirkt in der Psychotherapie. Facultas, Vienna, pp 177-
192
Sedlak F, Chiba R (2001) Mit Traumen Brucken bauen. Eigenverlag Sedlak, Vienna
Wilke E (1983) Das Katathyme Bilderleben bei der konservativen Behandlung der Colitis
ulcerosa. In: Leuner H (ed) Katathymes Bilderleben. Ergebnisse in Theorie und Praxis.
Huber, Bern Stuttgart Vienna, pp 186-208
Translated from the German by Luna Gertrud Steiner


Psychoanalysis (PA)
AUGUST RUHS
On the Issue of Psychotherapeutically Relevant Diagnoses
with Specific Regard to the Psychoanalytic Perspective
Preliminary Note
In an essay, the writer Jorge Luis Borges quotes a Chinese encyclopedia
which states that animals are grouped in the following categories:
a) animals belonging to the emperor, b) embalmed animals, c) domesti-
cated animals, d) suckling pigs, e) sirens, f) mythical creatures, g) abandoned
dogs, h) those belonging to this category, i) those acting like madmen, k)
those painted with a fine camel hair brush, I) and so on, m) those having
smashed the water jug, n) those which look like flies from afar.
Many a pattern of outdated nosological classifications in general medi-
cine or psychiatry may appear as curious and bizarre as this caricature of
cataloging, although people, as long as the systems were valid, had appreci-
ated them as coherent and self-evident. In the psychological realm, which
particularly caters to those specifically human qualities which are bound to
individuality and subjectivity, are evenly distributed, hardly distinguishable,
intricately interwoven and, moreover, dependent on the predominating cul-
ture as well as susceptible to the vicissitudes of history, any counting, meas-
uring and classifying pose specific problems. This is also the reason why
such nosologies usually compete with coexisting systems and why they are
relatively short-lived, so that they continuously have to be revised, abridged,
or extended.
In reference to the Diagnostic Guideline for Psychotherapists we naturally
have to consider all these factors. Under the specific Austrian societal,
health political, and legal conditions under which this particular project was
realized additional and partly conflictual issues had to be broached. Firstly,

138
August Ruhs
there was the need to heed the specificities of the numerous psychothera-
peutic schools and methodological inventories as well as their respective
ideas of man, their subject areas, objectives and procedures and, secondly,
a unifying diagnostic classification system was to be erected on the basis of
these considerations which would ultimately result in a - nonexistent but
quasi virtual - general or uniform psychotherapy. Despite this precarious
start and thanks to the patience, the fundamental mutual benevolence, and
the finally prevailing willingness to reach a consensus, a compendium was
finalized which led to the discovery of the badly needed greatest common
denominators and the smallest common multiple, in a way that the loss of
those method-specific issues which were omitted was not too painful for
their proponents, and that such issues were somewhat evenly distributed
over the various schools.
Due to the limited space of this paper, it will not be possible to discuss all
psychoanalytic points of view considered in the Guideline, and less so what
their implications are as to the presuppositions and the individual sections.
I nstead, we give here an excursive overview of how these issues are handled
within psychoanalytic psychotherapy with its specific historical background,
to encourage the reader to decide and judge for himself as to what extent
these viewpoints are reflected in the Guideline. On principle, we should
note that just as in the formulation of the Vocational Training Guidelines
(which include psychoanalytic key components such as self-awareness and
personal growth training, theory classes and supervision), psychoanalytic/
psychodynamic principles have contributed decisive issues to the elabora-
tion of process-oriented diagnostics, which is chiefly based on the therapist-
patient-relationship. Evolving our thinking along this vein, we regard suffering
and disorder as the primary pathological categories which, in their essence,
stem from distressed relationships with oneself and others, or from a dis-
turbed psychological development with its manifold interdependencies of
psychic, social, and biological dimensions.
Diagnostics in Medicine, Psychiatry, and Psychoanalysis
In somatic medicine, the diagnostic process for the identification and the
distinction of specific illnesses is usually subdivided into three sections:
a) description of the disease pattern on the basis of clinical observation
b) underpinning the observation by an anatomic substrate, and
c) disclosure of the etiological mechanism
An analogous procedure was followed in psychiatry for diagnosing mental
illnesses and psychological disorders. A significant step towards a successful
realization of this project was taken in the course of the 19 th century through

Psychoanalysis (PA)
139
the discovery of the etiological, pathogenic, and morphological conditions of
thitherto unexplained illnesses (progressive paralysis, Alzheimer's and Pick's
disease, Huntington-Chorea, epilepsy, etc.), with the result that the organ
and brain-pathology-based psychiatry was established. Soon, however, the
scientists realized that there was no direct correlation between an organic
process and the psychiatric symptom clusters, and that more complex theo-
ries would have to be formulated which focus on the organic-dynamic per-
spective. The organic-clinical deviations could then be looked upon in a way
that an inflicted lesion, on one hand, led to the disorganization of psychic
experiencing while it, on the other, reorganized according to its own dynam-
ics and those psychic structures that had remained intact.
Henceforth, the notion of the psychic process, or the distinction of pri-
mary and secondary symptoms (Bleuler) was introduced, particularly where
schizophrenia was concerned. The replacement of the expression 'dementia
praecox' by 'schizophrenia', also inspired by Bleuler, accounts for this new
perspective.
Another step towards subtler degrees of differentiation was made by the
realization that, on one hand, a toxic factor might prompt various psycho-
pathological conditions (manic, depressive, paranoid, or schizophreniform)
and that, on the other, a certain psychopathological condition might flow
from various pathogenic factors. Therefore, a manic condition may not only
be the manifestation of a manic-depressive illness but also be called forth by
an infection, another toxic cause, or a clearly psychogenic factor such as
bereavement reaction. This led to the necessity that psychiatry abdicate the
notion of a specific correlation between clinical and etiological diagnostics.
Both domains need attention because of this premise, in order to arrive at a
complete diagnostic picture, a demand that is not always practicable.
Sigmund Freud and psychoanalysis gave rise to the diagnostics of neuro-
ses which, until that date, had played a marginal role within psychiatric dis-
ease patterns. Along with this development, the objective form of diagnosing
became less important since the diagnostics of neuroses was primarily root-
ed in subjectively experienced ailments, feelings, instinctual forces and be-
havior patterns, as the patient described them. The structural diagnoses
emerging from these descriptions in the psychiatric as well as in the psycho-
analytic realms mainly revealed hysteric, obsessive-compulsive, and phobic
structures in the light of drive dynamics and object relations. Analogically,
and with regard to an environment-based etiology, the other major clinical
units such as psychoses and paraphilias were also viewed and judged in this
new light. It was precisely this etiological momentum which, over the last
decades, has led to the creation of the present, widely used psychiatric clas-
sification systems, which had discarded most of the strongly psychoanalysis-
biased terminology in order to organize disorders in the most descriptive
ways and as unburdened of theories as possible.

140
August Ruhs
From the psychoanalytic point of view it is most obvious that, in the
realms of neuroses and particularly character neuroses (as opposed to symp-
tom neuroses), the boundaries between normality and pathology are blurred
and have to be reconsidered as phenomena which are subject to currently
dominant cultural, sociological, and political circumstances. Since a patient's
subjective criteria are held prominent, an attitude that naturally defies objec-
tification, the representatives of psychoanalysis have discussed endlessly on
whether diagnoses made any sense at alt although they evidently may be
useful as well as detrimental when one deals with mental disorders and dis-
tress.
Stating a diagnosis runs the risk of not only estranging the patient by labe-
ling him and nailing his existence down to one single notion, but it may in-
hibit the treating person's capability of acting, once a diagnosis has been
ascertained. In order to avoid this, it is crucial to acknowledge a certain
hierarchy of semiological components, and to distinguish a clinical sign from
a symptom, and a symptom from a syndrome. It is moreover meaningful to
discriminate objective signals from subjective ones, bearing in mind that psy-
chiatry mainly relies on the objective, by equally considering everything
seen and heard in the diagnostic process. In psychoanalysis, however, it is
the subjective signals which are weighed the highest, a process in which the
things heard are nearly the only decisive parameters. We finally should be
attentive to the fact that in clinical psychoanalysis the actual diagnosis evolves
in the course or at the end of the treatment; thus, it should be regarded as a
diagnosis ex iuvantibus, as it were, which implies that there is a junktim of
healing, researching, and diagnosing.
In the beginning, this principle used to be taken very seriously; hence, an
intake interview in contemporary terms was rare and frequently replaced by
a trial treatment. Because of the insurance carriers and the public administra-
tion entering the scene, it is now a usual practice to state the diagnosis at the
beginning of the treatment. Gradually, also psychoanalysts awoke to the im-
portance certain diagnostic assessments bear for warding off disagreeable
developments on the couch.
As a psychiatrist Freud was familiar with the relevant diagnostic criteria.
He very soon realized the distinction between defense neuroses and actual
neuroses, psychasthenia and neurasthenia, and of the transference neuroses
and the narcissistic ones. All these classifications had meanwhile ceased to
be merely descriptive but could also be determined by their functions. Di-
agnostic questions usually arose along the way when the psychoanalytic
development was being focused on, practically as well as theoretically. In
the beginning of his teachings, Freud found that in the case of the defense
neuroses, for instance, the underlying conflict needed to be worked on and
recollection needed to be prompted, whereas in the case of the actual neu-
roses he held the alteration of the life style crucial. Later and along with the

Psychoanalysis (PA)
141
libido theory, the stages of psychosexual development were relied on and
regarded as the foundation of nosological criteria. Subsequently, the ego-
functions and the capacity of the ego to fend off regressive tendencies and
traumatic effects were focused on, besides the so called healthy ego-parts
in the relationship with the therapist. Further categories were connected to
the characteristics of a twofold classification of development, based on the
question whether a patient had reached the oedipal stage or not. From this
perspective, pre-genital or pre-oedipal disorders were marked by specific
ego-deficits and shortcomings in the intersubjective relationships, from
which practical considerations arose on whether a modified form of psy-
choanalysis should be applied in these cases or not. As a consequence, in
the next generation of psychoanalysts a number of conceptualizations de-
veloped, regarding the narcissistic personality disorders and the borderline-
personality-organizations, which, despite the alterations of the terminology,
still rested on the foundation of the first classification attempts of psycho-
analytic development theories. These two main currents of psychoanalytic
diagnostics were oriented to the instinctual vicissitudes, to the libido theory,
and its genesis and maturation on one hand and, on the other, to the histo-
ry of object relations along with the characteristics of ego-integrity. These
were soon joined by a third current which adhered to the notion of 'charac-
ter', defining it as the crystallization and solidification of defense behaviors
and certain ways of instinctual discharge leading to certain fixated relations
with oneself and the environment. As generally known, these may be inte-
grated in the overall personality without any suffering or distress (as ego-
syntonic features), or experienced as a strange and disagreeable characteris-
tic by the patient (ego-dystonic features). Various techniques such as resist-
ance analysis and character analysis are bound to this classification criterion
also.
In contrast and as suggested above, frequently counter-currents emerged
opposing the differentiation and the improvement of diagnostic appraisal
and clarification. The American psychoanalyst Karl Menninger, for instance,
refuted qualitative classification attempts altogether for their apparent intel-
lectual sterility and the associated social hazard. He firmly held that classifi-
cation always implied labeling, and that labeling necessarily involved stigma-
tization. Under such premises, the therapists would no longer treat a person
or a subject but merely a representative of a category in a stereotyped man-
ner that was in line with the concepts of a nosological entity. There was
basically only one constitutive mental illness, which was reducible to a dis-
ordered psychological equilibrium. This disorder could reach different de-
grees of severity, from which a quantitative form of diagnostics in five grades
would arise, depending on the degree of success or failure of the intrapsy-
chic defense mechanisms. If, on one end of the gamut there are states of
slight discomfort and functional somatic disturbances, we find the total

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August Ruhs
breakdown of all defense formations on the other, manifesting itself as psy-
chosis and/or as suicide or murder.
If we observe all the criteria and categories mentioned, we may conclude
that the psychoanalytic thinking, which mainly stems from practical treat-
ment, has contributed significantly to the initially solely descriptive psycho-
pathological diagnostics within psychiatry and psychotherapy, even though
current movements of the predominantly biologically oriented psychiatry,
however regressive this may be, still abjure any subtler phenomenological
differentiation, in favor of the coarser entities (such as depression, anxiety
disorders, and stress).
In psychoanalysis itself, a psychodynamic, structural way of diagnosing
has taken hold, which interrelates the current psychogenic distress to its in-
dividual and biographic conditions of origin, using disorders of the narcis-
sistic and oedipal object relation structures and of the developmental stages
of the libidinal-aggressive drives to achieve a classificatory distinction of per-
sonality features with reference to specific symptom profiles and character-
ologies. Evidently, this kind of diagnosis cannot possibly or satisfyingly be
represented by a single term. As much as the psychoanalytic case history
should, according to Freud, always be written and read as a novella, the
psychoanalytically relevant diagnosis should also be capable of answering
the question as to whether a meaningful coherence between a certain (psy-
chic or physical) symptom profile and its causative situation, the life story of
its bearer and his personality and character structure is traceable, an opera-
tion which definitely takes more than a digit or a word. Hence, the possibil-
ity of establishing a positive psychoanalytic style of diagnosing may grow, in
which the identification of mental illness is not accomplished by the sheer
exclusion of organic agents.
What we still have to include in this diagnostics is the elaboration of the
criteria which decide on the patient's treatability by psychoanalysis; these
criteria are primarily determined by the well known factors such as the abil-
ity of introspection, the understanding of psychogenesis, mental suffering,
and the presence or absence of a major secondary gain from illness.

Psychodrama (PD)
MICHAEL WIESER
Psychodrama Therapy
In psychodrama we employ specific diagnostic techniques. With the literal
meaning of 'diagnostics' being 'discerning', it is important to note who and
from which perspective someone discerns, and in reference to which inter-
ests he does so. It is a special feature of PO to view a number of perspectives
in order to comprehend various segments of reality. Overall, it is more a
'procedural' (i.e., process-oriented) and interpersonal diagnostic approach.
When implementing psychodramatic techniques in the diagnostic phase, we
focus on the illumination of the patterns of interaction between the patient
and her' most significant others in her social surround as well as on the em-
bodiment of internalized roles and role ideals. By tradition, recovery, coping
competence, and the reactivation of resources have been in the foreground
('positive labeling') rather than nosological considerations. Diagnostics is
idiographic (describing the singular) and predictive rather than nomothetic.
Moreno, the founder of psychodrama therapy, put this key question into the
following words: "What is the situation like? What has led us there? What
gets us out of it?" The concerns about cognition, the active self-exploration,
and the 'self-efficient change' (Burmeister 2004b, 388) belong together.
Diagnosing Roles
Role diagnostics is subdivided in somato-motor, emotional, cognitive, and
social aspects. The role status, provided that it is functional, future-oriented,
coping, clarifying, or progressive, makes for successful encounters (role com-
1 We usually include the male gender when using female pronouns.

144
Michael Wieser
petence), but it may also be fragmented and dysfunctional (Burmeister
2004b). Psychodrama understands the self (personality) as a role cluster.
Diagnosing Spontaneity: Spontaneity and Situation Testing
Moreno liked people to extemporize when they enacted roles such as 'po-
liceman', 'mother', and 'scientist' to see in what different ways the patients
realized their tasks. Spontaneity and creativity are considered the core com-
ponents of health.
Diagnosing Action
Actions serve as a sort of actionaP self-exploration (Burmeister 2004a,
2004b). This brings up the reference to DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders) which, in its fourth and fifth axes, lists concepts
such as situational imprint, strain caused by psychosocial stressors, and cop-
ing (competences of acting and problem-solving), which may be compre-
hended well during the execution of an action (Burmeister, Leutz & Diebels,
n. d., 95).
Sociometry
This specific measurement of interpersonal relationships was devised by
Moreno (Wieser & Ottomeyer 2000). A relationship is usually mutual. In
psychodrama we operate with the term 'tele' which, as opposed to empa-
thy3, denotes 'Zwei-fUhlung' (two-feeling) - the ability to experience two-
way empathy ('tele'), as it is indicated by the tele-index. What this is all about
is the assumption that we possess an 'inter-psyche' and interpersonal facul-
ties such as relational abilities (com peten ces). This takes us right to the gen-
eral procedures of the Inventory of Interpersonal Problems (lIP; Horowitz,
StrauB & Kordy 1994), SASB (Strucural Analysis of Social Behaviour; Burg-
meier-Lohse 1996), and to the Self Concept Repertory Grid by Kelly (Orlik,
Arend & Schneider-Duker 1982). The underlying conflict models vary, how-
ever, at least in parts. The Social Network Inventory (SNI) by Treadwell,
2 i.e., active, acting, or action-related (translator's note).
3 German: Ein-fuhlung literally means 'to enter another person's feelings by using one's
own feelings', or, more idiomatically, 'to put oneself into another's shoes'; the syllable
'Ein' in Ein-Fuhlung has a double meaning: 1) 'hinein' - 'into', and 2) 'eins' - 'one'
(translator's note).

Psychodrama (PD)
145
Leach and Stein (1993) is closely linked with psychodrama. The networks are
subdivided in:
- The psychological quadrant: the smallest number of significant persons,
pets or objects that affect one's life.
- The collective quadrant: the smallest number of groups one belongs to
that influence your life.
- The individual quadrant: the smallest number of people from the collec-
tive quadrant that one develops friendships with.
- The ideal dream quadrant: the smallest number of people /wished for'
that could make one's life 'perfect'. /Ideal' must be defined cautiously,
depending on the population that is being measured and it is, therefore,
variable (Treadwell, Leach & Stein 1993, 161).
We also inquire into the quality and the scope of the relational field to obtain
the relational or interpersonal status. We analyze the number of choices and
rejections (sociometric status; Freeman 2000), the degree and the quality of
closeness and distance, the cohesion (to what extent people stick together),
and the connecting, i.e., seeking and establishing links with other networks.
Kulenkampff (1991) goes as far as to claim that he tests personality structures
by using this technique. Sociometric test results are graphed in a sociogram
and enriched by sociometric perception tests, which inquire how the patient
apprehends others and how she thinks she is apprehended by them. By
briefly interviewing the patient in the role of her most important attachment
figure, the presumptive or experienced perspective of this person on this
patient is illuminated in a very descriptive way. In such a process, the patient
adopts the role of her significant other through action. The goal of this role
playing is to learn to empathize with the role of one's alter-ego, and to create
a new identity experience. The categories of 'choosing' or 'rejecting some-
body' are complemented by another, namely 'ambivalence' (Vander May
1975, 132). Buchanan (1984, 158) altered the definition of sociometry as fol-
lows: sociometry is the mensuration, observation of and interference with
the natural choice and rejection processes in groups. The procedure is
deemed objective and logical as to its contents, its realization, and evalua-
tion (Eberwein 1997a). The patients' relational fields can be depicted by very
simple means (e.g., coins or buttons) in the sense of a 'social atom' (from
Greek: atomos = undividable).
Moreno used the term 'social atom' to express the circumstance that the
social factor is innate in the human existence.
Humans differ as to the amount of interest and attention paid to them by
others. The social atom reveals a network of social emotions. The attractions
and repulsions eradiate into all possible directions; sometimes they meet;
often they cross or bypass each other (Moreno 1967, 160).

146
Michael Wieser
The core of the social atom consists of individuals who are emotionally
meaningful to the subject. Petzold (1979), for instance, elaborated this in
reference to the elderly. The structure of the social atom cannot be observed
directly, which is why it has to be developed by psychodramatic means.
Besides the simple representation of the social relations, the social atom, by
implementing the role reversal technique, provides for a closer inspection of
the way patients interact with various significant others.
The social atom brings out real life-relationships as well as those wished
for. In his test called 'Test auf Lebenssituation - Checking for life situation',
Lodders encourages patients to not only chart people but inanimate objects,
values, and ideas as well (Wieser 1991, 147f). In individuals with mental
disorders, the number of important relationships apparently is only half as
big as with healthy people. The distinctive structural feature of the social
atom is strongly linked with the question how supportively it works (Engel-
hardt, Feldkamp & Sader 1989). The authors underline that the social atom
should be used as a diagnostic instrument only when there is a norm to refer
to, which is yet to be developed. In the genogram, emotional entanglements
that stretch over generations are entered and worked on. The purpose is to
disclose hidden messages and assignments (unfinished businesses).
Another example of the diagnostic tools that psychodrama uses is the
timeline. A piece of string or a long paper roll is placed on the floor of a
room, and the patients pace out important incidents of their lives; they do
not only narrate them but also briefly enact them as vignettes. With respect
to age-appropriate behavior, the early scenes are usually acted out on the
floor. Schonke (1982) illustrates how the enactment of family photograph
constellations serves diagnostic purposes. This resembles the living sculpture
(Eberwein 1997b). Another resourceful way is the fairy tale association test
(Kruger 1992), a projective procedure that unveils the individual's major con-
flict. Kaspar (1990) tries to achieve clarification of the life situation and rela-
tional structure in the intake interview. Coins of different sizes represent sig-
nificant others in the sociometric apperception test. A box filled with all sorts
of buttons is even more expedient for this purpose. The 'social atom' repre-
senting a certain period of a patient's life is to be evaluated as to the number,
the quality, and the degree of mutuality of relationships as well as enacted,
the latter of which yields an even higher validity. The 'cultural atom' encom-
passes the roles an individual plays along with the complementary counter-
roles adopted by the partners he interacts with. They also exhibit certain
properties and characteristics, and they enforce action. The answer to the
question: 'what is missing in the social atom' serves the ascertainment of
indications.
In the setting of psychiatric rehabilitation (Leeb 1991), psychodrama en-
deavors to 'diagnose and treat' even the institution. Moreno thought institu-
tions to be solidified cultural preserves, implying that psychiatry was still

Psychodrama (PD)
147
awaiting its transformation into a therapeutic community. From the socio-
metric angle, the patient's contacts with persons of his past as well as with
the current ones have to be diagnosed and balanced. The constellation
within apartment sharing communities can be captured by sociometric
means and altered by allowing more freedom of choice. Veltin, Kruger,
Zumpe, and Timpe (1981) examined the sociodynamics of the groups of
hospital residents who were suffering from schizophrenia. Ernst, Wiertz, and
Sabel (1980) diagnosed choice and apperception behaviors in depressive
patients. Pajek (2005) found that the quantitative sociometric status of an in-
patient was the essential predictor of the treatment success. An early com-
prehension opens up various possibilities of intervention.
Indication of Psychodrama Therapy
The spectrum of indications is practically boundless (Ottomeyer & Wieser
1996, 204). The application of the psychodramatic techniques often brings
up spontaneous material usable for diagnostic purposes and essentially fa-
cilitates decision making on those conflict areas which the psychotherapeu-
tic work should focus on.
Synopsis
It was Burmeister who succinctly described psychodramatic diagnostics:
Psychodramatic diagnostics makes use of the situational (symptom scene in-
cluding spontaneity level and role status) and of the contextual (SNI, Social
Network Inventory) assessment of ailments.
Key contents of the situational assessment of ailments:
- Detailed description of the complaints on the physical, imaginary, and
behavioral levels including the conditions that immediately preceded the
consequences: symptom scene
- Description of how the ailment has been dealt with hitherto by giving a
sample vignette
- Description of the course the ailment originally took by means of the
timeline
- Analysis of the subjective disease model tHealth-Belief-Mode/')
- Motivation for treatment rintrinsic' versus "extrinsic'), fears related to
treatment
- Symbolic representation of the ailment and its treatment: hopes and tar-
gets

148
Michael Wieser
Establishing role status and role analysis including the progressive, dys-
functional, and idealizing parts thereof.
Key contents of the contextual assessment of the ailment:
Action-supported exploration of life and disease history
Current SNI including symbolic enactment
Former SNI-findings. If indicated investigation of persistent fundamental
beliefs (messages and values, loyalties and delegated assignments) (Bur-
meister 2004b, 394, 395).
Psychodramatic diagnostics is the assessment of personalities, situations, and
interactions (Kellermann 2004).
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Diagn.doc
Translated from the German by Luna Gertrud Steiner

Person- and Client-Centered Psychotherapy (PP & CP)
ROBERT HUTTERER
Discussion and Development Threads
Some 30 years ago, in a lecture held in Vienna, a German person-centered
psychotherapist declared that, for her psychotherapies with patients in a psy-
chiatric hospital, she neither made a diagnosis nor did she need one. She
would not even inquire about the diagnoses customarily established by the
physicians in the course of hospital admission, in order to remain therapeuti-
cally open to the patient's way of experiencing.
This skeptical and cautious, or even depreciative attitude towards diag-
noses was absolutely typical for the then practicing 'Rogerians'. This attitude
follows from Rogers' own opinion and from his critical remarks on the role
diagnoses and diagnostics played in client-centered psychotherapies. In his
book published in 1951, Rogers thoroughly and meticulously reviewed the
"issue of diagnosis": starting from the question whether therapy has to set
out from a diagnosis or build up thereon, he critically analyzed the "medi-
cal" and "organ-centered" models, whose first step of treatment is an accu-
rate diagnosis before the treatment plan is made. According to him, the
"medical" approach was very intriguing, and this was why the ideal of
equally precise diagnoses in psychotherapy accrued, which were related to
the causes of a disease and thus eased the compilation of an unambiguous
and adequate treatment plan. Rogers did not favor this idea, though, arguing
that "psychological diagnosis as usually understood is unnecessary for psy-
chotherapy, and may actually be a detriment to the therapeutic process"
(Rogers 1995/1965, 206/220), and "therapy ... proceeds hand in hand with
diagnosis" (Rogers 1965, 219). "Some aspects of it, at least, can begin before
there is any knowledge of the difficulty or its causation" (Rogers 1995/1965
219). And further "In a very meaningful and accurate sense, therapy is diag-
nosis, and this diagnosis is a process which goes on in the experience of the

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Robert Hutterer
client, rather than in the intellect of the clinician" (Rogers 1995/1965, 208/
223).
Since in Client-Centered Psychotherapy the process-related exploration of
the client's experience from her very frame of reference constitutes the core
of this method, Rogers concluded that JJ a diagnosis of the psychological dy-
namics is not only unnecessary but in some ways is[sic!] detrimental or un-
wise" (Rogers 1995/1965, 209/223).
In his influential work published in 1957 'The necessary and sufficient
conditions of therapeutic personality change', he pointed out that in psycho-
therapy it was not necessary, JJthat the therapist have an accurate psycho-
logical diagnosis" (Rogers 1997/1989, 182/231). Rogers' rejection of diagnosis
is factually justified by the character and the logic of client-centered method-
ology: diagnosis did not fulfill any function in the sense that it guided thera-
peutic action. It was only in this specific task of guiding action, however, that
he denied diagnosis any function and therefore held it insignificant. Rogers
did not foster an overall skepticism, for he also emphasized that diagnostic
instruments fulfilled important functions in research, particularly in Client-
Centered Psychotherapy research (cp. Rogers 1997/1989 232).
When probing the question as to what degree psychotherapy should set
out from a complete diagnosis, or in how far it was sensible and helpful to
build up on such a preliminary diagnosis, Rogers takes a very exposed stance
for a number of objective reasons, which critically differed from the main-
stream of the medically dominated approaches. Notably, nearly all founders
and pioneers of therapeutic methodologies and 'schools' were alike in adopt-
ing skeptical or declining positions (cp. Laireiter 1999). Physicians who also
work as psychotherapists also explicitly questioned the significance of the
'medical concept of diagnosis' for psychotherapy (see Official Expertise of
University Professor Hans Strotzka, MD, and of Assistant Professor Raoul
Schindler, MD).
Students of Rogers have underpinned this view of the role of diagnostics
in manifold ways, as it is for instance expressed in the following quotation,
JJ... client-centered therapy has only one treatment for all cases. This fact
makes diagnosis entirely useless. If you have no specific treatment to relate
to it, what possible purpose could there be to specific diagnosis" (Shlien
2002, 402). A similar statement was made by Seeman (2002, 399) JJ... psy-
chodiagnosis is irrelevant to the internal process of client-centered thera-
py ..." but JJthere are occasions when referral for psychodiagnosis is part of
our ethical/professional responsibility."
This approach to the significance of diagnosis in client-centered psycho-
therapies as formulated by Rogers and some of his closest disciples gave rise
to a series of further discussions on this subject which, to this day, have been
led controversially and, in some cases, rather indiscriminately. We may, how-
ever, note that this has spawned many fruitful discussions on diagnostics in

Person- and Client-Centered Psychotherapy (PP & CP)
153
Person- and Client-Centered Psychotherapy, and that this has, in turn, height-
ened the awareness of the problem. The impetus of these advanced discus-
sions had partly come from outside, thanks to the increasing professionaliza-
tion and legal regulation of the psychotherapeutic occupation, the integra-
tion of Client-Centered Psychotherapy in the Public Health Care System, and
with the willingness of the health insurance companies to cover or reimburse
treatment costs. Another push toward a more engaged discussion resulted
from the fact that Client-Centered Psychotherapy, since its pioneering days
between 1940 and 1960 in the USA, and between 1960 and 1980 in the
German-speaking countries, had collected a substantial treasure trove of
experience, by applying their method to a vast variety of diagnostically dis-
tinct client groups. This has drastically changed the conditions of discussing
the value of diagnoses, which, in any case, clearly differ from those under
which Rogers had evolved his conception. In the following, we will back-
track and discuss some of these development threads, positions, and figures
of argumentation concerning the problem of diagnostics within the client-
centered approach.
Regarding the Client's Internal Frame of Reference
A series of controversies has accumulated around this methodological prin-
ciple when diagnostics is under discussion: in Client-Centered Psychothera-
py, the client's subjectivity plays an important part, which entails that the
therapist empathically follows his or her subjective experience. Addressing
oneself to the client from the perspective of an 'internal frame of reference',
contrasts that of an 'external frame of reference'. Any judging and categoriz-
ing from an extraneous and thus a 'strange' point of view harm or irritate the
client's subjectivity and turns him/her into an object. Diagnoses and diag-
nostic information or judgments are thus sheer exemplars or components of
an external frame of reference. Keeping away anything that possibly upsets
the client's self-exploration, such as acting from a position within the exter-
nal frame of reference, is a key factor of any therapeutic strategy. There is a
number of varying opinions, mainly on how far this principle should go and
to what extent it is applicable. When applied to therapeutic action, the de-
bates focused on the question as to what extent diagnosing was compatible
with empathy, noting that diagnostic classification asked for a different mind-
set and attitude on the therapist's part than did empathic regard. For this
reason, some practitioners forbear from setting up diagnoses and simultane-
ously treating the same client. Others solve the problem by consciously
changing their perspectives, assuming that demanding reorientation of the
client was acceptable to her and would not permanently hamper the thera-
peutic relationship. Another rather extreme way of reasoning suspects that

154
Robert Hutterer
the client's subjectivity would be upset in any case, no matter which form of
diagnosing, classifying, assessing, and categorizing was applied, even when
it was carried out for research purposes only. It can hardly be denied that
there are dogmatic and ideological streaks to this rather radical argumenta-
tion. Therapists often exhibit a certain awkwardness in the face of diagnoses
or even aversion, in order to protect the client's integrity and her own ability
to empathize (as alluded to in the introductory statement of the German cli-
ent-centered psychotherapist). The dogmatic part about this attitude reveals
itself whenever the repudiation of diagnoses is indiscriminately extended to
any assessment of processes, any evaluation of relationships, and any other
forms of detached reflection (an attitude which, carried to even further ex-
tremes, would also rule out supervision). What ever path the discussion
takes - be it either in touch with experience or a dogmatic and, therefore,
restricted one, the caveats resonating in those apprehensions might be
summed up as follows: diagnoses and the process of diagnosing are detri-
mental to the quality of the therapeutic relationship, or they narrow the
therapeutic potential.
Diagnostic I nstruments for Research and Evaluation
I rrespective of the above reviewed - partly dogmatically run - discussions on
the interrelations between diagnostics and the client's internal frame of refer-
ence, a number of instruments for research and evaluation of Client-Cen-
tered Psychotherapy have been devised. Since Client-Centered Psychothera-
py had emanated from the empirical research on real therapeutic situations,
the diagnostic issue had been part of the therapeutic procedure from its very
start. Categories and constructs have been generated for the purpose of
process research as well as of the effectiveness and efficacy studies, which
yet had to be operationalized via diagnostic instruments. It is noteworthy that
many of theses instruments directly root in the theory of Client-Centered
Therapy. This was the reason why therapy and method specific survey meth-
ods have been designed. In this paper, we will name only some examples of
these operations, one of them being the Regensburg Incongruency Analysis
Inventory (Speierer 1997, Speierer 2002, Speierer et. al 1999), the SEE - the
Self-Report Scales for the Experience of Emotions (Behr & Becker 2004) - or
instruments for documenting the process and success of person-centered
counseling and psychotherapy (Tscheulin 2001). Theses procedures are
based on key constructs of client-centered personality and therapy theories.
This led to the circumstance that we have theory-related and method-spe-
cific instruments on our hands, which are apt to support indication and the
diagnostics of achievement.

Person- and Client-Centered Psychotherapy (pP & CP)
155
Specifiable Forms and Functions of Diagnostics
Another parameter that has modified the framework of discussions on the
significance of diagnostic investigation in psychotherapy has been imposed
on psychotherapy by external factors. Or, to put it less cryptically, the more
psychotherapy underwent professionalization and strived for integration in
the Public Health Care System, the clearer the demands which society put
on psychotherapy. Particularly when the issue of psychotherapy cost absorp-
tion by the health insurance companies (social insurance system) was being
discussed, it was nearly impossible to further parry counterclaims (e.g., for
diagnoses, documentation, etc.). Psychotherapeutic orientations which until
then had treated the diagnostic subject in their method-specific and, let us
say, idiosyncratic ways had to resume the discussion of the issue in a novel
and more extensive context. The outcome of this debate was that Client-
Centered Psychotherapy eventually arrived at a more sophisticated differen-
tiation of diagnostics and its various subdivisions (initial, status, course, proc-
ess, change and evaluative diagnostics, etc.; cp also Sommer & Sauer 2001).
In the course of this, different functions of diagnostics were acknowledged
(identifying variables for research, support with the ascertainment of indica-
tions, providing a binding terminology for the communication with col-
leagues, for the documentation of processes, for evaluation, etc.).
Diversity of Clientele and Differential Inquiry
Another factor to be mentioned concerns the spread and the internal devel-
opments of Client-Centered Psychotherapy. In company with his students
and staff, Carl Rogers had elaborated the Client-Centered Therapy (then
called 'non-directive counseling') on the basis of their experiences with one
specific, relatively homogenous client group (adult neurotics and college
students). Eventually, they did apply their method to other client groups as
well (people suffering from schizophrenia, addictions, personality disorders,
etc.), and to newly identified disorders. Thus, comprehensive and novel ex-
periences with very diverse client clusters were gathered and put together;
these experiences constituted the foundation for the advancement of the cli-
ent-centered approach for theoretical insights and conceptualizations as well
as for mapping out methods and strategies. Simply for the purpose of com-
municating and sharing these experiences with colleagues, one had to resort
to a diagnostic language. As a consequence, the necessity of asking differ-
ential questions arose, a process that shed new light on the significance of
diagnostic undertakings.
These tendencies and threads of discussion provide the conditions for an
even more intense engagement in diagnoses and diagnostics within Client-

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Robert Hutterer
Centered Psychotherapy. A number of further questions will be spurred with
the interplay of these factors. The necessity for diagnostic clarification for the
purpose of documentation, a demand imposed on psychotherapy from with-
out, has set off new debates on how the client's internal frame of reference
and its methodic significance should be interpreted. Furthermore, docu-
menting experiences is vital for conjointly setting up diagnoses. The Diagnos-
tic Guideline for Psychotherapists is a helpful framework for accumulating
even more experience, and for discussion.
References
Behr M, Becker M (2004) SEE-Skalen zum Erleben von Emotionen. Hogrefe, G6ttingen
Laireiter A-R (1999) Diagnostik in der Psychotherapie. Perpektiven, Aufgaben und Qua-
litatskriterien. In: Laireiter A-R (ed) Diagnostik in der Psychotherapie. Springer, Vien-
na New York
Rogers CR (1995) Die klientenzentrierte Gesprachspsychotherapie (Original edition
1951/1965: Client-Centered Therapy). Fischer, Frankfurt/M
Rogers CR (1997) Die notwendigen und hinreichenden Bedingungen therapeutischer
Pers6nlichkeitsveranderung (Original edition 1957/1989: The Necessary and Sufficient
Conditions of Therapeutic Personality Change). Psychotherapie Forum 5 (3): 177-185/
Original in: Kirschenbaum H, Land Henderson V (1989) The Carl Rogers Reader.
Houghton Mifflin, Boston, pp 219-236
Seeman J (2002) Symposium on psychodiagnosis: (ii) A response to 'Psychodiagosis: a
person-centered perspective'. In: Cain 0 J (ed) Classics in the Person-Centered Ap-
proach. PCCS Books, Ross-on-Wye
Shlien J (2002) Symposium on psychodiagnosis: (iii) Boy's person-centered perspective
on psychodiagnosis: a response. In: Cain OJ (ed) Classics in the Person-Centered Ap-
proach. PCCS Books, Ross-on-Wye
Speierer G-W (1997) Das Regensburger Inkongruenz-Analyse-Inventar (RIAl). Erste Ergeb-
nisse. Gesprachspsychotherapie und Personzentrierte Beratung 28 (1): 13-21
Speierer G-W (2002) Das differentielle Inkongruenzmodell der Gesprachspsychothera-
pie. In: Keil W, Stumm G (eds) Die vielen Gesichter der personenzentrierten Psycho-
therapie. Springer, Vienna New York
Speierer G-W , Helgert N, Rosner S (1999) Aktuelle Ergebnisse zur Validierung und Nor-
mierung des Regensburger Inkongruenzanalyse Inventars (RIAl) (Internet)
Sommer 1<, Sauer J (2001) Indikation und Diagnostik in der Klientenzentrierten Psycho-
therapie. In: Frenzel Pet al (eds) Klienten-/Personzentrierte Psychotherapie. Konzepte,
Kontexte, Konkretisierungen. Facultas, Vienna
Tscheulin 0 (2001) Wurzburger Leitfaden (WLF) zur Verlaufs- und Erfolgskontrolle per-
sonenzentrierter Beratung und Psychotherapie. GwG-Verlag, Cologne
Translated from the German by Luna Gertrud Steiner

Diagnostic Guidelines for Systemic Family Therapists (SF).
It is Time for Integration
GERDA MEHTA
Historicity meets the challenge to capture identity
within a flux and to detect the options for change
and alternatives within...
Hartmut van Hentig
Guidelines Facilitate the Integration of Diagnostics Within the
Systemic Approach
Kurt Ludewig wrote that there are good reasons to assume that there exists a
long-lasting secret love affair between psychodiagnostics and systemic ther-
apy (Ludewig 2002, 79) and thus he captured the insecurities many systemic
family therapists experience when dealing with diagnoses. Diagnoses are be-
ing used in daily work, but theoretically they do not match with the sys-
temic constructivist principles. The general quest for - first diagnostics, then
psychotherapy plan followed by interventions - cannot be realized by sys-
temic family therapists due to their epistemic posture, in which each action
or even non-action is also considered to be an intervention and invitation for
opening (new) possibilities. For systemic therapists psychotherapy starts from
the very beginning; not only after diagnosing. Furthermore, diagnosis is seen
by systemic therapists as a more or less useful construction, one way of de-
scribing that enables something and prevents or obstructs other things, which
will be elaborated in the following.
Words - and labels - create reality. Diagnoses create reality. They are
not mere descriptions. They also bring forth social consequences; they be-
come mighty labels for people as they carry social impact, and usually
point towards deficits or weaknesses. Considering diagnostics as a means of

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Gerda Mehta
(defining) power, the descriptions (professionally made statements/judge-
ments about persons) primarily contribute to stagnation and fixation. From
diagnosis a legitimate need can be followed, a treatment can be justified.
Claims can be made and are justified (for example, availability of treatment,
costs covered by insurance company or other agencies, requesting respon-
sibilities by therapists, medical system and sometimes environment of pa-
tient, claims for a special kind of therapeutic treatment). In the positive
case, an incentive for change goes along with being diagnosed. But for the
diagnosed it also can become a more or less enduring label and leads to-
ward a (new) kind of identity. And sometimes diagnosis results in less
chances of getting jobs or promotions and could be a cause for social with-
drawal or even exclusions.
In dialogue with other professionals, diagnoses become helpful means for
immediate mutual understanding and easy communication (abbreviation of
long elaborations by stigmas), which can lead to mutual support and col-
laboration between professionals for reaching a therapeutic success.
In the work with patients, systemic family therapists handle 'diagnosis'
like an 'intervention': previously being an extensive concept, it has become
an aspect of seeing the situation, the client, the problem, the social labeling
process. Diagnosing can also be seen as a parallel, continuously reflecting
process during the therapy. It is a part of the therapeutic encounter, like 'Ian-
guaging' is. It can be a means for finding a communicable expression for
what is relevant. Diagnosing sometimes implies the need for specifically ob-
tained observations and information, useful for capturing relevant aspects for
dissolving the concern and general aspects about and of the person.
Shifts have also taken place over years with other aspects of the therapeu-
tic process. The big closing intervention at the end of the family counselling
session, which was made famous by the Milano School (examples of the
paradox interventions of Selvini Pallazoli, that should stop the family from
continuing in the same old way of interacting, went around the world), has
transformed slowly into a generally approved alternative described by the
works of Karl Tomm on the interventive interviewing (1988). Since then sys-
temic family therapists have acknowledged that every question, every com-
ment and even questions not asked, and any reaction of any kind are consid-
ered to be potentially important interventions in psychotherapy processes. It
is more the patient who determines if something becomes interventive, is
ignored or remains unproductive or is not even recognized. That posture
called for the search for multiple perspectives and for a variety of relevant
psychotherapeutic ideas, from which the patient can choose and draw his/
her consequential steps.
The guidelines now confirm a continuous and multidimensional approach
also for diagnostics as such. The acknowledgment of a continuous diagnostic
process, diagnoses for various purposes and goals, new attempts of capturing

Diagnostic Guidelines for Systemic Family Therapists (SF)
159
many moments within the treatment and considering contexts the patient
finds him/herself in, are informative for understanding the patient, and his/
her situation can now be integrated in the systemic approach. Also, the one
diagnostic label of the patient is now replaced by a reflective continuous
diagnosing process throughout the therapeutic process.
Contextualizing the diagnostic process by including its impacts on other
contexts will now be important for all psychotherapists: motives of classifi-
cations are being mentioned in the general part of these guidelines; the pre-
amble stresses the importance of the method-specific diagnostics for col-
laboration with the patient and with other professionals, as well as for its
indication. In future all psychotherapists need to reflect upon the following:
for whom the diagnosis might be important, which information can be
drawn from the given diagnosis in the worst case, what meaning is implied
by it for everyone involved, which message the diagnosis is supposed to
convey and not to convey to whom, how meaningful will it be for all people
involved, under which circumstances the very diagnosis might be given up
and what negative effects the diagnosis could have on the patients' lives,
e. g., what will not be expected of them any more. These aspects have been
business-as-usual for systemic family therapists for a long time.
The central positioning of the therapeutic relationship by these guide-
lines, in which both diagnostic and interventive elements are embedded,
conforms with systemic understanding. Systemic family therapists, however,
go one step further: they consider and focus on the relationships of their
patients with their families and important others, their resources, limitations
and attachments in general. The diagnosis of the relevant others of the pa-
tient may have an important impact. It often leads to being sent for thera-
peutic help (my husband wants me to.. .). The utilization of their environ-
ment for the specific impacts in reaching the therapeutic goal is (also) rele-
vant. The psychotherapeutic relationship functions as a bridge, a tool, a
transitional substitute, until other 'natural' relationships enable or provide
again what is necessary to live fairly well. In that sense it also can serve the
function of relaxing the relationship with the partner, as problems or emo-
tional help can be dealt with in therapy, and the relation lets the partners
"breathe" again.
Not preset norms, but rather how patients match (and influence) with
and within their social network are guiding principles of systemic interven-
tions (including the questioning of matching with the people they are close
to). Expectations, urgencies and confinements of the surroundings and the
patient's stability versus his/her liability are important aspects for the urgen-
cy of help and relieflchange. The needs and expectations of the patient's
closest social environment also call for consideration as a factor in the ther-
apeutic process. Systemic therapists make these issues also explicitly impor-
tant.

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Gerda Mehta
Characteristics of Systemic Diagnostics
Systemic family therapists are generally considered to be versatile, experi-
mental and open, also towards their own views and perceptions. As con-
structivists they believe in the versatility of points of views, testing rather than
assuming, questioning rather than approving, enlarging and putting into per-
spective rather than fixating. This is also true for their theories and tools.
Every information, observation, intention is only one point of view, a descrip-
tion, an orientation amongst many alternatives. This versatility is necessary,
as organisms (humans) act according to their own sometimes unique inner
laws, their history, their prior experiences, their holding networks and their
readiness, and not necessarily according to general theoretical assumptions
described by the theory. Systemic therapists are guided by the generally ac-
cepted concept of autopoiesis (Maturana).
Words generate meaning through intentions, interpretations and social
interactions, through the usage and in the dialogue with others with whom
one interacts and whom one refers to. What a psychotherapist deals with is
a construction of how clients construct their own reality (De Shazer 1988,
218). Based on this concept, patient and psychotherapist co-construct their
shared therapeutic reality. Meanings and attributions are negotiated in the
course of the therapy.
Based on their assumptions, tools and theories, therapists introduce new
differentiations and create an atmosphere, a /stage: upon which relevant
new information and new perspectives can be gained and can be experi-
mented with. As part of the psychotherapeutic system, psychotherapists are
participating in the process of differentiation, observation and understanding.
The psychotherapists intentionally introduce new differentiations since it is
assumed that they probably bring forth the environment that can help the
disturbing, the upsetting, the frightening, the aberration, the pathological to
slowly disappear and need not be further addressed as it is not creating trou-
ble any more in the life of the patient.
Cierpka suggests that the diagnostician should understand himself/herself
as a member of the family system to be able to derive diagnostic considera-
tions and reflections from 'within/, utilizing also their own feelings and
thoughts as well as impressions and actions and reactions as a member of
the psychotherapist-family-system (Cierpka 2000/ 218).
In the process of searching and clarifying what and how it is, what pa-
tients are missing, what is bothering them (in varying degrees of urgency),
and approaching the goals patients wish and hope their lives would trans-
form into and change to, the patients and the psychotherapists set out to
search for something powerful and effective for dissolving their concern. In
the course of the discipline, diverse systemic tools and instruments have
been developed for this search. Diverging theoretical approaches and, as a

Diagnostic Guidelines for Systemic Family Therapists (SF)
161
result various diagnostic systems and tools have been developed that are
characteristic of various systemic approaches and schools.
As stated above, traditional, descriptive diagnostics is generally rather
problem preserving than resolving. Alternative methods for bringing forward
relevant information that promotes transformation/change have been devel-
oped: some focus on the diagnostic investigation of the goals and future
orientation, describing how it will/should be when therapy is not needed any
more, when the miracle has happened and when the life is as it should be.
The clues of that goal are searched for and diagnosed, which systemic thera-
pists believe lead towards strengthening motivation. Exceptions to the prob-
lem indicate paths for solutions. Discovering novel claims and objectives
help to manoeuvre and lead towards problem dissolving. The supporting
system with its specific resources and obstacles is to be considered as an
important starter.
A problem (also called symptom, concern, personality disorder, etc.) is
comprehended as a difficulty creating concern and anxiety of something or
someone. And someone experiences the need, often an urgency, to do
something about this problem. The patients and sometimes also their fami-
lies or important others (people close to them, including teachers, doctors,
bosses) use this problem description when they address their concerns in the
dialogue with the psychotherapist to make clear what bothers them or others
(Goolishian, Anderson 1988, 207). So systemic family psychotherapists ex-
plore what makes people worry, who is worried (and likes to see and experi-
ence change). They explore the persons, thoughts, ideas and initiatives that
can help to bring about a change/transformation of the problem-saturated
system (a system is a network which is grouped around an idea; the ideal
theme is constituting its memberships). Solution-oriented systems are differ-
ent from problem-saturated systems, and perhaps differ also from the sys-
tems people engage in when having overcome the problematic.
The search for problem dissolving, and the search for what can be helpful
towards that, brings forth certain dialogues and information. In the process
there is a focus on goal orientation and solutiontalk - a conversation about
initiating and implementing changes. It is a way of languaging that focuses on
solutions, and by engaging in talking about solutions they actually happen
more and more. It is selectively picking out aspects towards change. As it is
assumed that some constructions limit and others facilitate perspectives and
space for manoeuvring, depending on what we put our emphasis and obser-
vations, one can shift the attention. So why should we not focus on the as-
pects which are only beneficial for achieving the therapeutic transformation
and reaching the goal by approaching them directly from the first minute of
the therapeutic encounter?
The core aspects of the systemic family therapists' psychodiagnostics are
to capture the moments within the psychotherapeutic process that have the

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Gerda Mehta
potency for change, solutions and transformation. Key words, exceptions and
the miracle questions (aiming to bring forward the descriptions of the desired
outcome) are important diagnostic tools. Also useful are visualizations, like
the positioning of the (family) constellations in the room or on the 'family
board', or using other tools for concretization of the therapeutic goals, visu-
alization of networks and their preferences and goals, or visualizing and
playing with ways towards them, and detecting and identifying the obstacles
and resources on the way to the realization of one's goals.
It is the psychotherapists' obligation to introduce new aspects, new dif-
ferentiations that initiate or draw attention to other perspectives, new obser-
vations, rules and reactions. In the course, the new differences will have to
prove their effectiveness by making a difference: that the problem, the symp-
toms, the disturbances, the pathologic do not bother any more.
Process- and goal-orientation require an emphasis on the half-full glass. It
needs constant reassessment of what is useful as well as continuous (re)search,
experimentation and revisiting of formerly neglected aspects for the next
steps towards the dissolution of the problem; it continuously needs creating
potential options for possibilities of agency and assessment of what new
small steps and small risks for new options could be taken to come closer to
the therapeutic goal. It needs evaluations and new investigations of what
patients consider possible, what can be ventured and risked, and it needs
positive connotation for what has been already achieved regarding their psy-
chotherapeutic target. The patient needs this reassurance of a solid founda-
tion, a beneficial psychotherapeutic support, a psychotherapeutic relation-
ship that generates a sense of security and thus creates hope for success and
courage to experiment.
The utilization of the diagnostic instruments is based upon psychothera-
pist's personal preferences, methodological background, training, experience
and creativity. The main tool is the use of language and expression. "Lan-
guage becomes alive and develops in a sphere, in which individual orienta-
tion and constructions and collective holding and shaping are constantly
molding, shifting, creating tension and conflicts, which call for re-dissolving
and new solutions." (Stierlin 1994, 15). The search for 'appropriate' words
sharpens terminology and understanding, and leads to new perceptions. The
over-determined key words, equipped with multiple meanings, are indicators
of the potential for change and can become manifestation of flux and move-
ment.
Systemic diagnostics aims at exploring and using resources that enable
patients to cope and deal with their lives. Ludewig refers to this as survivor
diagnostics (2002, 46).
Systemic diagnostic investigations also look at the pool of resources of
relationships around the patient and his/her environment with its potentials
and stressors in everyday life. Entering possible new relationships, environ-

Diagnostic Guidelines for Systemic Family Therapists (SF)
163
ments and alternative surroundings for the patients are also issues that are
worth addressing during psychotherapy.
Family therapy formerly used to focus on an index patieni (symptom
holder) and to explore the dysfunctions of the family system (attempt to shift
the description of the disturbance from individuals to contexts and inter-
actions). Fiegl and Reznicek (2000, 235) have explained why the concept is
not tenable any more: the specificity hypothesis (Spezifitatshypothese) has
been refuted, the blame indirectly put on the families by the hypothesis is
unacceptable, and the assumed linear causality has been refuted as well.
Moreover the manifold interactions are brought forward by administering
the circular questions technique. With this technique information can usual-
ly be generated in a new, astonishing and inspiring way for all people in-
volved, so that the families start to become curious about themselves and
the views of their members, and start to find new solutions by an inspired
dialogue in a new way.
Possible Ways of Overcoming the Burdened Systemic
Relationship with Diagnostics
In Aprij 2003, Familiendynamik - the leading German systemic journal - is-
sued an edition that focussed on diagnostics, JJDiagnostik in der Familien-
therapie". In the preface, the editor stated that the family therapists have a
hard time when it comes to their relationship with diagnostics. Why is this
opinion transmitted over years? The following paragraphs list several points
in support of my belief that theoretical convictions contribute toward this.
Labeling, a certain way of structuring the information to match with the
diagnostic manuals - and this is what systemic family therapists think about
when they refer to diagnostics in a conventional sense - serves for obtaining
specific information. It is a process for generating specific knowledge with an
unavoidable by-product: it generalizes and oversimplifies the situation which
leads towards a loss of information. That information, however, would be
beneficial for conducting psychotherapy, as the exact wordings indicate
possible interventions and possibility for modifying meaning. Besides, the
descriptions, the languaging, the ways of expressing become indicators of
progress and indicate the solution. The discourse itself points towards a
change. These concepts are in accordance with the new guidelines. Psychi-
atric diagnoses lack this psychotherapeutically useful information.
Techniques for assessing the rules of the families, patterns, games families
play and paradox interventions became popular in the 1980s through the
Milano School. At the same time, the theoretical approaches focussing on
the change without investigating the status quo, the patterns of interaction,
the rituals or a person's or family's background and history have also been

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Gerda Mehta
developed and discussed. Some stated that the goal assessment is plenty of
information and sufficient for the decisions necessary for the psychothera-
peutic process. Goal- and solution-oriented diagnostics are not in contradic-
tion with the new guidelines.
The patients' subjective experiences, the extent of their suffering, their
willingness and their urgency, readiness and need to receive treatment (in-
cluding the perspectives of others dealing with them) are excluded in the
traditional diagnostic codes. Diagnostics as a shared hermeneutic entelprise,
however, could be a useful tool and a concrete helpful source of relevant
information for the therapy process for the therapists and the patients (Borst
2003, 206). This aspect is partly addressed in the chapter on risk level in the
guidelines.
Local information is generated and reassured (held alive) actively and in-
teractively. When contextual factors and social phenomena are included in
the diagnostics, it becomes complex. When the epistemological and con-
ceptual emphasis is on what can be observed, communicated and under-
stood, including possible alternatives, we are dealing with a complex matter.
Also, diagnosis can only be a label that generates meaning on the basis of a
(in an optimal way consensual) conclusion at a given moment and context.
Psychotherapeutic diagnostics embedded within a relationship and a
given context should facilitate a change. As a complementary part of the
psychotherapeutic process, it feeds back and affects this process continu-
ously and immediately. Diagnoses may generate (new) realities. It needs to
be recognized that certain diagnoses reconfirm the problem, which should
be eventually resolved by treatment. Labelling might be considered an in-
terim step, which serves scientific and documentary purposes. The diagnos-
tic endeavour, however, might carry psychotherapeutic implications for
others, including some with structural power. The process freezes in the mo-
ment when diagnoses are communicated to others outside the therapeutic
endeavour.
Psychotherapeutic diagnoses are basically relational. However, they be-
come one-sided by being shaped and fitted in a prescribed categorical sys-
tem. For a more relational diagnostic process, the GARF-Scale described in
the appendix of the ICD-l0 is useful (for assessment of the functioning of the
relationships in general, problem solutions, organization and maintenance/
change of social habits and the emotional climate of the psychotherapeutic
process). If the term 'relational' includes the collaborative creation of diagno-
sis, in the sense of differentiation and consensual verbalization and finding of
the proper wordings, then the ideographic models are favored (generating
stories with the patients). A relationship-based process diagnostics does not
contradict that concept.
The pathological models that the patients and their families believe in and
that make them come to psychotherapy might be a starting point. The future

Diagnostic Guidelines for Systemic Family Therapists (SF)
165
perspective creates different relevant images and communication/under-
standing between the patients and the psychotherapists. The therapists focus
on a mutual understanding by relating and co-constructing, by co-creating
experiences and images that are beneficial for the progress in the psycho-
therapeutic process. Local descriptions can allow more space for manoeu-
vering and hope for change than scientific categorization and labeling.
Complex understanding of the psychotherapeutic diagnostics, as de-
scribed in this book, holds the potential for refuting many of the concerns
about conventional 'labeling' and reductionism of diagnostics that were
fought against by the systemic therapists in the past. This new approach
adopted by the guidelines would surely enable and encourage the integrative
use of the psychotherapeutic diagnostics also by the systemic family thera-
pists in their therapies, and in the exchange of information for collaborating
with other professionals.
Note:
The author wishes to thank Margarete Fehlinger, Elisabeth Frieser, Jutta Fiegl,
Harry Merl and Hedwig Wagner for their valuable suggestions for improving
the text, and Susanne Lastin for her significant contribution towards the
translation.
References
Borst U (2003) Diagnostik und Wissen in der psychiatrischen Klinik: Bis wohin nutzlich,
ab wann hinderlich? Familiendynamik 2/28: 201-218
Cierpka M, Stasch M (2003) Die GARF-Skala. Ein Beobachtungsinstrument zur Ein-
schatzung der Funktionalitat von Beziehungssystemen. Familiendynamik 2/28: 176-
200
DeShazer S (1988) Therapie als System. Entwurf einer Theorie. In: Reiter, Brunner E,
Reiter-Theil S (eds) Von der Familientherapie zur systemischen Perspektive. Springer,
Wi en, pp 217-230
Fiegl J, Reznicek E (2000) Diagnostik in der Systemischen Therapie. In: Laireiter A-R (ed)
Diagnostik in der Psychotherapie. Springer, Wien New York, pp 235-245
Goolishian H, Anderson H (1988) Menschliche Systeme. Vor welche Probleme sie uns
stellen und wie wir mit ihnen arbeiten. In: Reiter, Brunner E, Reiter-Theil S (eds) Von
der Familientherapie zur systemischen Perspektive. Springer, Wi en, pp 189-216
Hoffman L (1984) Grundlagen der Familientherapie. ISKO-Press (Foundations in Family-
therapy)
Ludewig K (2002) Leitmotive systemischer Therapie. Klett Cotta, Stuttgart
Maturana H, Varela F (1987) The tree of knowledge. New Science Library, Boston
Schlippe Av, Schweitzer (1998) Lehrbuch der systemischen Therapie und Beratung.
Vandenhoeck & Ruprecht, Gottingen
Simon F, Clement U, Stierlin H (1999) Der Sprache der Familientherapie. Ein Vokabular.
Klett-Cotta, Stuttgart
Tomm K (1988) Das systemische Interview als Intervention. System Familie 1: 145-159

166
Gerda Mehta
Tomm K (1996) Die Fragen des Beobachters. Schritte zu einer Kybernetik zweiter Ord-
nung in der systemischen Therapie. Carl Auer Verlag, Heidelberg
Weltgesundheitsorganisation (2000) Internationale Klassifikation psychischer Storungen.
ICD-l0 Kapitel V (F). Klinisch-diagnostische Leitlinien. Huber, Bern

Transactional Diagnosis (T A)
AMANDA BERGHOLD-STRAKA
Diagnosis in transactional psychotherapy is process-related and interactional
according to its definition. Diagnosing is not seen as an act of putting la-
bels, but as a working hypothesis - more or less an interim statement of
what has been accomplished so far in the therapeutic process. This proce-
dure allows the therapeutic process to be vivid and flexible with a view on
the clients' past, present and possible future. Differential diagnosis in TA is
the action of classifying a special pathology in reference to others with sim-
ilar symptoms. The different elements of a special pathology as well as the
client's resources are gathered and put in relationship in order to under-
stand the client's script as well as its environmental and developmental
causes.
This special form permits the classification of all specific symptoms with-
in the diagnostic criteria of OMS and also ICD 10; especially the multiaxial
system of OMS comes very close to the form of diagnosis typical for T A.
The five different axes of OMS
I. clinical syndromes,
II. disturbed patterns of personal development and personal disorders,
III. corporal impairment and somatic problems,
IV. seriousness of personal stress and strain, and
V. global judgment.
may almost completely be transferred into the TA procedure.

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Amanda Berghold-Straka
TA Diagnosis and Its Possibilities
A. Diagnosis of Ego States
There are three types of ego states:
1. Parent ego states, extereopsyche
2. Adult ego states, neopsyche
3. Child ego states, archaeopsyche.
An ego state is a collection of consistent and interrelated patterns of being,
decisions, feelings and behavior that the person herself perceives as consist-
ent and is visible in her behavior (Summerton, 1994).
The significant quality of ego states is relied on when it comes to the di-
agnosis of human psychological suffering.
A.1. Behavioral Diagnosis (observation of behavior). The executive power
gives rise to its own idiosyncratic patterns of organized behavior. This relates
to psychology, psychophysiology, psychopathology and neurophysiology.
The behavioral diagnosis is drawn from observations. By observing certain
words, intonations, gestures, facial expressions, the therapist uses his own
inner concepts of the parent, adult and child to associate which ego state is
in charge. Those inner concepts are related to behavioral observations and
scientific methods.
A.2. Social Diagnosis (personal relation). Each ego state is capable of adapt-
ing its behavioral response to the social situation in which the individual
finds himself. This brings them into the realm of social sciences. Social diag-
nosis is done in reference to which ego state is apt to be elicited in the vis-a-
vis. This diagnosis takes place by contacts.
A.3. Historical Diagnosis (biographical information). Biological fluidity means
that responses can be modified as a result of natural growth and previous
experiences. This raises the historical questions which are the concerns of
the psychoanalysis.
The historical diagnosis is drawn from the biography and is made evident
by questioning.
Example: A client was driven by his mother to try hard and not to fail. He
had anxieties of failure even in his childhood. These anxieties of failure and
also the "try hard" are embodied in his child ego state. In his parent ego
state, he hears this inner voice "You should try hard". The historical diagnosis
refers to the contents of the ego states.
A.4. The Phenomenological Diagnosis. Mentality refers to the way in which
phenomena of the experience are being conveyed. These phenomena are

Transactional Diagnosis (TA)
169
being dealt with in introspective psychology, particularly in phenomenologi-
cal, structural and existential psychology. Phenomenological diagnosis is
developed in the process of the therapy.
If, for example, a client presents himself as parental or childlike, the
therapist will ask him about his feelings and perceptions at the very moment.
It turns out that the client presently has the same feelings as he had in a
given situation in his childhood.
The complete diagnosis of an ego state requires all these four aspects.
The behavioral and the social diagnosis are related to the external process
while the historical and the phenomenological diagnosis are related to the
internal process.
B. Diagnosis of Games
The theoretical concept of games must not lead to misconceptions. This
concept does not necessarily implicate fun or amusement. 'Games' in TA are
patterns of communication which proceed without awareness of the adult
ego state. Therefore diagnostic questions which appeal to this part of the
personality are of special interest. The risk in confronting games lies in the
feeling of being blamed, shamed or humiliated. This danger can be avoided
if it is possible to engage the adult ego state, because each person is able to
uncover her own individual games. There is a number of different approach-
es to represent the concept of games; in this context emphasis is placed on
the following:
B.l. The Behavioral Aspect: I n Steve Karpman's (1968) well known model of
the drama triangle, the involved social roles become apparent. There are
three typical parts or roles involved in a game.
//Victim" is a person who pretends
1. that she is lacking the power of problem solving,
2. that others must change for her well-being,
3. that her need detains her from problem solving,
4. that her intelligence is insufficient.
//Rescuer" is a person who
1. perceives herself in a grandiose way, capable of helping and rescuing oth-
ers,
2. takes care of thinking and solving problem for others without being
asked,
3. does more for others than she tells them,
4. does for others, what they do not like to do for themselves.

170
Amanda Berghold-Straka
//Persecutor" is a person who
1. blames others and is overly critical,
2. wants to punish others,
3. provides suffering for others.
Generally somebody starts the game from one of these three positions. T en-
sion arises from the fact that these roles are changed frequently, so that con-
fusion emerges as to who has which part in the communication. If humans
are intrigued in one of these three roles, they react with the patterns from
their past and not from the here and now. They interact with the old-script
bound strategies, which they had decided as children, or had taken over
from their parents.
B.2. The Transactional View: From the transactional point of view, the am-
biguous message is the decisive part of the games. Games can be easily
identified by tracing the incongruity between the content (deriving from the
adult ego state) and the process (facial expression, gesture, intonation), which
results from the adapted child ego state or from the parent ego state. Such a
statement could be: "I will show you the report" (adult ego state) with an
anxious expression (child ego state).
B.3. The Payoff: At the end of a game, emotions arise and are perceived
which in TA are described as "racket feelings". This is generally a familiar
emotion which was acquired and supported in the childhood and was expe-
rienced in many different situations of stress.
The expression of a racket feeling as a method of problem solving up to
the adulthood implies maladjustment.
B.4. Repeated Patterns of Behavior: The following questions help to trace
repeated patterns of games.
1. What happens again and again?
2. How did the game start?
3. What happens then?
4. How does the game end?
5. Which feeling remains with the participant?
c. Diagnosis of Passive Behavior
Passive behavior is defined as a behavior which does not result in problem
solving. Observing this type of behavior can lead to understanding the
internal process. Behavioral problems especially show in driver patterns

Transactional Diagnosis (TA)
171
(directed from parent ego states) and also stereotype patterns of games and
passive behavior.
D. Diagnosis of Thinking Disorders
The thinking disorders which are described here do not refer to the ability of
thinking itself, but they affect the thinking ability through inner processes,
like redefinition, discounting and others. This means that a person discounts
herself, others or the situation. Schiff (1975) describes the thinking disorders
as internal mechanisms which help maintain a special frame of reference:
1. Overgeneralizing
2. Overdetailing
3. Escalations
4. Confounding reality with fantasy
E. Script Diagnosis
A script is an unconscious life plan, based on decisions from early childhood
(Berne 1966). Erskine and Zalcman later developed the racket system (script
system). The connection between the racket feelings and the racket behavior
as a manifestation of the script are related with the inner and unconscious
script structures.
E.l. Life History:
Script beliefs about:
1. Oneself
2. Others
3. The quality of life
Underneath are
1. repressed needs
2. basic emotions
E.2. Behavioral:
Script behavior
1. observable behavior
£.2.7. phenomenological
2. related inner experiences
3. fantasies

172
Amanda Berghold-Straka
f.3. Relational
Reinforced experiences
1. Actual events
£.3.7. Phenomenological
2. Old emotional memories
3. memories about fantasies seen as reality.
f.4. Indications of a Script in Action
- Frequent repetition of similar conflicts, stereotyped thinking
Self distant expressions like: one sees a lot..., it happens
Overemphasizing or minimizing problematic childhood experiences
Strong dependency on other person's opinions, rationalizations
Magic expectations (time, rescuer, miracles, etc.)
Holding on to childish illusions about one's own or other person's impor-
tance (grandiosity)
Gallows laughter (making fun of one's own pain)
Lacking alternatives
Overgeneralizing (always, ... never)
A further diagnostic criterion of the script-bound topics is the body language
such as avoidance of eye contact, gestures, script signals like flat breathing,
pressed voice and lack of modulation, childlike or parent like expressions,
gallows laughter, etc.
F. Diagnosis of Different Types of Adaptation and Levels of Functioning
In diagnosing and planning during the therapy process, it is useful to differ-
entiate between the conflict neurosis and the developmental or traumatic
psychic disorders.
The type of adaptation is determined by the contents of the script, and
the functional level is determined by the kind of internalized object relations
(Divac Jovanovic and Radacovic 1990).
The psychoanalytical view differentiates between the disturbances which
are originated by the inner psychic conflicts and those which are originated
by the developmental impairment. In TA, those conflict disorders are seen as
conflicts between ego states. They are described in detail as script con-
tents.
The developmental disorders are described with the model of psychic
energy or cathexis of ego states and also with the related structural model.

Transactional Diagnosis (TA)
173
References
Berne E (2001) Die Transaktionsanalyse in der Psychotherapie. Junfermann, Paderborn
Berne E (1988) Spiele der Erwachsenen. Rowohlt, Reinbek
Hennig G, Pelz G (1997) Transaktionsanalyse. Herder, Freiburg
Stewart I, Joines V (1990) Die Transaktionsanalyse. Herder, Freiburg

Behavior Therapy (BT)
ERWIN PARFY
How Behavior Therapists Could See Themselves Represented
in the Diagnostic Guideline of the Federal Ministry of Health
and Women's Affairs
Doubtlessly, the just released Diagnostic Guideline for Psychotherapists will
be received rather controversially on the part of behavior therapy. On the
one hand, the behavior therapists traditionally feel closely related to psychol-
ogy and thus to clinical-psychological diagnostics, since the theoretical core
of behavior therapy is rooted in this very field. On the other hand, many
behavior-therapeutic treatment approaches definitely orient themselves to-
wards the clinical pictures of psychiatry and are therefore bound to psychiat-
ric-diagnostic routines and systems.
Why establish a psychotherapeutic form of diagnostics then? Is it to un-
dermine the sublime and academically rooted art of the provenly scientific
diagnostics? Is this, under the aegis of the Austrian legislation on psycho-
therapy, meant to be another blow against those professional standards one
takes for granted in all the other European countries, and even more so over-
seas? Why, in any case try to invent the wheel anew, when everything has
been working well anyway? Who is interested to impose additional obliga-
tions on us? And which, for heaven's sake?
I can well relate to this nervous response since I noticed it within myself
when I joined the Research Committee of the Advisory Board for Psycho-
therapy as a representative of the Austrian Society for Behavior Therapy, in
order to participate in the design of this questionable Guideline. I soon real-
ized that the representatives of the various psychotherapeutic disciplines who
had been involved before were not so much motivated by the interests of their
professional associations, but really concerned with finding the optimal de-
scription of those often unnamed rules that guided their daily psychotherapeu-

176
Erwin Parfy
tic practice. We often lost ourselves in the details of one or another psycho-
therapeutic case which, at various times, emphasized this or another aspect.
The very lengthy discussion process (it took in fact several years) finally al-
lowed for an alignment of the diverse positions to the extent that - at least in
my opinion - each psychotherapeutic school could easily find itself repre-
sented in it or trace an affinity with it. I am going to discuss this in greater
detail in the following paragraphs, in how far this applies to behavior therapy.
During the design process of the Guideline/ a new course was set by sug-
gesting that any kind of presented symptoms should be viewed against the
background of the personality of an individual, and that the specific quality
of a psychotherapeutic relationship should not be ignored in any case, as it
was a first-rate diagnostic source. These focuses may thus easily be related to
the development which behavior therapy has gone through during the last
decades - a fact that might puzzle those who still foster those rather out-
dated and exaggerated ideas of behavior therapy being a conditioning instru-
ment under 'black-box' premises.
As a matter of fact, with the frequently quoted 'cognitive turn' within be-
havior therapy, those personality-specific, internal processing patterns which
mediate between self-experience and environmental relatedness took center
stage (Mahoney 1974; Beck 1976). Cognitive Therapy therefore requires a so-
phisticated 'cognitive diagnostics', the objective of which is to comprehend the
properties of an individual's thinking (Merluzzi & Glass 1996). These relatively
stable personality features were, however, considered as related to the symp-
toms of, e.g., dysphoria or generalized anxiety; since then, a psychotherapy
that is to induce change has increasingly set out from the processes within.
Along with treating monosymptomatic disorders, more complex, Le., co-
morbid disorders were discussed, which lead to the conception of the ex-
plicit personality disorders (Fiedler 1994). The behavior-therapeutic concept,
which had been tailored to the treatment of them, quickly abandoned or
rather transcended the purely cognitive approach (Beck & Freeman 1990) and
included emotional processes (Linehan 1993), viewing them on the backdrop
of the biographical experiences and the ways the patients experienced their
world (Young 1994). 'Personality' thus became diagnostically comprehensible
in its emotionat cognitive, and interhuman dimensions, an insight that clearly
enhanced the understanding of a patient's susceptibility towards certain dis-
eases and of the functions the individual symptoms fulfilled.
Appreciating the therapeutic relationship as the venue where diagnostic
investigation takes place goes back to the behavior-therapeutic approach of
the Plan Analysis (Caspar 1989). There, the statements and behavior patterns
which the patient fed into the relationship used to be (and still are) meticu-
lously examined as to their underlying plans and motives. The therapeutic
relationship was then structured deliberately and shaped in a complemen-
tary way, which was a strategy to purposefully trigger change-relevant new

Behavior Therapy (BT)
177
experiences within the therapeutic relationship itself and to submit them to
the reflective process.
Another thread of development may be traced in the conjunction of the
behavior therapy and John Bowlby's attachment theory (Guidano & Liotti
1983). This tradition not only emphasized the biographical experiences in
the context of attachment relationships as a subject of therapeutic work and
as an essential parameter of the quality and the severity of personality-spe-
cific symptoms (Liotti 1989), but the relational offer of the psychotherapist
could henceforth be defined as the interactive space in which the patients
turn to their therapists with their particular efforts and strategies to satisfy
their attachment needs (Liotti 1991). This allows for further diagnostic in-
sights and, hence, adjustment of the relationship, that now assumes the qual-
ity of a 'safe basis', the indispensable prerequisite for a successful (self-)explo-
ration of the patients.
Last but not the least, we should not leave unmentioned that the aware-
ness of the behavior-therapeutic process or course has risen, a trend that
culminated in the concept of therapeutic stages and the accurate observation
and structuring of their succession (Kanfer & Schefft 1998). Process-bound
diagnostics has thus gone beyond the sheer ascertainment of clinical effec-
tiveness and turned into a multidimensional device that embraces the high
complexity of the experiential therapeutic space and necessarily affects the
further dealing of therapists.
Strongly recommending the just finalized Guideline to Behavior Thera-
pists would be taking coal to Newcastle, particularly if we consider their
developmental history as characterized above: teaching therapists and stu-
dents (mainly in Austria) have racked their brains over precisely these issues
for years or rather decades. Training modules, workshops, and conferences
were organized, called together, and offered in order to heighten the aware-
ness for these fields that seem so important to us. We deem it crucial that the
issues of personality development be discussed profoundly and on the basis
of psychotherapeutic theories, and that the psychotherapeutic relationship
be structured and shaped accordingly. This modus operandi should hold a
firm position within the spectrum of techniques of a modern-day behavior
therapy (Parfy, Schuch & Lenz 2003).
By comparison, the so far unmentioned diagnostic concern to attend to
the degree of severity of a disorder seems to be rather independent of meth-
od-specific considerations and routines. This certainly reflects the usual
practice of psychotherapists who make their own choices responsibly, but
the Guideline makes it explicit in a way that is suitable for standardizing and
hence simplifying the communication between various clinicians.
At last, we can only hope that the Guideline will not turn into a bureau-
cratic burden of any kind, of which we are currently witnessing a lot of un-
pleasant instances in our neighboring countries; there, texts written out in

178
Erwin Parfy
full tend to be abused as keys by which the authorities determine whether a
person is in true need for psychotherapeutic care or not. The growing and
expansive reporting in the media brings about highly developed and refined
formulation skills, which often lose touch with the sometimes cumbersome
practice as revealed by the conversations with the colleagues involved. In-
stead of such an implementation that merely invests itself in favorable ap-
pearances, my personal concern is that the respective contents and tech-
niques should be communicated lastingly within the basic, advanced, and
post-graduate psychotherapy trainings.
References
Beck AT (1976) Cognitive Therapy and the Emotional Disorders. International Press, New
York
Beck AT, Freeman A, Associates (1990) Cognitive Therapy for Personality Disorders.
Guilford Press, New York. German edition (1993) Kognitive Therapie der Personlich-
keitsstorungen. Psychologie-Verlags-Union, Weinheim
Caspar F (1989) Beziehungen und Probleme verstehen. Eine EinfUhrung in die psycho-
therapeutische Plananalyse (2nd revised edn 1996). Huber, Bern
Fiedler P (1994) Personlichkeitsstorungen. Beltz, Psychologie-Verlags-Union, Weinheim
Guidano VF, Liotti G (1983) Cognitive Processes and Emotional Disorders. Guilford
Press, New York
Kanfer FH, Schefft BK (1988) Guiding the Process of Therapeutic Change. Research
Press, Champaign
Linehan MM (1993) Cognitive Behavioral Treatment of Borderline Personality Disorder.
Guilford Press, New York. German edition (1996) Dialektisch Behaviorale Therapie
der Borderline Personlichkeitsstorung. ClP-Medien, Munich
Linehan MM (1993) Skills Training Manual for Borderline Personality Disorder. Guilford
Press, New York. German edition (1996) Die Dialektisch Behaviorale Therapie der
Borderline-Personlichkeitsstorung. ClP-Medien, Munich
Liotti G (1989) Attachment and Cognition. In: Perris C, Blackburn I, Perris H (eds) Cogni-
tive Psychotherapy: Theory and Practice. Springer, Berlin Heidelberg New York
Tokyo, pp 96-112
Liotti G (1991) Patterns of attachment and the assessment of interpersonal schemata:
Understanding and changing difficult patient-teaching therapist relationships in cog-
nitive psychotherapy. Journal of Cognitive Psychotherapy 5: 105-114
Mahoney MJ (1974) Cognition and Behaviour Modification. Ballinger, Cambridge. Ger-
man edition (1977) Kognitive Verhaltenstherapie. Pfeiffer, Munich
Merluzzi TV, Glass CR (1996) Kognitive Diagnosemethoden. In: Margraf J (ed) Lehrbuch
der Verhaltenstherapie. Springer, Berlin Heidelberg New York Tokyo, pp 201-216
Parfy E, Schuch B, Lenz G (2003) Verhaltenstherapie. Moderne Ansatze fUr Theorie und
Praxis. UTB-Facultas, Vienna
Young JE (1994) Cognitive Therapy for Personality Disorders: a Schema-Focused Ap-
proach. Professional Resource Press, Sarasota
Translated from the German by Luna Gertrud Steiner

3. Diagnostics in Different Professions

Diagnostics in Medicine, Psychiatry, and
Psychosomatics
STEFAN WIESNAGROTZKI
The term 'diagnosis' is derived from ancient Greek, and it originally referred
to 'determination', 'decision', or 'distinction'. Today, 'diagnosis' subsumes all
cognitions as well as the ascription to certain clinical pictures as described
in our nosological systems. It is the methodic exploration of a person's traits
(symptoms), in order to comprehend her or him by the common concepts of
medical science, psychiatry, and psychosomatics.
Hence, diagnosis is an act of distinction between a number of interpreta-
tion models used for occurrences which, primarily, are not immediately ac-
cessible to the intellect and, henceforth, have led to constructs which we
have come to name 'disorder' or 'disease'. Diagnosis thus serves the recogni-
tion (or 'objectification') of disorders to base treatments thereon.
Medical science most frequently uses disease-related diagnoses, although
Balint, as early as in 1957, had called for a more comprehensive diagnosis
(overall diagnosis), i.e., for the inclusion of clinical and individual diagnoses
which constellate in the doctor-patient relationship.
Whoever establishes a diagnosis should know how the body and the psy-
che normally function, to be able to detect deviations from these norms. It is
from this knowledge only that a synthesis of symptoms may be assembled
and subsequently assigned to the accordant clinical pictures.
Furthermore, diagnoses serve as a means of communication regulating the
interaction between doctor and patient. The symptoms are given names and
thus stripped of their 'scariness' and their incomprehensibility, and elevated to
a level which determines the role behavior of the doctor and the patient.
The diagnostic process sets in within the afflicted person herself. She real-
izes deviations, groups them and either allocates her symptom or does not.
Hence, subjective theories on the nature of the disease come forth, which

.....
182
Stefan Wiesnagrotzki
sometimes make it difficult for the physician to correctly discern an illness.
The patient intensifies the interaction with herself which, in turn, affects the
interaction with the doctor in either a clarifying or an impedimental way.
Today's medical practice is thus facing a big challenge to leave aside all
these 'interfering' elements, in order to arrive at a so-called 'objective' diag-
nosis. This mechanistic and cause-oriented search for grounds bred a note-
worthy progress and success in the medical science. The more 'hold-ups'
interfering with the etiological research there are, though, the bigger the di-
lemma for the medical art.
Establishing a diagnosis
Anamnesis is the recollection or the backtracking of the history of symptoms.
In medicine, psychiatry, and psychosomatics, most examinations commence
with a face-to-face conversation. There, today's medical practice focuses on
the symptom profile and proceeds along the etiological lines, that is, follows
the teachings of the causes of a disease. These etiological findings result in a
treatment plan which is supposed to eliminate the causes of the disease and,
thus, its symptoms. The history taking is ensued by a physical examination,
and findings are gathered to support the presumptive diagnosis. If this does
not yield the desired result, further routines are administered to find out the
causes of the symptoms.
The psychiatric diagnosis rests on three columns:
1. history taking
2. standardized observation
3. obtaining auxiliary results
When talking to the patient, anamnestic data are collected such as disease
and family histories, development of relationships in the family of origin and
later, sexual development and the patient's social surround.
Depending on the doctor's orientation, she will either use a mechanistic,
socio-psychiatric, or psychodynamic approach to form a psychiatric-diagnos-
tic opinion. The observation of the patient results in the determination of a
psychopathological status, or, correspondingly, of internal or dermatological,
or other statuses. The auxiliary findings, be they physical or psychometric in
nature, lead to the preclusion of physical illnesses underneath the mental, or
to the amplification of the initial diagnostic assessment.
All these data should be supplemented by the information gained from
expediently interviewing the patient's social environment (indirect anamne-
sis), and they should eventually render a picture of the patient that does not
only hold the disorder but his personality also.
Objectivity is very essential in medical and psychiatric diagnostics. How-
ever, false diagnoses do occur through uneven methodological proceedings

Diagnostics in Medicine, Psychiatry and Psychosomatics
183
which go astray and thus overlook and misinterpret symptoms. Enriching the
examination by psychotherapeutic methods, particularly by including the
diagnostic dimension of the psychotherapeutic relationship, lessens the haz-
ard of false diagnoses and approximates the fulfillment of Michael Balint's
claim.
This complementary procedure, which implies that the psychotherapist
thoroughly involves himself in the relationship with the patient, will increas-
ingly enrich the interaction between the patient and the doctor and improve
the quality of treatment.
Summary
Diagnosis is the systematic search for symptoms in order to encase them in
established concepts. Diagnosis serves the recognition of disorders and sets
the stage for the best possible treatments.
In the medical domain, the doctor is often urged into a rather active role
when help is expected of him.
If problems of interaction arise, the limits to this role become obvious.
They may be pushed further afield with the support of psychotherapy.

.......

Psychotherapeutic Diagnostics in Forensics
ELISABETH WAGNER
After a brief introduction to the work context of forensic psychiatry, this pa-
per outlines the specific demands on psychotherapeutic diagnostics when
applied within forensic psychiatry. The three dimensions of the Diagnostic
Guideline will be specified as to their applicability to mentally disordered
offenders. Further on, I will focus on the features that distinguish psycho-
therapeutic from psychiatric diagnostics.
Forensic Psychiatry - Enforcement of Measures
Those persons are committed to a forensic psychiatric facility who, lIunder
the influence of a major mental or psychic deformity", have committed a
crime punishable by one or more years of incarceration, if they pose the risk
of IIcommitting another penal offense with serious consequences as a result
of th is deform ity".
When the decision on the admittance to or a potential discharge from a
forensic psychiatric facility has to be made, usually expert evidence is ob-
tained from the judges in charge. On admission, the expert not only has to
ascertain the examinee's capacity to appreciate the wrong of his offense
and/or to act accordingly, but needs to predict the degree of dangerousness
also. Only in those cases where the examinee lIunder the influence of this
deformity" could IIcommit another indictable offense with serious conse-
quences" he or she will be transferred to a forensic psychiatric facility. The
degree to which the mental or psychic deformity contributed towards the
offense under prosecution is held of paramount importance.
During the discharge proceedings, it is the assessor's duty to judge the
IIreduction of the specific dangerousness" from the perspective of his par-
ticular domain. In many cases, it is actually the (psychotherapeutic) treat-
ment progress that is under scrutiny.

186
Elisabeth Wagner
Even though this suggests that the psychotherapeutic appraisers for the
prediction of the danger in the discharge procedure should be included
here, this paper will not primarily focus on how to draft expert opinions,
since this subject and all its implications have been dealt with elsewhere
(cp. Wagner 2002). The contribution on hand will instead focus on psycho-
therapeutic diagnostics within the framework of treatment and law enforce-
ment planning.
1. Utilization of the Diagnostic Guideline for Treatment
Planning
Psychotherapy within the forensic psychiatric setting is not a private agree-
ment between a certain therapist and his client. The decisive criterion I am
referring to in this assertion is not the fact that psychotherapy is embedded
in the institution but that it has a 'statutory treatment assignment' and is sub-
ject to the public 'control of achievement'. Occasionally, psychotherapy is
also administered as part of the regular prison sentences (standard law en-
forcement). For an inmate to benefit from the psychotherapeutic offer, he has
to be very determined and request it on his own initiative. This kind of treat-
ment is principally voluntary and does not have any effect on the proceed-
ings of sentence enforcement and even less so on the release date. This issue
is dealt with differently in forensic psychiatric facilities where the detention is
supposed to "improve the inmates' condition to the degree that they are no
longer expected to commit punishable acts" ( 164 StVG - criminal code)
and who, to that end, are treated "according to the principles and approved
methods of psychiatry, psychology and education science, or taken care of
by medical, particularly psychotherapeutic, psychoprophylactic and educa-
tional means" ( 166 StVG). Regardless of the request and goals of the in-
mate, the treatment serves the purpose of "reducing dangerousness". The
fact that treatment has been instituted by the public authorities to observe
the third party interests (or those of society in general) that are worthy of
protection has to be observed inexorably in any treatment planning, in addi-
tion to the subjective suffering conditions of the individual concerned.
The three dimensions of the Guidelines for Psychotherapeutic Diagnostics
should, therefore, be specified as follows:
Symptomatology in Relation to Personality Aspects
A delinquent must be consigned to a forensic psychiatric facility when "he,
under the influence of a major mental or psychic deformity" has committed
a crime. The correlation between "a major mental or psychic deformity" and

Psychotherapeutic Diagnostics in Forensics
187
the offense is, in some cases, logically consistent and easily understandable
to the non-expert: if a patient with a paranoid psychosis attacks his putative
pursuer, the offense may actually be understood as a 'symptom' of his psy-
chiatric condition. With most patients in a forensic psychiatric institution,
however, and particularly those whose primary diagnosis was 'personality
disorder', the coherence is more complex and can only be described on the
basis of differentiated personality diagnostics. It is not only the subjective
suffering, the deficits in experience and behavior, and the potential deforma-
tions of the relational patterns that have to be broached and weighed criti-
cally in psychotherapeutic treatment, but also what these phenomena imply
as to former or future violent behavior.
Besides concentrating on the offense, psychotherapeutic work with foren-
sic patients must also regard the 'dependency on the subjectivity of experi-
encing and suffering', a feature typical for psychotherapeutic diagnostics. It
holds particularly true for the forensic patients that in psychotherapeutic
treatment many of them, for the first time in their lives, experience some-
body who cares about their subjective perspectives, seriously and lastingly;
very often, it is the delinquent's first opportunity to experience himself or
herself as the subject of attention and discussion. When working with delin-
quents, this appreciative interest, which is a vital component of any psycho-
therapeutic treatment, must be continuously counterbalanced by an external
perspective, to ensure that therapeutic work promotes accountability rather
than the tendencies towards denial.
The Psychotherapeutic Relationship
There are two factors within forensic psychiatry which inhibit the build-up of
a confidential therapeutic relationship: the first one is the totally institutional-
ized setting which naturally calls forth distrust and defensiveness, and the
other is the mostly rather pronounced pathology of the person under treat-
ment. In an examination, Coid (1992), when examining violent inmates, as-
certained an average of 3.6 personality disorders (along the lines of DSM III)
per person. On one hand, this questions the usefulness of the well-estab-
lished diagnostic systems in the realm of personality disorders (an issue I am
going to address more specifically later) and, on the other, it reveals the devi-
ant and pathological personality structures one is faced with in this particular
setting.
For the planning of treatment as well as for prognostic considerations,
apart from diagnosing personality disorders according to ICD or DSM where
the comorbidity principle prevails, the assessment of the degree of severity
of each case is indispensable. When doing so, the deliberations of the struc-
tural and of the maturity level of the defense mechanisms have proven to be

.....
188
Elisabeth Wagner
very useful because they allow for conclusions on the relational abilities and,
thus, on the treatability by psychotherapeutic means, at least to a certain
extent (cp. Kernberg 1992).
As opposed to psychiatric diagnostics which hardly provides any concep-
tual inventory to describe relational styles and interaction patterns and thus
offers little 'depth of focus' in this area, the assessment of the dimension
'relationship' is one of the core competences of an experienced psycho-
therapist. Thanks to their theoretical concepts and their training in differenti-
ated awareness of relationship experiences, psychotherapeutically trained
diagnosticians are usually capable of understanding dominant relationship
patterns and pathological relational cues. For the treatment itself it is, further-
more, crucial to address the latter in an acceptable form to make the client
aware of them.
The most frequently met difficulties in treatment within coercive forensic
settings are by no means caused because those concerned would refuse
psychotherapy, but because they usually undermine it by exploiting it for
other purposes than it is meant for: they use the therapist as a 'wailing wall',
for instance, or as an accomplice against the penal system which is per-
ceived as inhumane, or they idealize the therapist as 'all-good' and as the
one who brims over with understanding and empathy. In such cases, the
therapist needs to be highly vigilant to notice such tendencies. The therapeu-
tic relationship must include a sound measure of confrontation with the
problematic personality aspects, and the demand to deal with one's own
violent potential should be pursued actively.
Susceptibility to Crises
In the work with mentally disordered delinquents, the reliable assessment of
the imminence of crises is vital, a circumstance which presumably does not
need further substantiation. Since it is chiefly violent offenders who are de-
tained in forensic psychiatric facilities, one has to be prepared for violent
assaults upon the therapist also during treatment. Particularly when the crisis
puts a strain on the therapeutic relationship, such as when the delinquent
either invests in denigration or paranoid acting-out, the suspension of thera-
py for the sake of crisis management with another therapist should be envis-
aged. The murder of a female therapist in the psychiatric prison at G611ersdorf
was the tragic outcome of the false assumption that a benefit would accrue
from the inclusion of a therapist in a truly critical situation (cp. Wagner 1998
for more details).
In the work with violent offenders, the diagnostic assessment of the criti-
cal potential has to be supplemented by a careful evaluation of the potential
danger. While in an outpatient or an inpatient setting, psychotherapeutic

Psychotherapeutic Diagnostics in Forensics
189
treatment is almost automatically intensified when crises are imminent, in
the forensic arena a modified procedure has become the preferred choice.
Since the therapist's judgment capacity may be misguided in critical situa-
tions, particularly by countertransference phenomena or by being over-
whelmed by her own inclination to adopt responsibility, it should become a
routine to consult 'external' experts in the case of crises. In the forensic after-
care clinic and in the psychiatric prison Mittersteig, usually the psychiatric
director used to decide, after conferring with the treating therapist and after
thorough exploration of the person concerned, whether to continue or sus-
pend the therapy when the therapeutic course turned critical. Such an inter-
vention firstly protects the therapist involved, and, secondly, it is of therapeu-
tic worth: if not at an earlier stage, the inmate will awaken to the fact that
people perceive him as a potential violator, which, in the medium term, will
promote his willingness to engage in this subject.
2. Differentiation: Psychiatric or Psychotherapeutic Expertise?
The psychotherapist working with mentally disordered offenders should plan
and reflect on the treatment in his method-specific ways and include every
available quality assurance measure, such as supervision, and intake- and
process-related diagnostics; these are precautionary measures that are par-
ticularly crucial in the treatment of individuals who have committed serious
acts of violence. Apart from the necessity to include the patient's dangerous-
ness in the design of the treatment plan, treatment-related diagnostics follows
the same rules as in any other field. In addition to the diagnoses made in the
course of psychotherapeutic treatment, psychotherapeutic diagnostics could
be employed in the decision making process in law enforcement and in
treatment planning. Besides evaluating the treatment progress to decide on
the potential easing of sanctions, it will serve to establish differentiated indi-
cations of various treatment options.
In 1995, an assessment department was set up and commissioned to ex-
amine the need of treatment and the treatability of all Austrian sexual delin-
quents in the psychiatric prison 'Mittersteig' who had been admitted to this
forensic psychiatric facility under the terms of  21/2 (criminal code). In con-
cert with psychoanalytically trained psychologists, I examined approximately
200 sexual delinquents. Apart from the psychiatric diagnostic classification
system (ICD 10), various psychological test results and structural diagnoses
according to Kernberg were surveyed.
Since all examinees had formerly been detained in a psychiatric prison,
previous forensic psychiatric reports were available of all of them which,
apart from detailed anamneses, usually encompassed neurological examina-
tion findings and, in some cases, additional technically supported examina-

190
Elisabeth Wagner
tion results (e.g., EEGs) and, above all, a - more or less differentiated - psy-
chopathological, i.e., symptomatological report. The descriptive part of the
psychiatric examination report generally consists of a non-systematized de-
scription of the testee's overall demeanor during the examination (appear-
ance, contact with examiner, compliance during examination), and of the
systematized assessment of single psychic functions and areas: conscious-
ness, orientation, psychomotor activity, mood, affective responsiveness,
thinking, perception, attention, concentration, memory, intelligence, and
ego-awareness. A few more psychopathologically relevant characteristics,
such as aggressiveness, suicidal tendencies, awareness of illness, empathy,
capability of entertaining guilt feelings, and control of one's actions are in-
cluded in the descriptive psychological report.
Yet, such surveys do not provide any basis for treatment planning. Why is
a ICD or DSM diagnosis of such little significance in treatment planning
within the forensic setting? IDC-l0 and DSMIII-R are descriptive diagnostic
taxonomies, i.e., their classifications are based upon the description of ob-
servable phenomena, the target of which is the 'atheoretical' operationaliza-
tion of diagnostic criteria, thus renouncing hypotheses on etiology and
pathogenesis. No distinction is made, for instance, between endogenous and
neurotic depressions.
The benefits of this are the following: the diagnostic procedure can be
learned easily and executed quickly. Self-ratings and screening-question-
naires may be submitted, by which a high interrater reliability is guaran-
teed.
This high reliability makes IDC-l0/DSM-III-R indispensable tools of any
research. Currently, it is hardly possible to publish a survey without defining
the examined population along ICD/DSM diagnoses. This precludes the risk
of local diagnostic habits blurring the distinction as to which individuals the
research findings relate to.
After elaborating on the usefulness of these diagnoses in research, we
need to enlighten its usability in clinical practice. Diagnoses are useful when
they describe a relatively homogenous group, to which common statements,
e.g., on the responsiveness to therapy or on the prognosis, are applicable. If
ICD-10 helps to distinguish a panic disorder from a generalized anxiety dis-
order and, as we have learned from controlled studies, if these two forms of
anxiety disorders have to be treated by different types of medication, the dif-
ferential diagnosis has proved its clinical expedience. To what extent does it,
however, discriminate the single personality disorders from one another?
DSM-III-R as well as ICD-l0 juxtapose individual personality disorders. If
a patient meets the criteria of more than one personality disorder, several
disorders - comorbidities - will be diagnosed which, incidentally, is not the
exception but the rule. Principally, the prevalence of comorbidites is hardly
ever questioned.

Psychotherapeutic Diagnostics in Forensics
191
In a survey conducted by Coid (1992) titled 'DSM-III diagnosis in criminal
psychopaths', 95 0 10 of the individuals diagnosed with a certain personality
disorder exhibited more than one. As mentioned above, the average was 3.6
personality disorders per person.
This regularly encountered accumulation of personality disorders casts
doubts on the current ICD-l0/ DSMIII-R categories and their ability to iden-
tify distinct personality types which, taken by themselves, occur at significant
frequencies. If however, the single diseases or disorders hardly ever manifest
by themselves but in characteristic combinations only, the concept of comor-
bidity in the realm of personality disorders seems questionable altogether.
Since accurate comprehension of the personality or of the structural deficits
of the personality is central to diagnosing mentally disordered offenders, I do
not find the descriptive ICD 10/DSM IV diagnoses very helpful for this field.
Equally, Berner and Katschnig as early as in 1975 arrived at the conclu-
sion that "apart from the few secured cases of mental illnesses, for which
psychiatry - partially - provides secured understanding", its "competency
was more than questionable". Similarly, Reiter and Gabriel (1973) concluded,
"the nomenclature of traditional psychopathology and the diagnostic taxons
as a system for organizing the diversity of mental disorders are frequently
unable to comprehend and describe the complex phenomena of interaction.
Frequently this model fails for those clinical profiles which mostly represent
conflictual engagement in the environment".
By the description of observable phenomena and the atheoretical opera-
tionalization of diagnostic criteria, the descriptive psychiatric diagnostics
ensures a high reliability of diagnoses, but it is not useful for understanding
the individual action and the pertinent motivational background. Rather so-
phisticated psychological or psychotherapeutic models are required to com-
prehensibly represent the interplay of motivation, emotion and cognition, of
conscious and unconscious processes in individuals, and to draw conclu-
sions on the treatability and predictability therefrom.
The descriptive diagnostics of mental disorders is the sovereignty of psy-
chiatry. The detailed observation of psychic functioning, primarily in those
humans who do not suffer from severe affective, organic or psychotic disor-
ders, may be considered the domain of psychotherapy.
Sophisticated statements on an individual with a narcissistic personality
disorder or a paraphilia can be expected from those psychotherapists who
are experienced in the forensic field; firstly because they have familiarized
themselves with the psychic functioning of these individuals in countless ses-
sions and, secondly, because, with certain psychopathological manifesta-
tions, only psychotherapeutic theories offer a frame of reference to ease the
understanding of coherences.
Wherever statements on the complex psychic functioning, e.g., on the
degree of maturity of the defense mechanisms or the structural level of per-

192
Elisabeth Wagner
sonality need to be made, psychotherapeutic practitioners have an advan-
tage over the (non-psychotherapeutic) psychiatrists or psychologists, in that
they may draw on a richer experiential background, a more differentiated
terminology, and more adequate theories.
In this debate, the heterogeneity of the psychotherapeutic theories does
of course raise certain problems. As long as neither psychology nor psycho-
therapy possesses a 'grand unifying theory', we have to accept that psycho-
therapeutic model formations helpfully underpin diagnosing by allowing
comprehensible inferences on treatability and predictability. This is the more
so, as it is psychotherapy only which is particularly versed in observing psy-
chological systems and their responses to interventions.
The factor that limits the value of the psychotherapeutic diagnostics is,
therefore, less the heterogeneity of psychotherapeutic theories - as we very
much hope that the recently established Guideline will lead to the establish-
ment of minimum standards. To my mind, the bigger problem is the refusal of
many psychotherapists to adopt the role of the objectifying impersonal diag-
nostician, primarily in those cases where decisions are to be deduced which
run counter to the immediate interests of the client. If, for instance, a unit of
a psychiatric prison is run as a therapeutic community and directed by a fe-
male psychotherapist who, in her department, offers group therapy, the diag-
nostic judgments gained from the group therapeutic process will immediately
affect the pending decisions on the enforcement of sanctions. In the eyes of
many therapists, this would entail role confusion, and they therefore refuse to
take on any official function within the institution. This self-restricting stance
of psychotherapists and their insisting on the 'service model' of psychothera-
py may help to avoid individual role conflicts, but it is inadequate where
psychotherapeutic-diagnostic competence is to be made available to the insti-
tution and the inmates committed to it (cp. Werdenich, Wagner 1998).
If, hence, psychotherapeutic diagnostics is to be utilized in the forensic
field, an assertive and thorough revision of the psychotherapeutic identity is
required which pays tribute to the professionalism and the accountability
needed in the therapeutic community; it should be above the individual
therapeutic schools and reach beyond the minimum standards as enforced
by the existing Guideline.
References
Coid JW (1992) DSM-III diagnosis in criminal psychopaths: a way forward. Criminal Be-
haviour and Mental Health 2: 78-94
Kernberg OF (1992) Schwere Per6nlichkeitsst6rungen. Klett-Cotta, Stuttgart
Berner W, Katschnig H (1975) Medizinische Aspekte abweichenden Verhaltens. In:
Abele, A, Mitzlaff S, Nowack W (eds) Abweichendes Verhalten. Erklarungen, Schein-
erklarungen und praktische Probleme. Frommann-Holzboog, Stuttgart, pp 127ff

Psychotherapeutic Diagnostics in Forensics
193
Reiter L, Gabriel E (1973) Diagnose "Psychopathie" und diagnostischer Proze. In: Strotz-
ka H (ed) Neurosen, Charakter, soziale Umwelt. Kindler, Munich, pp 119 ff
Wagner E (1998) Scheitern, Krisen, Katastrophen. In: Wagner E, Werdenich W (eds) Fo-
rensische Psychotherapie. Facultas, Vienna
Wagner E (2002) Gutachten im Bereich des Strafvollzuges. In: Lanske P, Pritz A (eds) Das
psychotherapeutische Gutachten. Lexis Nexis ARD Orac, Vienna
Werdenich W, Wagner E (1998) Die Kunst der Zwangsbehandlung. In: Wagner E, Wer-
denich W (eds) Forensische Psychotherapie. Facultas, Vienna
Translated from the German by Luna Gertrud Steiner

......

Clinical-Psychological and Psychotherapeutic
Diagnostics
ANTON-RUPERT LAIREITER
Introduction
In view of the legal situation concerning the Austrian Health Care System,
various health professions came into being for the purpose of supplying the
population with various services, of enhancing health and treating irregu-
larities and disorders as well as alleviating mental and social sufferings
(Kierein, Pritz & Sonneck 1991). The most important ones are clinical and
health psychology on one hand, and psychotherapy on the other. It was
mostly the Psychologists Act (Psychologen-Gesetz, PG) that ascribed those
duties and responsibilities to clinical psychology which are partly similar to
and overlap with those of psychotherapy (psychological treatments and in-
terventions). Conversely, it is the methodologically correct psychotherapy
which is obliged to carry out comprehensive diagnostic inquiries and to
state indications, areas which by tradition had been the key tasks of clinical
psychology, accredited to it by law (cp.  3, para 2 of the Psychologists Act
(PG), BGBI. Nr. 360/1990; quoted from Kierein et al. 1991, 17). This led to
a number of intersections between these two health professions and to the
necessity to conceptualize and define the functions of both, and to distin-
guish their fields of activity from one other. The present paper is dedicated
to this very purpose. Since, herein, we primarily refer to the Austrian Health
Care System, the following disquisition will for the most part deal with facts
that are specific and relevant to the Austrian situation. Preliminarily, I will
elaborate on the legal framework and on the legal regulations of both pro-
fessions; subsequently, I will also go into the substance of the matter, high-
lighting the similarities and dissimilarities between clinical-psychological
and psychotherapeutic diagnostics within this specific Austrian legal frame-

.....
196
Anton-Rupert Laireiter
work. Our objective is, by no means, to kindle any rivalry or adverse com-
petition between these professions, but to contribute to an accurate theo-
retical and practical definition, to give an idea of the different competences
and activity structures and of the different entrance regulations and training
requirements for both professions, and to thus enhance the collaboration
between clinical psychologists and psychotherapists within the Austrian
Health Care System.
Legal Framework: Clinical-Psychological versus
Psychotherapeutic Diagnostics
Psychologists and Psychotherapy Acts (PG and PthG)
Pursuant to the above mentioned Psychologists AcC the practice of this pro-
fession encompasses three key activities ( 3, para 2):
- Clinical-psychological diagnostics of performance, personality traits, be-
havioral disorders, psychological changes, and distress; counseling, prog-
noses, certificates, and expert opinions based thereon
The application of psychological treatment strategies for the purpose of
prevention, treatment, and rehabilitation of individuals and groups, or the
counseling of legal persons as well as research and teaching activities in
the fields mentioned, and
Devising measures and projects for the purpose of enhancing health
(Kierein et al. 1991, 42).
Characteristically, the Act prioritizes clinical-psychological diagnostics in the
task list of clinical and health psychologists, a circumstance which, most
importantly, underlines the significance which this activity occupies within
the psychology profession.
In the Psychotherapy Act, a comparable catalogue of diagnostic functions
and tasks as an integral part of the psychotherapy profession is, however,
missing (cp.  1 PthG), which is most notable in the face of the significance
of diagnostics in the psychotherapeutic treatment process (see Diagnostic
Guideline in this volume; Janssen & Schneider 1994, Laireiter 2000a). There,
psychotherapy is merely defined as JJthe comprehensive, conscious, and
planned treatment of psychosocial or else psychosomatically caused behav-
ioral disorders and sufferings" (Kierein et al. 1991, 87). Hence, we have to
conclude that diagnostics, according to the legislator's will, is not an activity
performed independently by psychotherapy professionals and that it is not
held tantamount to psychotherapeutic treatment. The Psychotherapy Act, if
at all, mentions diagnostics as an implicit component of psychotherapeutic
treatment, by paraphrasing the psychotherapeutic profession as 'planned'

Clinical-Psychological and Psychotherapeutic Diagnostics
197
treatments. The notion of planning does imply the comprehension and the
analysis of the client's current state, including a systematic anticipation of
changes and the chances these hold. It is for this reason that we have to
conjecture that the idea of 'planning' is, at least implicitly, related to diagnos-
tic operations (see below).
Qualifications Required for Practicing Clinical-Psychological and
Psychotherapeutic Diagnostics
The distinctions made between the activity structures of the different diag-
nostics as referred to in the mentioned vocational laws correspond to com-
pletely different training requirements. For psychologists, diagnostics is a
major teaching subject in their academic curriculum and in their post gradu-
ate program in which they qualify as clinical and health psychologists; this
fact does not apply to psychotherapists, at least not to the same extent.
Psychologists have to attend courses of instruction and take examinations
which cover fields of psychology and of psychological studies as listed in
Table 1, which prepare them for their future functions as clinical and health
psychologists. The Psychologists Act, moreover, obliges them to study diag-
nostically relevant contents of teaching which are also listed in Table 1.
Psychotherapists, who are not professional psychologists or educators as
well (the latter also have to attend a certain number of courses in psycho-
logical diagnostics), cover very little diagnostically relevant contents during
their vocational training. There is a total of 60 periods only (Le., 4 hours per
week over one semester) under the heading 'Introduction to Psychological
Diagnostics and Report Writing', and some matter taken from psychiatry and
psychopathology related to the subject. The other contents listed in Table 2
constitute basic knowledge and background qualifications only.
As Table 2 further demonstrates, the training of a specific therapeutic
method, at least by its legal foundation, does not make any provisions for
psychotherapists to acquire diagnostic competences and functions. The pre-
definition which and how much diagnostic contents are to be taught is
solely in the hands of the method training institutes. To state an example,
each of the two certified behavioral therapy training institutes, namely the
AVM and OGVT1, teaches 60 periods of therapy-relevant and clinical diag-
nostics: 30 periods each of behavior and problem analysis (including process
diagnostics and evaluation), and 30 periods of clinical and disorder-related
diagnostics (general and specific diagnostics, e.g., diagnosing anxiety, de-
1 AVM: Arbeitsgemeinschaft fUr Verhaltensmodifikation - Working Group for Behavio-
ral Modification; OeVT: Osterreichische Gesellschaft fUr Verhaltenstherapie - Aus-
trian Society for Behavior Therapy (translator's note)

198
Anton-Rupert Laireiter
Table 1. Diagnostically relevant training components for clinical and health
psychologists
1. University Syllabus for Psychologists (Master's Degree)*
Basic Knowledge and Background Qualifications
Courses in:
- Psychological methodology
- Statistics
- Personality and differential psychology
- Developmental psychology including psychology of aging
- Biological psychology
- Social psychology
- Clinical psychology, psychopathology, and psychiatry
Key Qualifications
Courses in:
- Psychological diagnostics
- Introduction and fundamentals
- Practical training of performance, intelligence, personality, interests, and aptitude
diagnostics
- Appraisal and report writing
- Test theory and test design
- Clinical psychology
- Clinical-psychological diagnostics: fundamentals and fields of application, ICD-l0;
DSM-IV
- Clinical interviews and scales
- Disorder-related diagnostics
- Educational psychology: development and school readiness screening
- Biological psychology: neuropsychological diagnostics
- Forensic psychology: forensic diagnostics and expertise
2. Clinical and Health Psychologist Trainings ( 5. para 2, Z.2 and 8, PG)
Basic Knowledge and Background Qualifications
Contents from the training modules concerning:
- Rehabilitation
- Psychiatry, psychopathology, psychosomatics & psychopharmacology
Key Qualifications
Contents from the training modules concerning:
- Clinical-psychological diagnostics
- Psychological report writing
- Psychological practice
- Psychological student supervision
*
According to the master's course of studies of the University of Salzburg Austria
2003

Clinical-Psychological and Psychotherapeutic Diagnostics
199
Table 2. Diagnostically relevant components of psychotherapeutic trainings
1. The Propaedeutic Course to Psychotherapy ( 3, para 1, PthG)
Basic Knowledge and Background Qualifications
Courses in:
- Introduction to the history of the problems of psychotherapy
- Personality theories
- General psychology
- Developmental psychology
- Rehabilitation, special education, and orthopedagogy
- Fundamentals of research and science methodology
Key Qualifications
Courses in:
- Psychological diagnostics
- Introduction and fundamentals (including report writing)
- Psychiatry, psychopathology, and psychosomatics (of all ages)
- Introduction and fundamentals
2. Specific Psychotherapeutic Method Training ( 6, para 1 and 2, PthG)
Basic Knowledge and Background Qualifications
Contents from training modules concerning:
- Theories of healthy and psychopathological personality development
- Personality and interaction theories
- Psychotherapeutic literature
- Psychotherapeutic internship and supervision thereof
Key Qualifications:
Contents from training modules concerning:
- Methods and techniques of psychotherapy
- Independent psychotherapeutic practice
- Psychotherapeutic student supervision
pression, pain, personality disorders, etc.).2 The trainee also acquires the di-
agnostic competence during his active psychotherapeutic practice, particu-
larly in the student supervision concomitant to it. It is not possible, however,
to quantify this part of vocational training.
As the cognitive-behavioral psychotherapeutic approaches are compara-
tively strongly oriented towards diagnostics, we have to assume that the
number of training modules covering diagnostics is lower in the other psy-
2 While the English version of this volume was under way, the AVM had slightly modi-
fied this model; it now comprises 25 periods of behavior and problem analysis; 10
periods of process diagnostics, documentation and evaluation; 10 periods of general
clinical diagnostics and 35 periods of disorder-related diagnostics (author's note).

200
Anton-Rupert Laireiter
chotherapeutic schools. Szigethy (2004) has provided evidence to support
that conjecture. He, moreover, found that nearly all exponents of psycho-
therapeutic schools were deploring this predicament and were well aware of
it. In the above mentioned study, they also formulated their request that
more (clinical as well as method-specific) diagnostics should be taught in the
respective training institutions.
First Interim Resume
Summarizing the points made so far, we note that clinical psychology and
psychotherapy are clearly distinct as to their diagnostic functions and com-
petences; this holds true for their task structures as regulated by law and
particularly for their ways of skill acquisition. Diagnostics is an important
constituent in the remit of clinical-psychology, and the clinical psychologists
are usually prepared for it very well and thoroughly. From the legal point of
view, diagnostics is neither an independent nor a major domain of psycho-
therapists within the Austrian Health Care System. Expectedly, their voca-
tional training provides only very little schooling in this field. The quantity of
obligatory tuition in diagnostic concepts and techniques within their specific
method trainings is so scarce that one has to suspect that traditionally trained
psychotherapists are inadequately equipped - even where the specific psy-
chotherapeutic diagnostic competence is asked for (Laireiter 2000a). For this
reason, the Diagnostic Guideline, elaborated by the Advisory Board for Psy-
chotherapy, must be appreciated as a greatly needed and welcomed cor-
rective which clearly regulates and structures the diagnostic issue and its
teaching within the propaedeutic course for psychotherapy as well as in the
actual psychotherapeutic method training.
Some Aspects Regarding Content: Clinical-Psychological
versus Psychotherapeutic Diagnostics
Comparison of Concepts
In order to further analyze the contents we need to define both concepts to
render more palpable what we are expatiating in the following.
According to Jager and Petermann (1992, 11), psychological diagnostics is
a scientific discipline, Le., a system of rules, instructions, and algorithms to
provide methods by which psychologically relevant characteristics of certain
carriers are gained and processed, and by which the data material is inte-
grated in a judgment to prepare decisions as well as predictions and the
evaluation thereof. Individuals, groups, institutions, situations, and objects

Clinical-Psychological and Psychotherapeutic Diagnostics
201
are the potential carriers of those features. Amelang and Zielinski (2002, 3)
further specify that psychological diagnostics represents not only a science-
based system of rules but also a goal-oriented practical activity, the function
of which is to comprehend the inter-individual differences of experience and
deportment, intra-individual features and changes as well as the precondi-
tions which spurred them, and to predict future experience and behavior and
their changes in defined situations in a satisfactory and accurate way.
Theses definitions are very broad and neutral as to their application,
which implies that psychological diagnostics is suited to handle very diverse
diagnostic issues in very disparate fields of work. The traditional fields of ap-
plication of psychological diagnostics are education including school psy-
chology, clinical psychology, work, industrial and organizational, traffic and
forensic psychologies. In recent years, diagnostic questions and procedures
have increasingly been developed to fit market, advertising, health, ecologi-
cal and biological psychologies including neuropsychology (Amelang and
Zielinski 2000, Fisseni 2004). We would exceed the compass of this paper if
we discussed the various problems of all those fields of application at greater
length (see related text books for details). To give just one example, work
psychology mainly engages in aptitude diagnostics and in supporting career
choices as well as in the selection of suitable individuals who apply for cer-
tain vocational positions, whilst the diagnostics of educational and school
psychology particularly screens children for their school aptitude, it identifies
learning and performance disorders and also mental and social irregularities
including their environmental preconditions and causes.
Clinical-psychological diagnostics, which we are primarily dealing with in
this context, has, as we will demonstrate in the following paragraphs, a
number of different functions. For a better understanding of the following,
we need to point out that the concept of 'clinical-psychological diagnostics'
is defined in varyingly broad senses in the relevant literature. More narrow
conceptions define it as a diagnostic activity related solely to psychogenic
disorders (Amelang & Zielinski 2002), or to (clinical-psychological) interven-
tions (like the concept of psychotherapeutic diagnostics as it is used in this
paper) (Bastine 1992), or both (Baumann & Stieglitz 2001, Fydrich 2002).
Broader definitions understand clinical-psychological diagnostics as the
transfer and the application of all psychological and diagnostic questions,
examination strategies, methods and tasks to the realms of mental disorders
and somatic illnesses (including intervention and disorder-related diagnos-
tics) where physical factors playa significant role (this amounts to the appli-
cation of psychological diagnostics to the context of mental disorders, so-
matic diseases and their treatments). The broadest definition of the concept
is laid down in the Austrian Psychologists Act which comprehends the clini-
cal-psychological diagnostics within the health care system simply as "the
diagnostics of performance, personal traits, behavioral disorders, psychologi-

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Anton-Rupert Laireiter
cal changes, mental distress as well as the counselings, predictions, certifi-
cates and expert opinions based thereon" (Kierein et al. 1991, 17). Since the
present paper undertakes the differentiation of clinical-psychological and
psychotherapeutic diagnostics within the Austrian Health Care System, we
base our thoughts on an understanding of the concept as it is regulated by
law, which also includes narrower definitions.
The concept of 'psychotherapeutic diagnostics' has been discussed and
defined thoroughly in this volume at various occasions. A few more words
should hence suffice. As opposed to the clinical-psychological diagnostics,
the concept of 'psychotherapeutic diagnostics' will be used in a double
sense: as diagnostics associated with psychotherapeutic interventions, as
defined in the Diagnostic Guideline by the Advisory Board (cp. Diagnostic
Guideline in this volume; see also Laireiter 2000b), and as orientation or
school-specific diagnostic concepts and methods, as opposed to the empiri-
cal-psychological or clinical psychiatric ones.
Psychotherapeutic diagnostics, or diagnostics in psychotherapy, fulfills
very specific functions within the psychotherapeutic process (see below),
and it avails itself of a variety of diagnostic models and means (Laireiter
2000b; see below).
Purposes and Functions
As shown in Table 3, both ways of diagnosing (the clinical-psychological
and the psychotherapeutic one) share a number of purposes and functions,
namely those of description, classification, indication, explanation, predic-
tion, and evaluation. When carried out in the context of psychotherapeutic
diagnostics, these functions are far more oriented towards therapy, whereas
clinical-psychological diagnostics, apart from its application in interventions
and treatments, is applied in a number of other fields beyond those (see
below).
Because of its functional interrelation with interventions and treatments,
psychotherapeutic diagnostics serves a number of further purposes, which
are naturally inherent in clinical-psychological diagnostics also, if applied
within psychological treatments, namely the assistance with case concep-
tion, i.e., the support with the design of a theory-based therapy concept for
a certain set of problems in a particular person (attributing them to an expla-
nation model and suggesting a certain treatment strategy which, in the Diag-
nostic Guideline, is described under the item "indication of a specific psy-
chotherapeutic treatment option"), the monitoring of therapy, the control of
its progress in the sense of registering change and adjusting indications, the
documentation of status, process and modifications to perform the docu-
mentation which psychotherapists are beholden to (cp. Kierein et al. 1991),

Clinical-Psychological and Psychotherapeutic Diagnostics
203
Table 3. Purposes and functions of clinical-psychological and of psycho-
therapeutic diagnostics
Clinical-Psychological Diagnostics Psychotherapeutic Diagnostics
(Perrez 1985) (Laireiter 2000b)
- Description (of psychological - Identification and Description of
phenomena) psychological irregularities, symptoms,
- Classification of mental disorders disorders, etc.
- Indication of treatment strategies - Classification and Categorization of
- Explanation of causes and therapy relevant phenomena
preconditions - Explanation of etiology
- Prediction of therapeutic process and - Case conception
of treatability - Indication of strategies and methods
- Evaluation of interventions - Prognosis of therapeutic courses and
treatability
- Monitoring therapy and controlling its
process
- Documentation
- Evaluation
- Therapy
and therapy or therapeutic effects triggered by diagnostic cognitions (e.g.,
the explanation of a clinical picture unknown thitherto and the recognition
of a certain relationship pattern).
We, therefore, may conclude that clinical-psychological and therapy-re-
lated diagnostics widely overlap as to their formal purposes and functions,
but we do find differences also. This overlapping is presumably the reason
why, for a long time, the possibility had been considered to replace one form
of diagnostics by the other, which would not make sense though, as their
overall functions differ too significantly, as to their theoretical as well as to
their methodological foundations and procedures (see below). In order to
fulfill its tasks in the best possible way, psychotherapeutic diagnostics must
above all be integrated in the theoretical and praxeological frame of refer-
ence of the respective psychotherapeutic school. Consequently, the specific
contents and aspects of mental irregularities and psychic distress have to be
comprehended as a first task and, as a second, changes and effects have to
be viewed and evaluated with the appropriate theoretical background and
related to its theoretical models (Laireiter 2000b). In this context, clinical-
psychological diagnostics can make important contributions to description,
classification, indication, and evaluation (Laireiter 2000b, Stieglitz & Bau-
mann 2001); it cannot replace psychotherapeutic diagnostics, however, as
little as psychiatric or other forms of medically-oriented diagnostics can (see
below).

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Anton-Rupert Laireiter
Fields of Appl ication and Activity
As shown in the explanation of both areas (see above) and as Table 4 dis-
plays, clinical-psychological diagnostics has a large number of function and
application areas (not only within the Austrian Health Care System). They are
by far more extensive than those of psychotherapeutic diagnostics, which, as
a rule, is limited to the evolution and to the indication of a particular psycho-
therapy, to diagnosing the progression, to monitoring its course, and to
evaluating the therapeutic process and its results. Psychotherapeutic-diag-
nostic statements are usually less frequently applied to issues outside therapy
than clinical-psychological ones are. As demonstrated in section 1, the voca-
tional psychotherapy training does not provide for this in any way.
Table 4 also demonstrates that psychotherapeutic diagnostics, Le., the
diagnostic concepts and cognitions gained from psychotherapy, do provide
answers to diagnostic questions when implemented within the various func-
tions and applications of clinical-psychological diagnostics. We will delve
into this more deeply further below.
Theoretical and Methodological Foundation
Besides the different range of problems and fields of application, there is
another striking differential feature, that is the theoretical and methodologi-
cal foundation and criteria (listed in Table 5), which clearly differ between
clinical-psychological and psychotherapeutic diagnostics.
Clinical-psychological diagnostics is apparently a key factor of diagnostic
psychology and clinical psychology (Fydrich 2002) and is thus deeply rooted
in academic psychology and its scientific approach. As an applied science,
it primarily orients itself toward the psychological methodology, toward the
developments and techniques of psychological diagnostics and toward the
models and tools of related disciplines (e.g., psychiatry, neurology). Its meth-
ods and procedures are predominantly technological in orientation with
psychological measuring instruments and tests being used, but the proceed-
ing is strongly directed towards the client, his needs, desires and requests,
and this is standard in each diagnostic investigation (e.g., building a relation-
ship, professional ethics, informed consent, empathic dialogue) (Amelang &
Zielinski 2002, Fisseni 2004). Expectedly, psychological statements are based
on statistics and norms or criteria (e.g., judging the intelligence level of an
obviously deranged alcoholic when the issue of his vocational rehabilitation
is under discussion). The personal points of view of the testee as well as the
standardized and non-standardized (i.e., qualitative) observations and im-
pressions of the diagnostician (observation and assessment of others) are,
however, incorporated in the psychological cognitions and statements (judg-

Clinical-Psychological and Psychotherapeutic Diagnostics
205
Table 4. Fields of application and functions of clinical-psychological and of
psychotherapeutic diagnostics
Clinical-Psychological Diagnostics Psychotherapeutic Diagnostics
I. Functions/Diagnostic Questions
- Function and performance diagnostics (normal - T reatment/i ntervention
vs. deviant performance; performance Diagnostics (see Table 3)
potential, memory, intelligence, etc.) - Mental irregularities and
- Personality diagnostics (characteristics, disorders
irregularities, premorbid personality, personal- - Indication of treatment
ity disorders, etc.) - Risk and resource analysis
- Aptitude testing (aptitude/capabilities of
individuals with mental irregularities, perform-
ance disorders, etc.)
- Diagnosing disorders including the attribution
of diagnostic categories (classification)
- Sociodiagnostics (couples, the patient's family
structures, irregularities, system aspects, etc.)
- Risk and resource analysis (social, psychologi-
cal, biological risk factors and resources, etc.)
- Psychophysiological diagnostics
- Biographic diagnostics: biographic background
- Evaluation and quality assurance
II. Application Areas/Functions
- Ability testing of patients (whether they are fit - Ability to work
for road traffic or for carrying fire arms, etc.) - Ability and aptitude
- Rehabilitation (e.g., social re-integrability, - Social re-integrability
ability to work, vocational aptitude testing) - Mental disorders & psychiatry
- Psychiatry of all ages - Diagnosing development and
- Psychotherapy/c1 i n ica I-psychol ogi cal i nterven- developmental disorders
tions (see Table 3) - Clinical-forensic issues
- Indication of treatment (e.g., in case of specific
disorders, pathological deviations or constella-
tions/patterns)
- Neurology, neurobiology, neuropsychology
(e.g., performance testing; indication of
treatment)
- Educational psychology/school psychology
(e.g., performance disorders and deficits in
selective functions; developmental disorders,
behavioral incongruencies)
- Family Law (e.g., child care and child custody)
- Clinical-forensic issues, e.g., credibility,
accountability
- Appraisals

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Anton-Rupert Laireiter
Table 5. Theoretical and methodological foundation and aspects of clinical-
psychological vs. psychotherapeutic diagnostics
Clinical-Psychological Diagnostics Psychotherapeutic Diagnostics
I. Theoretical Fundament
. Empiric-scientific orientation . Different approaches to science
. Psychological concepts and terms, e.g., . Theories and models of specific
- mental disorder psychotherapeutic orientations, e.g.,
- attention - psychoanalysis
- memory - behavioral therapy
- psychological risk factors - systemic family therapy
. Models and theories of psychology and - client-centered psychotherapy
its specifications e.g., . Concepts and terms from other
- personality models sciences, e.g.,
- intelligence models - psychiatry
- memory models - psychosomatics
. Models and concepts of clinical - psychology, esp. clinical psychol-
psychology, e.g., ogy
- models of mental disorders
- models of quality assurance
. Models and concepts of diagnostic
psychology, e.g.,
- adaptive testing
- evaluation models, change measure-
ment
. Results of psychological research in
various task and application areas (see
Table 4)
. Concepts and models from other
sciences, e.g.,
- psychiatry
- neurology
- biology
II. Methodological Fundament
. Fundamentals and methods from . General diagnostic tools and
psychological research methodology strategies, e.g.,
. Fundamentals and methods from - exploration, anamnesis, interview
general diagnostic psychology, particu- - observation of self and others
larly: . School-specific methods, e.g.,
- psychological test theories, e.g., - structured/qualitative interviews
- classical test theory - hermeneutic or phenomenological
- probabilistic test theories analyses
- exploration, anamnesis - projective procedures
- diagnostic interviews - empathy, scenic understanding
- observation of self and others - analysis of transference and
- psychological testing cou ntertra nsference
- computer supported diagnostics - systemic diagnostics
- problem and behavior analyses

Clinical-Psychological and Psychotherapeutic Diagnostics
207
Table 5 (continued)
Clinical-Psychological Diagnostics Psychotherapeutic Diagnostics
. Diagnostic instruments and procedures . Clinical-psychiatric methods, e.g.,
from various task areas, such as - diagnostic interviews
- clinical interviews - disorder-related anamneses
- clinical scales . Clinical-psychological tools
- neuropsychological testing - clinical scales
. Behavioral diagnostics and functional - clinical interviews
analysis
III. Methodological Criteria
. Multimodality . Subjectivity and subjective relevance
- multi-layer approach . Practical relevance
- diverse data sources . Theoretical orientation
- broadness of constructs . Individual statements
. Technological orientation . Clinical opinion forming
. Statistical opinion forming, norm . Orientation towards theoretical
orientation criteria
. Empirical quality criteria
ments and observations of her/himself) (see Amelang & Zielinski 2002, Fis-
seni 2004 for more details). Psychological diagnostics favors a multi modal
approach of data collection (Baumann & Stieglitz 2001) by considering vari-
ous constructs or aspects (e.g., attention, endurance, memory functions) that
are relevant to the particular diagnostic questions, and by including various
levels (subjective ways of experiencing, objective circumstances, perform-
ance aspects, etc.) where applicable.
On the other hand, psychotherapeutic diagnostics does not stand for a
consistent understanding of the subject area or its epistemology. The Diag-
nostic Guideline even assumes that for an adequate psychotherapeutic diag-
nostic operation several basic theory models have to be implemented of
which there are: a categorizing way of diagnosing which classifies the mental
disorders under treatment (ICD-l0), an interpersonal form of diagnostics to
grasp the relational functions between therapist and client, orientation or
school-based diagnostics to set up a differential and selective indication
(Mans 2000), and case conception and the elaboration of a therapy plan.
According to the ideas expressed in the Diagnostic Guideline (see also Lai-
reiter 2000b), somatic as well as psychiatry- or medicine-based clinical-psy-
chological diagnostics bear significance for psychotherapy also, an issue we
will deal with in greater detail in the next section.
As to the methodological foundation and the actual methodology of the
diagnostic tools, psychotherapeutic diagnostics hardly, if at all, pays heed to

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Anton-Rupert Laireiter
the statistical concepts, norms, or criteria, but much more so to the theoreti-
cal concepts of its respective school, and to the subjective reality and mean-
ing a phenomenon has in the eyes of the patient. Moreover, the individuals'
(the therapist's and the client's) as well as the clinical and the psychothera-
peutic relevance of the problems and difficulties playa more important role
than statistics. I n psychotherapy, diagnostics is scarcely, if at all, carried out
along standardized sets of tools - this idea is even strongly opposed, not only
by many psychotherapists, but also by some leading exponents of psycho-
therapy (see the contributions in Laireiter 2000a for more evidence); depend-
ing on the therapeutic orientation used, a very disparate range of means is
being implemented. It is behavior therapy only, and in some incidents, sys-
temic family therapy also, which consider it a norm to conduct diagnostic
analyses, using an explicit methodology including systematic ways of observ-
ing oneself and others. Classically, diagnostic statements within psychother-
apy are, therefore, based on 'clinical judgments', whereas clinical-psycho-
logical diagnostics, due to its methodological criteria and standards, strives
for statistical decisions, which may be underpinned by such subjective as-
sessments and observations of the diagnosticians which can be quantified
and thus objectified (see, e.g., Westen & Weinberger 2004).
Second Interim Resume
We may hence conclude that the clinical-psychological diagnostics within
the specific Austrian legal situation is based on a very broad understanding
of the concept, which equates diagnostic action with psychological diag-
nostics in the health care system, particularly where mental disorders and
somatic illnesses are concerned that are partly psychologically caused,
whereas psychotherapeutic diagnostics is mainly exercised within the frame-
work of an actual psychotherapy and restricted to the functions thereof (see
Diagnostic Guideline). For this reason, the comparison of the functions, task
areas, and fields of application has yielded a clear distinction between these
diagnostic 'modes'. Psychotherapeutic diagnostics operates on the basis of
clinical-phenomenological concepts which are related to certain orienta-
tions and schools, and its main tasks are the preparation, the chaperonage,
the documentation, and the evaluation of the psychotherapeutic process.
Conversely, clinical-psychological diagnostics commands a very wide range
of tasks and operations and comprises the entirety of psychological-diagnos-
tic issues (classification, selection, performance diagnostics, personality
screening, treatment indication, evaluation, etc.) within various fields of the
health care system but also outside it (e.g., clinical-forensic diagnostics,
developmental psychopathology). This argumentation has also revealed,
though, that clinical-psychological and psychotherapeutic diagnostics share

Clinical-Psychological and Psychotherapeutic Diagnostics
209
a number of functions and applications, which we will discuss in the follow-
ing section.
Substantive-Functional and Use-Oriented Intersections and
Differentiations
Due to its functions, methods, and epistemological possibilities, clinical-psy-
chological diagnostics (as, by the way, psychiatric and somatic-medical di-
agnostics do) claims to be equipped to ascertain the indication of psycho-
therapy (generally as well as particularly), that is to clarify which specific
psychotherapeutic interventions and treatment options are indicated (Mans
2000). Also, it is capable of diagnosing mental disorders. Moreover, it is in
possession of concepts and tools which allow for the accomplishment of the
key functions of psychotherapeutic diagnostics, such as: exploration and
clarification of the biographically relevant conditions of a mental disorder,
indication, documentation, and monitoring and controlling the psychothera-
peutic process as well as screening of the therapeutic success and the qual-
ity assurance (Fydrich 2002, Laireiter 2000b). Psychotherapeutic diagnostics,
on the other hand, claims to be able to independently ascertain whether a
disorder needs to be treated, and which treatment is indicated, a compe-
tence that is central to psychotherapy; it has occasionally been formulated
that psychotherapeutic diagnostics could also contribute judgments regard-
ing diagnostic issues of clinical-psychology (e.g., personality screening, per-
formance diagnostics, social re-integrability, working abilities and driving
fitness) in important work areas of clinical-psychological diagnostics (e.g.,
psychiatry, rehabilitation, psychosomatics, and forensics). These interfaces
may cause problems of distinction, conflicts, confusion, and uncertainty in
the consumers (clients) on the clinical-psychological or psychotherapeutic
performances, and we should, therefore, do our best to clarify these sub-
jects. The following section is dedicated to arguments and criteria of how to
resolve this confusion. In doing so, we will again consider the legal frame of
reference.
Legal Conditions
From the legislator's point of view, the answer to this problem seems to be
relatively clear, as we have pointed out in chapter two: the legislator does not
envisage that diagnostic competence of psychotherapists be employed out-
side psychotherapy, neither by the description of their vocational functions
and competences, nor in the curricula of their trainings. Consequently, psy-
chotherapists who are not clinical psychologists as well are thus not entitled

210
Anton-Rupert Laireiter
.,
,
I
to accomplish any diagnostic tasks or to fulfill diagnostic functions in the
Austrian Health Care System 3 . Their diagnostic competences are clearly re-
stricted to the psychotherapeutic process and only to those diagnostic tasks
which are carried out within this setting. Psychological diagnostic functions
outside psychotherapy are, according to the legislator's will, strictly reserved
to clinical psychologists trained in this field.
Clinical-Psychological and Psychotherapeutic Diagnostics that
are Concomitant to Interventions/Psychotherapy
The criterion for a functional distinction between the clinical-psychological
and the psychotherapeutic diagnostics which accompany psychotherapeutic
interventions is doubtlessly found in the definition of their assignments and
thus functional possibilities of both diagnostic strands. We, consequently,
have to pose the question: which diagnostic information and expertise psy-
chotherapists need, and which category of diagnostic concepts satisfies their
needs. As elaborated elsewhere, psychotherapists, in order to accomplish
their psychotherapeutic functions, require varied diagnostic cognitions and
diverse information which cannot possibly be delivered by a single diagnos-
tic concept (Laireiter 2000b). The endeavor of accurately comprehending
and describing a disorder can only be successful to a certain extent, when
orientation or school-specific diagnostic concepts are realized. For example,
to meet the claim of the diagnostic classification as required by the insurance
law, the diagnostician needs to fall back on clinical-psychiatric concepts and
criteria (see also Diagnostic Guideline), whereas such concepts are of little
help, when indication, case conception, and therapy planning are asked for;
thus, the diagnostician has to draw on orientation- and school-specific con-
cepts and methods (e.g., behavioral-therapeutic problem analysis, systemic
diagnostics, psychoanalytic diagnostics). In order to check the validity of bi-
ology-based hypotheses in the treatment of certain disorders (e.g., adiposity,
obsessive-compulsive disorders, and eating disorders), he frequently has to
recourse to additional internal medical and/or neurological findings. In order
to understand the relevant statements and results, psychotherapists need to
possess at least rudimentary knowledge in these fields.
What importance does then clinical-psychological diagnostics have in
psychotherapy, and in which way can or should it be integrated? From the
3 This requirement is emphasized in the catalogue of the vocational duties of psycho-
therapists, which states that "the psychotherapist when exercising his profession has
to restrict himself to those psychotherapeutic work fields and treatment skills in
which she has, provably, acquired sufficient know-how and experience (14, para 5,
PthG; quoted from Kierein et at. 1991, 144/145).

Clinical-Psychological and Psychotherapeutic Diagnostics
211
author's point of view (see also Laireiter 2000a,b), the significance of clinical-
psychological diagnostics mainly lies in the status diagnostic, introductory
phase of psychotherapy; it can, however, also make methodic contributions
to diagnosing the psychotherapeutic course and process as well as to the
final diagnostic-evaluative stage (change measurement).
Status Diagnostics at the Beginning of Therapy
In the initial stage of therapy dedicated to status diagnostics and to establish-
ing an indication, clinical-psychological diagnostics can make the following
contributions to psychotherapeutic diagnostics:
- screening psychological and psychosomatic disorders by specific inter-
views and self-assessment devices (screening interviews, screening
scales);
- diagnostics and differential diagnostics of mental disorders by the means
of clinical interviews, diagnostic check lists, and tests for assessing oneself
and others;
- quantification of mental irregularities and symptoms by the means of dis-
order-related scales for assessing oneself and others;
- drawing therapy-relevant findings and statements from various psycho-
logical construct areas (e.g., personality, performance, and stress endur-
ance);
- recommendations and directions as to specific goals and goal areas of
psychotherapeutic treatments (e.g., supporting vocational rehabilitation
and enhancing specific resources);
- general recommendations and decisions referring to indication as well as
to specific differential indications (e.g., exercise- versus insight-oriented
approaches);
- prediction of the therapeutic process, of treatability, and of the probabil-
ity of psychotherapeutic success;
- diagnostics concomitant to therapy, monitoring and controlling the course
with the aid of appropriate instruments (diaries, personal records, etc.)
and strategies;
- documentation of relevant clinical-psychological insights from psycho-
logical findings;
- therapy evaluation and assessment of success; and thus
- supporting the quality management and the quality assurance of psycho-
therapy.
In the face of this broad range of applications of clinical-psychological diag-
nostics within the psychotherapeutic treatment process, the questions natu-
rally arise as to what extent it will be employed, who will perform it and

212
Anton-Rupert Laireiter
what significance will it be attributed to within psychotherapy. These ques-
tions may be answered by consensus only, and the answers will depend on
a number of criteria. We basically have to assume that (see also the Diagnos-
tic Guideline) psychotherapists are not only competent but even obliged to
diagnose independently in order to conduct state-of-the-art treatments in
their specific method (Laireiter 2000b). They cannot and must not delegate
their diagnostic competence to anyone else! Treatment-specific diagnostic
examinations and decisions on the specific design of a certain therapy, or
case conception, indication, etc. can only be practiced by themselves and
self-reliantly on the basis of their respective methodic diagnostic and theo-
retical considerations. For particular purposes, the psychotherapists should
perform specific psychological-diagnostic examinations themselves, and
consult psychologists for additional diagnostic findings. From the author's
perspective, psychotherapists could by themselves apply psychological tech-
niques when the following tasks need to be done (these suggestions are
meant to be only recommendations, not rules):
- screening psychological disorders with the aid of diagnostic screening
interviews and/or self-assessment tools;
- attributing diagnoses on the basis of diagnostic criteria, particularly of di-
agnostic interviews and diagnostic check lists;
- comprehension and quantification of questionable psychological disor-
ders with the aid of disorder-related scales (e.g., degree of depression or
alcoholism risk); and
- comprehension of therapy-relevant psychological phenomena with the
aid of clinical interviews and scales.
If the psychotherapist is still in need for more information on psychological
findings or diagnoses, a clinical psychologist with a relevant qualification,
ideally one with a panel practice (i.e., one who is directly paid by the com-
pulsory health insurance scheme) should be consulted. The procedure as
outlined here has been practiced by the author of this paper for many years
and to his great satisfaction. Incidentally, this necessity and duty of consulta-
tion do not only hold true for clinical-psychologists but also for other health
professionals (e.g., neurologists, psychiatrists, internists) and is, firstly, a gen-
eral characteristic of professional psychotherapeutic work and, secondly, an
important feature in the catalogue of a psychotherapist's professional duties
(cp. 9 14, particularly para 2, PthG; see Kierein et al. 1991, and the Diagnos-
tic Guideline). Psychotherapists are thus faced with the question as to under
which conditions such a consultation should be, reasonably and necessarily,
sought. Table 6 surveys the most important aspects.

Clinical-Psychological and Psychotherapeutic Diagnostics
213
Table 6. Criteria for the consultation of clinical psychologists on clinical-
psychological issues by psychotherapists
. In the case of psychological abnormities and problems which are not identifiable
clearly by the skills the psychotherapist relies on (in such cases, consulting psychia-
trists makes sense and may even be a need!)
. Ambiguities as to the diagnoses and differential diagnoses of specific psychological
disorders (in such cases consultation of psychiatrists is required also!)
. If there is a need to comprehensively and systematically diagnose psychological dis-
orders and irregularities including personality and developmental disorders and ir-
regularities as described in Chapter XXI (Z), ICD-l0
. If there is a need to clarify specific psychological irregularities which require a dif-
ferentiated and systematic psychological-diagnostic repertory of methods and skills
. If there is a need to comprehensively and broadly diagnose and clarify important
psychological functions and personality areas
. Assessment of prognosis of the therapeutic process and of the treatability of patients
. If there is a need for statements on differential indication of different/alternative, or
further treatment options (rehabilitation, placement in a protected environment; med-
ical treatment, psychiatric treatment; retirement/pension payment, etc.)
. If the need for psychotherapy and other interventions and actions such as those of
reintegration in the work process and social rehabilitation, medical rehabilitation, etc.
have to be judged
. Differentiated assessment of the critical potential of a disorder by the terms of the
recently issued Diagnostic Guideline
. Request for specific clinical-psychological interventions and treatment options
. If there is a need to screen intellectual and psychological performance factors and
deficits (e.g., attention, concentration, and/or memory disorders)
. Aptitude diagnostics when patient is looking for a new professional direction and/or
psychotherapeutic reintegration measures within the framework of psychotherapy
. If neuropsychological and/or neurological deficits and problems are suspected, e.g.,
skull-brain-trauma; dementia; substance-induced organic, degenerative brain chang-
es, epilepsy; in these cases, the consultation of neurologists, particularly neuropsy-
chologists, is desirable and wise)
. Clarification of forensic-psychological problems and issues (in these cases, consulta-
tion of forensic psychologists and psychiatrists is required)
. If there is a need or necessity to clarify specific personality aspects and features and
potentially complex, partly sub-clinical personal characteristics and personality disor-
ders (consultation of psychotherapists of other schools and psychiatrists should be
considered)
· If there is a need to analyze specific risks and resources (social, psychological, bio-
logical risk factors and resources, etc.)
. If there is a need of specific social diagnostic inquiry (couple and family structures,
system aspects, etc.)
· Psychological appraisals of various questions
· Detailed evaluation of psychotherapeutic treatment

214
Anton-Rupert Laireiter
Diagnostics Concomitant to Therapy: Process and
Progress Diagnostics
One core function of psychotherapeutic diagnostics is the diagnosis of the
psychotherapeutic process and the course it takes. Because of its specific
functions, it has to be carried out mainly by the psychotherapist herself,
while she, as described in the Diagnostic Guideline, continuously monitors
the therapeutic course and the modifications of problems, disorders, and
symptoms throughout therapy, constantly adjusting her proceedings to the
changes that come her way, thus practicing adaptive indication (see also
Laireiter 2000c). One key function of this kind of diagnostics is to monitor
the therapeutic process as well as the therapy-concomitant (formative) qual-
ity assurance of psychotherapy. During this action, it is particularly the
qualitative, interpersonal process diagnostics as described in the Diagnostic
Guideline which is of importance, and which is based on theoretical and
method-specific psychotherapeutic concepts (for details see Diagnostic
Guideline; Laireiter 2000c). Psychotherapists should also, in an up-to-stand-
ard and process-oriented diagnostic procedure, quantify and document the
progress and the development of therapeutic changes, at least by a few indi-
cators. This last aspect is, according to the generally held opinion, an impor-
tant feature of the process-oriented quality management of psychotherapy
(Fydrich 2002, Laireiter 2000b). There are a number of systematic self-re-
cording methods for documentation (course documentation) as well as vari-
ous record instruments for the patients (diaries, therapeutic process and
course screening scales) (see Laireiter 2000c for examples). This methodol-
ogy is applicable by the psychotherapists themselves after only a short period
of briefing.
Which significance does clinical-psychology have within this process?
From a methodological point of few, the task of diagnosing the process and
the course of psychotherapy cannot be delegated - it is a key component of
the psychotherapeutic work as such; however, psychological ways of diag-
nosing can lend their methodic repertory to course, process and change di-
agnostics, and support the psychotherapists in this very function. The sup-
port of professional clinical-psychological diagnostics within the therapeutic
process can and should, moreover, be sought whenever new problems and
issues arise subsequent to the status diagnostic assessments and judgments
- a procedure by no means rare in the case of long-running and more com-
plex therapies. We often meet with the situation where the symptoms and
the clinical pictures appear in a completely different light and exhibit totally
different facets after a long therapeutic period. Such situations necessitate
new status diagnostic examinations for which, apart from the medical spe-
cialists, clinical-psychologists should be consulted. Such check-ups and ex-
aminations may be desirable and interesting from the change-diagnostic

Clinical-Psychological and Psychotherapeutic Diagnostics
215
perspective. In such a case it is vital to systematically evaluate if and to what
extent the therapeutic process, at a given point, has already engendered the
desired changes in the specific therapeutic target areas (e.g., the mitigation of
neuropsychological symptoms and deficits in selective functions). This kind
of systematic evaluation allows for rather accurate predictions of very spe-
cific therapeutic effects.
Therapy Evaluation: Change Diagnostics
It is not only within the context of indications and the therapeutic process that
the psychotherapeutic diagnostics is significant and applicable; it should also
be used for the evaluation of the achievements and for judging the therapeu-
tic change. The so-called change diagnostics has been devised precisely for
this purpose. Psychotherapeutic changes may be assessed by various strate-
gies and means, the systematic application of which is indispensable, if mul-
timodal change measurement and evaluation (quality assurance) (Stieglitz &
Baumann 2001) are sought. The 'direct change diagnostics' inquires into the
change perceived retrospectively by the subject under treatment, whereas the
'indirect change diagnostics' draws conclusions on the changes by relying on
the differences between the scores of two different statuses (before and after
therapy). The so-called /Therapy-Goal-Attainment-Evaluation' sets out from
the therapy targets that have been agreed upon at the onset of the therapy,
and the degree to which they have been reached is judged at the termination
of the therapy by the therapist as well as by the client. /Criteria-Related Evalu-
ations' consider the diagnostic criteria of normal versus irregular psychologi-
cal functioning and infer the success from the fact that certain psychological
irregularities were there at the beginning of the therapy but have disappeared
at its termination (e.g., a serious depressive disorder diagnosed at the begin-
ning of the therapy has abated at its termination); or, at the end of this therapy,
the degree of severity of the symptom measured by a particular scale is the
same as that for the clinically insignificant population (= 'Clinical Significance
of Change", cpo Fydrich 2002). Last but not the least, /Satisfaction and Quality
Assessments' indicate to what extent a patient feels satisfied with his therapy,
with its process, and its effects from his subjective point of view, and to what
extent he grades his therapeutic process as up to standard.
Many of these routines could and should be performed in this area also
either by the therapist herself, or she should submit them to the patient.
Clinical psychology may lend its method repertory to that end. As men-
tioned above, there are various circumstances when it may be wise and use-
ful to have the therapeutic success evaluated, either in general terms or,
more specifically, with respect to certain parameters or change areas, by
consulting a clinical-psychologist:

216
Anton-Rupert Laireiter
- if the target area centers around a symptom cluster, the comprehension of
which requires a specific psychological and/or psychophysiological set of
routines (e.g., in case of neurocognitive symptoms, problems with mem-
ory, performance disorders, or deficits in selective functions, personality
traits, responsiveness of blood pressure),
- if the grant of cost absorption or the refund by one's health insurance
company is to be extended, and specific evidence has to be submitted to
justify the expedience and the effectiveness of the psychotherapy under-
taken hitherto,
- if, for certain reasons, the efficacy of the psychotherapy needs to be ac-
cented,
- if the patient requests it,
- in cases where the collaboration with a physician, an institution, or an-
other facility (e.g., rehabilitation center) requires it, and
- when psychotherapy is part of an individual case analytic study.
Consequences
Clinical-psychological diagnostics is interesting and significant for psycho-
therapy mainly because of its status and change diagnostic procedures. In
both contexts, as well as in course and process diagnostics, psychotherapists
themselves can and should apply methods from clinical-psychological diag-
nostics, and they should seek the professional collaboration with clinical
psychologists, primarily when statuses and changes are to be diagnosed
which are relevant for indication. With regard to the psychotherapeutic train-
ing, be it basic, advanced, or post graduate, this implies that the psycho-
therapists, apart from their method-specific diagnostic competence which
they have to acquire in their methodological training curricula, must famil-
iarize themselves with the fundamentals of psychological, and the clinical-
psychological diagnostics in particular, to be capable of implementing and
applying simple instruments independently, and to interpret and process the
more complex and differentiated findings of clinical-psychological diagnos-
tics adequately. This know-how may be acquired within the general intro-
ductory ('propaedeutic') curriculum of psychotherapy.
Psychotherapeutic Diagnostics Applied to Psychological-
Diagnostic Issues
Theories, models, and concepts of psychotherapy are apt to issue state-
ments on various psychologically relevant affairs: e.g., on personalities,
mental and social functioning, aptitudes concerning certain requests, on

Clinical-Psychological and Psychotherapeutic Diagnostics
217
the family system, and the relationship pattern of a couple. For this reason,
concepts and models from psychotherapy should be hearken back to when
certain psychological-diagnostic problems are under scrutiny and insights
are needed. As much as clinical-psychological cognition is crucial in psy-
chotherapy, psychotherapeutic-diagnostic cognitions may be used in the di-
agnostic assignments of clinical psychology (e.g., description of psychologi-
cal irregularities, assessment of the personality, of capabilities, of achieve-
ments, or of the aptitude of a deranged individual, e.g., for a certain reha-
bilitation program).
Where the differentiation and collaboration between clinical psycholo-
gists and psychotherapists are concerned, the same principle holds true as
described above, albeit conversely: on principle, clinical psychologists
should perform their diagnostic tasks and functions on the basis of their
specific psychological body of knowledge and competences; they should,
moreover, be capable of including psychotherapeutic cognitions and ideas
in the respective areas. If further questions arise (e.g., when a specific psy-
chotherapeutic indication has to be decided on), psychotherapists or psy-
chiatrists and/or other health professionals should be consulted (cp. also the
related discussion under 9 13 PG, Duties of Clinical and Health Psycholo-
gists).
The Diagnostic Guidelines from the Perspective of Clinical
Psychology
The developmental steps taken in the wake of the elaboration of the Diag-
nostic Guidelines by the Advisory Board are to be welcomed joyfully from
the clinical-psychological point of view; firstly, for having contributed con-
siderably to the enhancement and improvement of quality; and secondly, it
is the first official statement on the significance of diagnostics for psycho-
therapy. As a consequence, diagnostics has finally assumed a part within
psychotherapy which, owing to its task structure and to its importance, is
finally appropriate. Psychotherapists of various methodical orientations are
thus called on to act concertedly and unanimously from their respective
theoretical frameworks. This enhances the confidence in one's possibilities
vis a vis the patients, as well as their own in what they may expect and
which rights they have. Also, standards and guidelines have been set regard-
ing the contents of diagnostic actions within psychotherapy, and as to the
realization and the tasks thereof. All these facets facilitate a much clearer
delimitation of tasks and targets of the different diagnostic 'ways' (clinical-
psychological, psychiatric, neurological, psychotherapeutic, etc.) within the
Health Care System, and they will contribute to the improvement and opti-
mization of the collaboration between the miscellaneous health professions.

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Anton-Rupert laireiter
Furthermore, the transparency of the functions and contents of psychothera-
peutic actions towards the public will be heightened. Physicians, psycholo-
gists, psychiatrists, etc. may now appreciate much more clearly what the
subject of psychotherapeutic diagnostics is; grounded on this understanding,
they may communicate much more unambiguously and transparently over
diagnostic matters with their fellow-psychotherapists.
On the other hand, from the clinical-psychological point of view, the Di-
agnostic Guideline seems to lean towards certain psychotherapeutic orienta-
tions, particularly because of its emphasis on the process-oriented way of
diagnosing and the interpersonal relationship, as well as its theoretical ap-
proach that resonates in the commentary. It is from the systemic as well as
from the behavior therapeutic perspective that a number of substantive
points of view and definitions as well as various guidelines are incomprehen-
sible and thus not justifiable. A broader reconnection with the pertaining
training institutions would have been more desirable. Also, again from the
clinical-psychological point of view, the evaluative function of diagnostics
and thus its function to assure the quality of psychotherapy sufficiently is not
attended to, and the obligation of consultation and its implications should
have been discussed in greater detail. These points should be considered
more attentively in future revisions of the Guideline.
Third Interim Resume
On recapitulating the above, we should note that clinical psychology, due
to its specific task structure, is able to make therapy-relevant statements and
to fulfill accordant functions. Due to the specific psychotherapeutic task,
psychotherapy can and must not delegate its specific diagnostic functions,
either to clinical psychology, or to psychiatry, or to any other health profes-
sion. This entails that psychotherapists have to accomplish their diagnostic
tasks in the framework of their psychotherapeutic treatments personally and
self-reliantly (cp. also 9 14 para 2 PthG). In terms of their professional duties
they are, however, also entitled and obliged to obtain information and find-
ings regarding specific clinical-psychodiagnostic problems within certain
areas and around certain issues (and, incidentally, also from other health
professionals). In this section, we have tried to develop and discuss the
most important questions. Clinical-psychological diagnostics, moreover, has
a very broad repertory of techniques which work for varied fields and func-
tions that are also covered by psychotherapeutic diagnostics. A systematic
use of these by psychotherapists is of such great importance for the indica-
tion of therapy, for monitoring its progress, and for evaluating the results as
well as a quality assured therapeutic practice that clinical-psychological
concepts and psychodiagnostic means should be applied by the psycho-

Clinical-Psychological and Psychotherapeutic Diagnostics
219
therapists themselves while they practice their profession. To meet this re-
quirement they should, however, be trained more broadly in psychological
diagnostics.
Psychotherapy can contribute to the clarification of various clinical-psy-
chological problems; in terms of an ideal and high-standard psychological
work performed by the psychologists, this should be taken into account as
much as the cognitions and stores of knowledge of other health profes-
sions.
Conclusions and Consequences
Psychotherapeutic diagnostics is primarily defined by its tasks and functions
within the actual practice of psychotherapy. Within this framework, psycho-
therapists operate independently and autonomously; if the need arises, they
must, however, turn to other health professionals and take either psychiatric or
clinical psychological advice. Psychotherapeutic diagnostics cannot be equat-
ed with clinical psychological diagnostics or even replace it, nor vice versa.
The differences of functions and performances are far too big. Both can,
however, contribute to fulfill complementary functions of the other profes-
sional specification (as do the concepts and techniques of other health pro-
fessions). If we strive for highly qualified and optimal health care, we should
attach utmost importance to mutual consultation and counseling in the treat-
ment and examination of human beings who suffer from mental distress.
Apart from different professional functions, clinical-psychological and
psychotherapeutic diagnostics differ as to their theoretical foundation and as
to their methodological orientation and handling, and their methodical pro-
ceeding. This opens up most far-reaching differences between them and
brings forth important directions and criteria of specific applications and
modes of operation. Clinical-psychological diagnostics primarily judges psy-
chological phenomena that are related to mental disorders, irregularities, and
suffering in a number of psychological domains and various fields of health
care and suggests indications of interventions and treatments, makes predic-
tions of the course, its development, treatability and reintegrability, identifies
psychological disorders, practices differential diagnostics, and monitors and
evaluates therapies. As clinical psychologists perform these functions, psy-
chotherapists should consult them on specific issues. Psychotherapeutic di-
agnostics is legitimized primarily by the task structure of psychotherapy, that
is, by the treatment of psychological irregularities, behavioral disorders, ail-
ments, disorders and somatic illnesses that have partly been caused psycho-
logically or socially. Here, we primarily have to do with the diagnostics of
disorders, differential diagnostics, general, differential and selective indi-
cations (Mans 2000), developing case concepts and conceiving treatment

220
Anton-Rupert laireiter
models, and with interpersonal control as well as with the necessity to
monitor the progression and the process of treatment. To accomplish this
task, psychotherapy is in need not only of method-specific diagnostic con-
cepts and techniques, but also of interdisciplinary, clinical-psychological,
and clinical-psychiatric ones.
This multifunctionality of the diagnostic tasks in the health professions in
the domain of mental disorders (clinical psychology, psychiatry, psycho-
therapy) makes their interrelation very complex. The Diagnostic Guideline,
developed by the Advisory Board, has made an essential contribution to the
structural and qualitative development by defining the task structure of psy-
chotherapeutic diagnostics and regularizing it by giving guidelines. This has
enhanced transparency and contributed to the clarification of the most di-
verse assignments, approaches and methodological preconditions of clinical-
psychological as well as psychotherapeutic diagnostics, thus facilitating the
collaboration between the two health professions. It would, however, be
even more vital and essential to further integrate the evaluative aspect of
psychotherapeutic diagnostics more systematically in the Guideline.
References
Amelang M, Zielinski W (2002) Psychologische Diagnostik und Intervention, 3rd revised
and updated edn. Springer, Berlin Heidelberg New York Tokyo
Bastine R (1992) Klinische Psychodiagnostik. In: Bastine R (ed) Klinische Psycho logie,
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Translated from the German by Luna Gertrud Steiner


Significance of Diagnostics for Psychotherapy -
A Survey
MARION BAUER-LEHRNER, URSULA MARGREITER
Preliminary Note
"The relationship between psychotherapy and diagnostics has always been a
difficult one and bred a great deal of friction. It was the history of the psy-
chotherapeutic theories on the one hand, and the evolution of the classifica-
tion systems of mental disorders on the other which had caused this circum-
stance. For a long time, diagnostics had been regarded as the responsibility
of the medical professionals only, in that sense that prior to any therapy a
diagnosis had to be accomplished" (Paulitsch 2004).
During the propaedeutic curriculum, which precedes the specific psycho-
therapeutic modality training, the prospective psychotherapists usually ask
questions like "According to which criteria does the diagnosis have to be
established? Who should primarily diagnose? Do different diagnosticians di-
agnose differently, and how are these dissimilarities related to their source -
or basic - professions? Can a diagnosis be restated in the course of treat-
ment, or is it possible to furnish more than one diagnoses simultaneously?"
These questions reflect the problems of diagnostics as well as the advan-
tages diagnoses bear for setting up a treatment plan. And yet in 1996, Lenz
and Kuefferle wrote, "In contrast to the medical realm, the significance of
diagnosing mental illnesses has been questioned over and over, and every
once in a while claims are raised that diagnoses should be done away with
altogether. The key arguments against psychiatric diagnoses are, in general,
that diagnosing a person does not do justice to the very particular situation a
patient finds herself in, and that the therapeutic and prognostic inferences
derived from these psychiatric diagnoses are rather insignificant and the
diagnoses themselves unreliable. If we do, however, regard each patient as

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Marion Bauer-Lehmer, Ursula Margreiter
unique and only so, any learning from experience and communication about
illnesses would be impossible".
Such controversial issues and the compilation of the Diagnostic Guideline
for Psychotherapists by the Federal Ministry of Health and Women's Affairs
stimulated the idea for this study.
The study, firstly, explores the significance diagnostics is conceded within
psychotherapy and, secondly, to what degree the design of the psychothera-
peutic leg of diagnostics is actually necessary. We interviewed psychothera-
pists who run private practices, either exclusively or in addition to an em-
ployment. According to a survey conducted by the Austrian Federal Institute
for Public Health Care, a predominant part of the psychotherapeutic service
in Austria is being provided by private practitioners (cp. OBIG 1997).
Subject of Inquiry
It was the objective of the present study to survey the views on how the in-
terviewed psychotherapists assessed the significance of diagnostics within
psychotherapeutic treatment. We, furthermore, wanted to put together argu-
ments to support or disapprove the development of an independent diagnos-
tic discipline within psychotherapy.
The target group interviewed consisted of psychotherapists who run pri-
vate practices. The target variables were the findings and the applications of
diagnostic formulae, the methods the interviewees had been trained in, their
professional experience, the question whether and how the basic profession
affected their diagnoses, the quality and the frequency of diagnosed dis-
orders, the referral context, the question how relevant diagnostics was for
treatment, the attitude towards the set-up of a specific psychotherapeutic
form of diagnostics, and the consideration of modality-specific features.
Execution of the Survey
The inquiry was realized within the framework of a project run by the stu-
dents of the propaedeutic psychotherapeutic curriculum of the OEAGG
(Austrian Association for Group Therapy and Group Dynamics). Its training
focus being "Fundamentals of Research and Science Methodology", it in-
cluded the participation of the research associates of those propaedeutic
studies (Michaela Felber, MA; Iris Jahn, MA; Marlies Wohlgenannt, MA),
with Dr. Gernot Schwentner (Empirical Social Research) contributing his
expert advice. The field inquiry was conducted over an eight-day-period
(23 July-31 August 2004) and focused on Upper Austria, with Vienna and
Lower Austria ranking next, and only a few data were collected in the prov-

Significance of Diagnostics for Psychotherapy
225
inces of Styria and Burgenland. The data were collected with the aid of a
structured questionnaire, which was submitted by the trainees of the OEAGG
propaedeutic studies during a face-to-face interview. The ideas and experi-
ences of the students had been considered and included in the conceptuali-
zation of this questionnaire.
Sampling
We interviewed a total of 48 independent psychotherapists with an approxi-
mately equal distribution of men and women, in order to identify any poten-
tial gender-specific differences. We, first of all, should note that about two
thirds of the certified Austrian psychotherapists are female (cp. www.psyon-
line.at - Wegweiser Psychotherapie/Statistik und Daten zur Psychotherapie,
as in December 2003; OBIG 2003). According to this site and by that date,
the proportion of female therapists was 58.3%, and of male therapists
41.7 %.
The average age of the interviewees was 47 years, and the distribution
was relatively broad (standard deviation: 7.2 years; minimum age: 35 years;
maximum age: 65 years).
A major proportion of the respondents (70.7 %) runs their private prac-
tices in the province of Upper Austria, followed by 18.8 % who work in Vi-
enna, 6.3 % in Lower Austria, 4.2 % in Styria and Burgenland. 35.6 % indi-
cated to have been working in private practice for up to 15 years, whereas
24.4 % stated to have been practicing in private practice for up to five years,
and an equal number for ten. As few as 8.9 % have been practicing for up to
20 years, and 6.7 % for up to 29 years in the same setting.
When answering the question 'which psychotherapeutic modality the
therapists were trained in', 41.7 % of the interviewees specified Systemic Fam-
ily Therapy; 29.2 % - Client or Person Centered Psychotherapy; and 14.6 %
- Integrative Gestalt Therapy, or Gestalt Theoretic Psychotherapy. The re-
maining methodological orientations were mentioned at less than 10 % .
Expectedly, they generally declared to use the same treatment modality
from which they had graduated. Accordingly, most of them (56.3 %) stated
Systemic Family Therapy, followed by Client or Person Centered Psycho-
therapy (27.1 %), and Integrative Gestalt Therapy or Gestalt Theoretic Psy-
chotherapy (16.7 %). What is interesting to note is that, in comparison with
the percentage of the psychotherapists trained in Systemic Family Therapy, a
significantly higher proportion use this modality as their work approach. We
may conclude from this that psychotherapists who graduated from other
schools, or those who do not hold a modality specific title do use this ap-
proach also, which suggests that they are using an interdisciplinary treatment
concept.

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Marion Bauer-Lehrner, Ursula Margreiter
A total of 68.8 % of interviewees stated to be registered in the official
psychotherapists list under a so-called "Zusatzbezeichnung" - an additional
title that certifies their graduation from a particular method or orientation
(rather than being a 'psychotherapist' under general terms), a characteristic
that holds true for a significantly higher proportion of men (85 %) than wom-
en. Contrariwise, only 57.1 % of female psychotherapists interviewed are in
possession of this extra title.
The most frequent basic professions psychotherapists emanated from
were: compulsory-school teachers (29.2 %), psychologists (22.9 %), medics
(12.5 %), diplomate social workers (12.5 %), and theologians (8.3 %).
Results
Familiarity with and Application of Diagnostic Formulae
At the inception, the interviewers asked open (non-structured) questions to
determine the therapists' familiarity with diagnostic formulae. The analysis of
these qualitative data revealed that all interviewees were at least acquainted
with the well known classification systems of either ICD-9 or ICD-l0 (Inter-
national Classification of Mental Disorders). When answering the subsequent
closed-ended question, 85.4 % stated to be acquainted with the classifica-
tion system DSM III/IV (Diagnostic and Statistical Manual of Mental Disor-
ders), and 31.3 % additionally mentioned the OPD (Operationalized Psy-
chodynamic Diagnostics).
77.1% of the respondents had acquired their diagnostic skills within their
psychotherapeutic vocational training. Out of these, 18.8% specified that
they had acquired some knowledge during their theoretical training within
the framework of the propaedeutic curriculum to psychotherapy, whereas
12.5% had gathered that information in the respective hands-on training. The
percentile scores of the acquisition of diagnostic knowledge within the set-
ting of the modality-specific training rate clearly higher. There, 70.8% indi-
cated to have obtained some diagnostic know-how within the theoretical leg
of their vocational training, while 56.3% stated the practical part.
A total of 56.3 % of the respondents deem the knowledge gained in this
way either fairly or even highly sufficient. Another 20.9% judge their knowl-
edge gained during their vocational training as less or scarcely sufficient. In
this context, we witnessed a tendency of the elder interviewees (aged 45 and
above) considering their diagnostic know-how as rather insufficient. This
might result from the circumstance that the completion of their training dated
further back.
When the application of the classification systems in their psychothera-
peutic practice was investigated, 93.8% of the respondents evidently use

Significance of Diagnostics for Psychotherapy
227
ICD-9/10, 18.8% DSM III/IV, and 2.1% use OPD (see also Table 1 below).
The ICD-9/10 systems seem to be used primarily in those cases that apply for
the partial refund of fees from their health insurance companies.
Table 1. Application of classification systems
Classification Application of No Application of Missing Values
Systems Classification Systems Classification Systems
Absolute Percentile Number Percentile Number Percentile
Number (n) Score (n) Score (n) Score
Application of 45 93.8 0 0 3 6.3
ICD-9/1 0
Application of 9 18.8 36 75 3 6.3
DSM III/IV
Application of 1 2.1 44 91.7 3 6.3
OPD
Application of 3 6.3 42 87.5 3 6.3
other systems
Another topic surveyed was the therapists' satisfaction with the utility of the
various diagnostic formulae by a five-step scale (1 = very satisfied; 5 =
scarcely satisfied). Since, as already mentioned, the majority was found to
use lCD, the results listed in Table 2 refer to this system only.
Table 2. Satisfaction with application of ICD-9/10
Grading of Satisfaction Absolute Number (n) Percentile Score
Very satisfied 3 6.3
Satisfied 22 45.8
Less Satisfied 7 14.6
Scarcely Satisfied 1 2.1
Not Applicable 3 6.3
Total 36 100.0
The satisfaction with the applicability of ICD-911 0 varied significantly, de-
pending on the number of years psychotherapists had been working in their
private offices: Just under 70 % of those who had been practicing freelance

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Marion Bauer-Lehrner, Ursula Margreiter
for more than 10 years were significantly less satisfied with ICD-9/10, com-
pared with the comparison group (p < 0.5). From this finding, we may infer
that the more experience the professional has, the more critical his attitude
is towards the existing psychotherapeutic diagnostic systems ICD-9/10. When
asked the introductory non-structured question "What comes to your mind
on hearing the expression 'psychotherapeutic diagnostics'?", the interviewees
expressed varied positions such as "It is the basis of the therapeutic plan",
and "It helps the clarification of symptoms"; they associated terms such as
"categorization", "labeling", or "an evil that has to be put up with for the sake
of the chi (compulsory health insurance) cost absorption".
We did observe another tendency, though, namely of psychologists as a
professional group to be less happy with giving ICD-9/10 diagnoses and,
therefore, to additionally use clinical-psychological diagnostic instruments.
Referral Context
When exploring the referral context, we were interested in how many pa-
tients came to the intake interview upon referral, and by whom (i.e., repre-
sentatives of which professions) they had been referred. The frequency dis-
tributions of their replies are shown in Table 3.
Table 3. Frequencies of patients referred
Percentile Scores of Referrals Number (n) Percentage (%)
Up to 20% 15 31.3
21-40% 8 16.7
41-60% 10 20.8
61-80% 11 22.8
81-100% 1 2.1
Missing Values 3 6.3
Total 48 100.0
The table demonstrates that the frequency of referrals for psychotherapists
who have worked freelance for more than 10 years is significantly higher
than for those with less professional experience. We may interpret this result
to the effect that psychotherapists with a long-standing professional and
practical experience have, over the years, created more efficient networks,
which consist of colleagues who stem from various occupational groups and

Significance of Diagnostics for Psychotherapy
229
institutions. Possibly, their employment for a long period of time in relevant
institutions also accounts for this result. 76 % of the respondents who work
with referred patients had their patients sent by physicians (p < 0.05) prima-
rily. In this respect, we do observe a slight gender-related difference (p < 0.1).
75 % of male respondents report to collaborate with medical doctors or
other experts (male or female), as against only 50% of female psychothera-
pists.
Concerning the ratio between solely privately paid therapists, and those
whose fees are partly reimbursed by the health insurance companies, a sig-
nificantly higher proportion of female psychotherapists (75 %) treats patients
who claim reimbursement from the health insurance.
It was moreover interesting to note the following result: about three
fourths of the interviewees (76 %) who had 40 % or more referred patients
indicated to be less satisfied with the traditional diagnostic systems. The fact
that the referred patients generally come with diagnoses stated by the refer-
ring person that may differ from that given by the psychotherapist, might
serve as an explanation. This may result in the apprehension that a new (and
differing) diagnosis could cause problems to those involved.
Type and Frequency of Disorders
The most frequent clinical pictures psychotherapists work with in their free-
lance practices are depressions and anxiety disorders followed by stress dis-
orders, with psychosomatic, behavioral and emotional disorders ranking
third.
When psychosomatic, behavioral and emotional disorders are diagnosed,
we witness highly significant differences in the referral contexts (p < 0.01).
95.7 % of respondents who primarily treat private patients significantly more
often diagnosed psychosomatic, behavioral and emotional disorders, perhaps
on the assumption that thus the 'labeling' of the patient was less severe.
Interestingly, those respondents registered in the list of Austrian Psycho-
therapists who hold an additional title (as described above) significantly
more often diagnose personality disorders (66.7%) and psychosomatic disor-
ders (75.8%). This may arise from the fact that these respondents are more
versed in handling diagnoses such as personality and psychosomatic disor-
ders because of their specific methodological training.
This conjecture is underpinned by an additionally observed tendency,
namely of respondents with additional titles claiming to have acquired their
diagnostic know-how in the course of their psychotherapeutic method train-
ings (p < 0.1). Those respondents who diagnose personality disorders also
deem diagnostics in psychotherapy very relevant. This result leads to the
discussion of the following issue.

230
Marion Bauer-Lehrner, Ursula Margreiter
The Relevance of Diagnostics for Psychotherapeutic Treatment
Basically, a majority of interviewees regarded diagnostics as relevant for psy-
chotherapy (see Table 4). In this context, another significant difference mani-
fested among the interviewees who, with or without the additional titles, are
chartered in the Austrian Psychotherapists List (cp. Psychotherapy Act, 9 17
para 4). Respondents with the additional titles feel diagnostics in psycho-
therapy to be significantly relevant, whereas psychotherapists without the
additional titles rather question this. We may hypothesize there also that
psychotherapists who bear additional titles are more versed in handling the
classification systems because they have gone through specific psychothera-
peutic method trainings.
Table 4. Assessment of the relevance of diagnostics for psychotherapeutic
treatment
Assessment of Relevance Number (n) Percentile Score
Very Relevant 20 41.6
Relevant 13 27.1
Rather Relevant 7 14.6
Less Relevant 7 14.6
Of Little Relevance 1 2.1
Total 48 100.0
Another phenomenon was observed in that those psychotherapists who hold
diagnostics relevant refer their patients to clinical psychologists less often
(p < 0.1).
Significant evidence was also gathered as to whether the elaboration of a
diagnostic discipline specific to the psychotherapeutic domain was rather
favored or disapproved. 89.5 % of the respondents who regarded diagnostics
as principally relevant took a very favorable position toward the design of an
independent psychotherapeutic diagnostic system.
Attitude toward the Design of a Specific Psychotherapeutic
Diagnostic System
The counting of frequencies of the responses on the question regarding the
attitude toward designing a diagnostic system specific to psychotherapy re-
sulted in a bell-shaped distribution. The answers followed a preset 5-step-

Significance of Diagnostics for Psychotherapy
231
scale: 1 = "I highly appreciate it"; 5 = "I do not appreciate it". The result re-
veals strongly polarized opinions that reflect the controversy the topic pro-
vokes. The results of the interviews are shown in Table 5.
Table 5. Response pattern on the question of a diagnostic system specific to
psychotherapy
Design of Specific Psychotherapeutic Number (n) Percentile Score
Diagnostic System
High Appreciation 12 24.9
Some Appreciation 7 14.6
'Don't Know' 7 14.6
Less Appreciation 7 14.6
Little Appreciation 14 29.2
Missing Value 1 2.1
Total 48 100.0
The length of the period of the professional experience correlates signifi-
cantly with the psychotherapists' position toward a specifically psychothera-
peutic diagnosing system: psychotherapists who have worked in their private
practice for more than 10 years (72.2%) are far more receptive to a form of
diagnostics that is specific to psychotherapy (p < 0.05).
Furthermore, we gained an interesting insight in the responses to the ques-
tion of how many patients a week a therapist usually treats in an individual
setting. Psychotherapists who treat more than nine patients a week in indi-
vidual settings (73.7 %) are far more open to specifically psychotherapeutic
diagnostics than those with a lower frequency of weekly patients (p < 0.05).
The more sessions (four or more) were needed to arrive at a reasonably
secured diagnosis, the more important the elaboration of a specific form of
diagnostics was held. 89.5 % of the respondents who reported to need more
than four sessions regard specific psychotherapeutic diagnostics as crucial.
Considering Modality-Specific Features in the Elaboration of a
Specific Psychotherapeutic Diagnostic System
52.1 % of interviewees are of the opinion that modality-specific characteris-
tics should be considered in the elaboration of a psychotherapy specific di-
agnostic system, whereas 45.8 % do not see any necessity for this. To those

232
Marion Bauer-Lehmer, Ursula Margreiter
respondents who favor the inclusion of modality-specific characteristics it
seemed vital that the 'idiosyncrasies' of each school, such as system-theo-
retical, learning-theoretical, or depth-psychological considerations be at-
tended to. Some of the respondents hold the view that certain modalities
are more suitable for certain clinical pictures than others. Some also sug-
gested the incorporation of relational, developmental, and ego-structural
aspects as well as resources and clear goal definitions in such a diagnostic
system.
Those interviewees who were against modality-specific considerations
were afraid that this could adversely affect the interdisciplinary communica-
tion. Some argued more pragmatically that the patient was the focus of the
treatment and not the modality, and for this reason the achievement of treat-
ment goals did not depend on the modality. According to them, the consid-
eration of the modality-specific features would cause confusion, since many
psychotherapists use an interdisciplinary work approach. These respondents,
more often, opted for the revision and the refinement of the existing ICD-
9/10 or DSM III/IV.
Significant gender-specific differences were observed: There are signifi-
cantly more men (73.7 0/0) than women (39.3 0 /0) who favor the consideration
and inclusion of modality specific features.
Another significant difference was observed between those respondents
who additionally apply clinical-psychological diagnostic tools and those who
do not. The former group favors the inclusion of modality-specific features.
We may thus assume that for these respondents a differentiated form of di-
agnostics is an essential component of their treatment concepts.
Summary
This study has revealed that all psychotherapists interviewed are familiar with
the classification systems ICD-9/10 and that most of them had acquired the
relevant knowledge during their specific therapeutic training. More than half
of the respondents regarded their knowledge as reasonably sufficient to
highly sufficient.
Nearly all respondents use ICD-9/10 classification systems in the context
of cost reimbursement or absorption.
As far as the satisfaction with the applicability of the ICD-9/10 systems is
concerned, two thirds of the respondents with ten or more years of work
experience in private offices appeared to be significantly less satisfied with
these diagnostic taxonomies.
During the exploration of the details of the referral contexts, it seemed
that the psychotherapists with ten or more years of professional experience
in private practice treat significantly more patients who have been referred to

Significance of Diagnostics for Psychotherapy
233
them by other professionals. The occupational group of physicians ranked
first in issuing those referrals, with mainly male psychotherapists stating to
cooperate with (male or female) physicians.
A higher score of female psychotherapists revealed to treat patients who
claim refunds from their health insurance companies. It is interesting to note
that the majority of the psychotherapists working with referred patients is
significantly less satisfied with the existing diagnostic nomenclatures.
Significant differences were also noticed in diagnosing various disorders.
Therapists who treat a lower number of referred patients more often diag-
nose behavioral and emotional disorders.
Therapists who hold an additional title are more inclined to diagnose
personality and psychosomatic disorders.
The majority of interviewees think diagnostics to be essential in psycho-
therapy. More specifically, a larger number of the psychotherapists in posses-
sion of additional titles deems diagnostics meaningful than those without.
The results, furthermore, demonstrate that those therapists who feel diag-
nostics to be principally relevant also favor the development of a diagnostic
system specific to psychotherapy.
We, nevertheless, should realize that the issue of an independent diag-
nostic system for psychotherapy has strongly polarized the community in the
sense of clear pro and contra positions. An approximately equal number of
therapists either strongly favor or oppose that idea.
The longer the professional experience in a private practice - i.e., ten
years or more - the more likely the therapists will approve of a specific diag-
nostic system for psychotherapy.
We also noticed that therapists with a higher frequency of patients per
week are much more sympathetic to an independent form of psychothera-
peutic diagnostics.
The number of sessions required to arrive at a reasonably secured diag-
nosis has a strong influence on the attitude the therapist adopts towards
psychotherapeutic diagnostics. Respondents who need four or more sessions
think the design of a specific diagnostic system to be important.
Nearly half of the psychotherapists are concerned that the inclusion of the
modality-specific features in the set-up of a psychotherapy-specific diagnos-
ing system could impede the interdisciplinary exchange. Such an inclusion of
modality-specific features is held to 'confuse' the psychotherapists, of whom
many use interdisciplinary work approaches. They rather request the refine-
ment of the existing procedures such as ICD-9/10 or DSM III/IV.
More than half of the respondents favor the inclusion of the modality-
specific features acknowledging the import the manifold theoretical ap-
proaches of the individual schools bear. Furthermore, the suitability of cer-
tain schools for the treatment of certain clinical pictures should be examined
and attended to.

234
Marion Bauer-Lehrner, Ursula Margreiter
In summary, the survey demonstrates that the psychotherapists deem di-
agnostics important for psychotherapy. However, the development of a spe-
cific psychotherapeutic form of diagnosing is controversial. This ambivalence
could possibly decrease, if self-reliant psychotherapeutic diagnostics were
not conceived as a counter model but as complementary to the existing sys-
tems and as a contribution to the quality of psychotherapy.
A more extensive study as a follow-up of this project would be wel-
come.
References
Federal Ministry of Health and Women's Issues (2004) Diagnostic Guideline for Psycho-
therapists. Vienna
Bortz J (1999) Statistik fUr Sozialwissenschaftler. Springer, Berlin Heidelberg New York
Tokyo
Dilling H, Mombour W, Schmidt MH, Schulte-Markwort E (eds) (2000) Internationale
Klassifikation psychischer St6rungen, ICD-l0 Chapter V (F). Klinisch-diagnostische
Leitlinie. Huber, Bern G6ttingen Toronto Seattle
Etzersdorfer E, Fischer P, Friedrich MH, Holubar K, Kuefferle B, Lenz G, Schlappach 0,
Sonneck G, Steinhardt K, Teutsch HR (1996) Medizinische Grundlagen der psycho-
therapie. Facultas, Vienna
Kierein M, Pritz A, Son neck G (1991) Psychologengesetz. Psychotherapiegesetz. Kurz-
kommentar. Orac, Vienna
Lenz G, Kufferle B (2002) Klinische Psychiatrie. Grundlagen, Krankheitslehre und spezi-
fische Therapiestrategien (Chapter 2 + Chapters 11-12). Facultas, Vienna
OBIG [Osterreichisches Bundesinstitut fUr Gesundheitswesen] (1997) Ambulante psy-
chotherapeutische Versorgung in Osterreich. Vienna
OBIG [Osterreichisches Bundesinstitut fUr Gesundheitswesen] (2003) Psychotherapeu-
ten, Klinische Psychologen, Gesundheitspsychologen, Entwicklungsstatistik 1991-
2002. Vienna
Paulitsch K (2004) Praxis der ICD-l0-Diagnostik. Ein Leitfaden fUr Psychotherapeutlnnen
und Psychologlnnen. Facultas, Vienna
SaB H, Houben I, Wittchen HU, Zaudig M (2003) Diagnostisches und Statistisches
Manual Psychischer St6rungen - Textrevision (DSM IV TR). Hofgrefe, G6ttingen To-
ronto Seattle
Translated from the German by Luna Gertrud Steiner

4. On the Meaning of the Fundamental
Terms

Suffering - Disorder, Illness - Illness Status
MANFRED BUCHSBAUMER
Digression
Since the beginning of time, suffering, disorder, illness status or illness va-
lence, and disease have preoccupied mankind; these concepts vary, depend-
ing on the century, the culture, and the social stratum in which they are in
use. No matter whose visions we contemplate - the magic-mystical ones of
the American Indians, Mesopotamians, or the shamans -, a clear definition
of what is 'ill' and/or 'healthy' is not to be found anywhere.
For a long time, the purely biomedical (or biochemical) approach to ill-
ness (Le., the attribution of the position of weakness) used to be focused on.
This dates back to Hippocrates (460-377 B.C.) of the antiquity, one of the
forefathers of the medical art. His opinion was that a mental illness mostly
explained itself by somatic causes.
With the inception of Christianity, 'illness' was extended by the notion of
guilt or guiltiness, a logical outcome of the 'original sin', which was thought
to inflict disease and death upon mankind. Both, suffering and illness were
the consequences of a culpable human behavior and were held inherent in
a superior power which interfered to restore order.
JJGod alone commands of the remedies which He has, however, admin-
istered by an all-too worldly power that fosters a sense of powerlessness in
humans in order to strengthen its own supremacy" (Buchinger 1992).
This medieval standpoint was changed radically by Descartes in the Age
of Enlightenment by his regarding man as a machine which, when ill, was
in an anomalous condition. He held reason (the mind) supreme over every-
thing else. The precise cognizance of the function of this corpus of rules
and regulations (Le., of man, or rather 'the body') is the prerequisite for cur-
ing a disorder, a task which is most usually administered from outside. This
- in today's judgment - reductionist perspective opened the floodgates to

238
Manfred Buchsbaumer
the science-oriented medicine which acknowledges evidence-based proofs
only.
As Erwin Ringel quotes the words of his friend Herbert Pietschmann,
JJThe science-oriented age has to come to the close; the earlier it ends, the
sooner we are saved; for in the sciences there is no place for love!", and he
continues, JJnot only do we miss resentment there, but love is not mentioned
either. Medicine cannot exist without love; this is the reason why medicine
has to cease to be sheer science. I emphasize the word 'sheer'; of course, we
cannot forgo the essential expertise of science. I stand by this statement and
I am committed to it, but I do add that medicine has to transcend the purely
scientific; it has to stretch to a place where the human being is whole. This
is where we have to get!" (Ringel 1991).
There is a vast variety of different disease models and concepts which
have - more or less - proved their worth. Neither the diverse psychothera-
peutic orientations, nor medicine, biology, philosophy, sociology, and juris-
prudence are in the state of providing a satisfactory and comprehensive
description.
The only exception is the social law, in which illness is a standardized
concept and thus bound to certain rights and claims: to healing, improve-
ment, alleviation of pain, or coping with problems; these concepts ascribe
the position of weakness to the patient or client. What is practically relevant
for the illness concept is the term 'disorder'. Certain disorders are given the
status of an illness or an 'illness value'. To 'value' or 'assess' involves the ap-
plication of a measure, which is triable on all levels of the judiciary system,
and the way it is handled differs from society to society. The norms accepted
by a certain culture or society determine what is considered ill, healthy, ab-
normal, etc.
With the introduction of the Austrian Psychotherapy Act in 1990, the
legislator provided the basis for redeeming the concept of illness from its
dichotomy (healthy versus ill), and for explicitly (instead of implicitly, as it
used to be the case) enriching it by psychosocial and psychosomatic factors
(see legal foundation and definitions). This also entails giving up the mono-
causal perspectives such as: JJ an ill person 'has' an illness, i.e., is in the pos-
session of pathological findings" (Engel 1960) and making the transition to a
multifactorial etiology and formulations that read as follows, JJThe label -
psychosocial or psychosomatic - is not meant to restrict illness to a oneway
psychogenesis, a socio- or somatogenesis, nor should it extend it; it rather
points to the origination of an illness, its possible course, its bio-psychosocial
impact, and its treatment options. In saying so, we are aware of the entire
spectrum of behavioral disorders and conditions of suffering - the JJpurely
physical" diseases, such as cancer, but also of the psychoses, the so-called
psychosomatic disorders or diseases in the classical sense, and the so-called
psychoneurotic disorders (Pritz 1990)".

Suffering - Disorder, Illness - Illness Status
239
An illness inevitably makes us stop short, interrupt our habits, and post-
pone planned actions. If a person is ill, she or he cannot possibly fully sus-
tain or keep up her life circumstances; she may be handicapped to an ex-
tent that all daily routines are hindered and can no longer be managed by
herself. Such a condition is usually accompanied by an intense sense of suf-
fering.
The German suffix' -heit' in 'Krank-heit' (ill-ness) originally used to denote
a person, a position, a rank, a species, or an entity.
Allocating a 'Krank-heit', an ill-ness, to a person places her in a position
that is inapt for psychotherapy. It is certainly inappropriate to add another
stigmatizing feature to a situation that is ridden with difficulties and problems
anyway; these are usually the circumstances under which the clients usually
come in for therapy. If a psychotherapist denies the label 'ill' to a client, she
or he will at first be irritated and uncertain as to what her position is. This
does, however, open the space for the patient/client to move about freely
and to work for and towards her well-being.
In our achievement-oriented society being 'ill' has turned into a stigma
which a human can no longer afford for herself (economically speaking),
without feeling guilty for her temporary inability to work/idleness (profes-
sionally, school-, family-, or relation-wise).
For all the above discussed reasons, it seemed indispensable to look for a
non-stigmatizing and less insulting concept of 'ill-ness', which was finally
found in the so-called illness status or illness value of disorders, scilicet of
disorders that qualify as diseases or are classifiable as such. All sciences re-
ferred to in this paper are urgently called upon to advance their research in
this direction, most of all psychotherapy.
The notion 'disorders of illness status or value' is thus more suitable for
psychotherapists, since it addresses and acknowledges the aspect of suffer-
ing, the deviation from the norm, the ill as well as the healthy aspects (re-
sources), and offers an understanding of the underlying conflict or problem
as generally human and changeable.
References
Kierein M, Pritz A, Son neck G (1990) Psychologengesetz und Psychotherapiegesetz: ein
Kommentar. Orac, Vienna
Buchinger K (1992) Zur Geschichte des Krankheitsbegriffes: Liber das Verhaltnis von
Krankheit und Schuld. In: Pritz A, Petzold H (eds) Der Krankheitsbegriff in der mo-
dernen Psychotherapie. Junfermann, Paderborn
Engel CLA (1960) Unified concept of health and disease. Persp Bioi Med III: 459-485.
German version in: Rothschuh (1975) pp 306-342
Pritz A, Petzold H (1992) Der Krankheitsbegriff in der modern en Psychotherapie. Junfer-
mann, Paderborn

240
Manfred Buchsbaumer
Pritz A (1992) Zur Definition von "Psychotherapie" in den psychotherapeutischen Schu-
len und ihre Implikationen fUr den Krankheitsbegriff. In: Pritz A, Petzold H (eds) Der
Krankheitsbegriff in der modernen Psychotherapie. Junfermann, Paderborn
Ringel E (1991) Was krankt, macht krank. In: Willert HG, Wetzel-Willert G (eds) Psycho-
somatik in der Orthopadie. Huber, Bern
Willert HG, Wetzel-Willert G (1991) (eds) Psychosomatik in der Orthopadie. Huber,
Bern
Translated from the German by Luna Gertrud Steiner

Personality - Personality Structure - Personality
Disorders
GERHARD PAWLOWSKY
The term personality has come to be used to describe a person only rela-
tively recently. It evolved from other concepts, such as that of the individual,
the character or the person to psychologically describe a human being as a
whole, and it has now become a term in its own right. The word "individual"
- often used as an antithesis to the word "crowd" - emphasized a single
person and their freedom to act as they please; the word "character" - which
was still denoted by the religious denomination on the baptismal certificates
of the 18 th century - stressed the characteristics of soul and behavior. "Per-
son" and "the personal" usually refer to the unique nature of an individual,
as described by the existential philosophers Gabriel Marcel and Ferdinand
Ebner, as well as Martin Buber's dialogic principle.
From these roots the term personality developed in the 20 th century. In
colloquial speech, it is rarely used unless to emphasize the noteworthiness of
a particular person, i.e., it is used almost as an augmentation of the word
"person".
In psychology and psychotherapy, the word "personality" - which Sig-
mund Freud still used synonymously with "person" or "I" in the sense of a
human being as a whole - denotes a holistic view of a person as a "psycho-
somato-sociological being" (Dolleschka 2000, 509) and as such replaces
earlier terms. A person is observed in the present, but her past is also con-
sidered, which leads to an understanding of the associated role behavior, or
the deviation from it, as well as the influence of a person's surroundings.
The term "personality structure" is closely linked to the concept of per-
sonality. It refers to the concrete and relatively stable form of the motivations,
characteristics, and behavior of a person. It is also used to describe patho-
logical conditions; for instance, when talking about a fearful or compulsive
personality structure.

242
Gerhard Pawlowsky
The concept of personality disorders, as described in the guideline, goes
back to the same roots. It is a relatively new concept: the narrower sense of
the word is just 15 years old. While it did appear in the fifth revision of the
ICD 9 from 1979, it was then used synonymously with psychopathies and
character neuroses (the term character neurosis was coined by Wilhelm Re-
ich in 1933). Hence the concept of personality disorders appears to be de-
rived from the former two terms. But there are other precursors: Sigmund
Freud writes about "personality disintegration" and, in the early 1970s, Heinz
Kohut differentiates between "narcissistic personality disorders" (which are
characterized by a lack of lust for life, by emptiness, or by functioning while
failing to achieve some sort of sense in life) and "narcissistic behavior disor-
ders" (which in turn describe a blossoming, colorful, and active narcissism).
It is not until the ICD 10 was published in 1991 that the concept was
broadened to differentiate between "personality and behavior disorders";
that is also the case for the DSM IV 1994. The term "personality disorder" as
used in the ICD 10 comprises eight different disorders: the paranoid, schiz-
oid, dissocial, emotionally unstable, histrionic, anankastic (compulsive), fear-
ful (evasive), and dependent (asthenic) personality disorders. The DSM IV
lists slightly different categories by citing subgroups or clusters. The prag-
matic concept of personality disorders is thus fully developed.
This seems to signal the renunciation of a description which included
thoughts about the causes (as did Reich's character neurosis or Kohut's nar-
cissistic personality disorder) and the orientation towards a purely sympto-
matic or phenomenological description.
References
Dolleschka B (2000) Keyword "personality" (Stichwort "Personlichkeit"). In: Stumm G,
Pritz A (eds) Worterbuch der Psychotherapie. Springer, Wien New York, pp 508 f
Swildens H (2000) Keyword "personality disorders'III (Stichwort "Personlichkeitsstorun-
gen"). In: Stumm G, Pritz A (eds) Worterbuch der Psychotherapie. Springer, Wien
New York, pp 509f
Translation by Christine Pawlowsky

Notes on the Psychotherapeutic Relationship
GERHARD PAWLOWSKY
The psychotherapeutic relationship has evolved through several stages in the
course of the development of psychotherapy. The form and significance of
the relationship between therapist and client/patient' have changed together
with our evolving image of man.
Let us go back in time. The paradigms on which the psychology and psy-
chotherapeutic theories are based on have changed in three concrete areas
over the past 100 years from Sigmund Freud's initial work to the present day.
These changes can be defined as:
- a shift from one-person-psychology to more-persons-psychology,
- a shift towards an understanding that significant learning will happen un-
der the condition of low psychic tension more than under the condition
of high psychic tension states, i.e., in relaxed situations; and further to-
wards evaluating the impact of the interaction between parents and child,
and
- a shift in the methods of psychotherapy from observation to empathy and
to a mutual understanding of reality or, as the case may be, through co-
constructing a subjective and intersubjective reality.
These new paradigms are based on a fundamentally changed concept of
man. People are no longer seen as autonomous entities that - at the pinnacle
of their development - exist independently of relationships with those around
them. We now consider an individual to be continuously involved in rela-
tionships with others and to develop from the archaic to the mature within
those relationships. The consequences of this revised concept are far-rang-
ing: while the view of man as an autonomous entity leads to an interest in
his intra-psychological processes, the focus in the latter view of man as
1 The terms "client" and "patient" will be used synonymously throughout this paper.

244
Gerhard Pawlowsky
shaped by his relationships shifts to varying relationship blueprints and the
influences of inter-psychological interactions on an individual's behavior.
In the Early History the Individual is at the Centre of Attention
At the beginning of the history of psychotherapy was Sigmund Freud. He
began his research by observing his patients' symptoms and behavioral pat-
terns from a psychological perspective. Freud used a medically orientated
model as well as mechanistic metaphors while maintaining a distant yet
courteous relationship with his patients. At the same time, he placed great
emphasis on the doctor, the "surgeon" (Freud, S. Ed., vol. 12, p 115, German:
1975, 175), who observed the patient's behavior, associations, and fantasies
under the strict principle of abstinence, "sine ira et studio", whose aim was
to assemble these elements into a classifiable syndrome and treat the latter
using the means of analysis, restoration of consciousness, and catharsis.
Freud's later work describes transference and later also countertransference,
i.e., the image the analyst brings up in the patient and vice versa, but the
therapeutic relationship still remained largely ignored. It featured (later) as a
"working alliance" and, in more casual terms, as "analytic tactfulness".
The individual and his/her intra-psychological processes provided the
central focus, and this was not particular to Freud - nearly all of his col-
leagues at the time viewed patients the way he did - it was simply a sign of
the time. At a time when the individual was only just beginning to stand out
of the crowd (crowds of manual laborers, soldiers, or those deprived of civil
rights), it was a groundbreaking achievement to shine the light on a single
person. Freud granted his patients this individuality, even when it came to
children whose independence was paramount to him, something he empha-
sized by highlighting their fantasies.
Freud and his followers focused on a one-person-psychology. The term
was coined in 1949 by the Hungarian psychoanalyst Michael Balint 2 to sig-
nify that in his theoretical work Freud conceived a person's psyche as an
autonomous machine. Freud's theories neglect aspects of relationship even
though he did engage in therapeutic relationships himself.
The concept of psychotherapy as "one-person-psychology" became prev-
alent as therapy developed further, but initially no consequences were drawn
as a result. That is to say that people did recognize that the personality of the
psychotherapist, his values, and education influenced his evaluation of the
2 "... almost all the terms and concepts of classical psychoanalysis originate ... from
one-person-psychology... That's why they can only provide us with a rough, ap-
proximate description of what happens in a psychoanalytical setting, which is in fact
a two-people-situation." (Balint 1949, quoted from Bacal et at. 1994, 307)

Notes on the Psychotherapeutic Relationship
245
client's symptoms and associations. A comparable change in the law meant
that criminal law now referred to the person committing the crime, not only
to the crime committed. One of the consequences for psychotherapy was
that empathy was stressed in approaching the patient - in spite of emphasiz-
ing a JJone-person-psychology" and focusing on the individual.
Those in the favour of using empathy in approaching a client (and some
of them founded their own schools of psychotherapy) therefore still sub-
scribed to a one-person-psychology. Carl Rogers, for instance, still devoted
extraordinary attention to one of the two people constituting a therapeutic
situation: the therapist and his attitudes. In 1942, Rogers referred to the then
sociologically common term JJindividual" (he later replaced it first with
JJclient" in 1951, and in the 1960s with JJperson"). Similarly Heinz Kohut, in
his papers between 1957 and 1981, refers to the person mainly at the ex-
pense of any relationship aspects that exist in the psychotherapeutic dyad.
Again, I do not mention these tendencies by way of criticism, but merely as
a reflection of the contemporary consciousness: in times of war, when life
was about no more than one's own survival, the ideal at the forefront of
people's minds was the individual, and this was perpetuated by schools,
further education and the church - i.e., society as a whole. It was in those
years that the individual was first starting to stand out from the crowd, and
hence there was little emphasis on relationships in the prevalent psycho-
therapeutic theories. It is also possible that among certain classes of the so-
ciety, day-to-day interactions happened more naturally and were questioned
less often; perhaps there was less of a need for analysis, and hence this natu-
ral interaction received no mention in the theories of psychotherapy.
It must be noted, however, that Freud, Rogers, and Kohut made significant
contributions to our understanding of the client/therapist relationship. Freud
came up with the notion of transference and countertransference, Rogers
pondered on the potential effects of the psychotherapist's attitude on the cli-
ent, and Kohut coined the term JJself-object", which denotes the narcissistic
relationship between the therapist and his/her patient. Yet all three of them
kept focusing on the patient's intra-psychological feelings. In their minds, the
therapeutic relationship was identical to the offer made by the psychothera-
pist to the patient (e.g., Rogers, Client-Centered Psychotherapy 1972, 61ff).
The Transition to Observing the Relationship
The two- or more-persons-psychology was first argued by Michael Balint
and was further developed in the object relationship theory in psychoanaly-
sis. The problem of two-persons-psychology was to keep a balance be-
tween observing the individual and observing the relationship or relation-
ships in the situation. While the former draws attention to the psychological

246
Gerhard Pawlowsky
processes within, the latter emphasizes recurrent actions, reactions, and in-
teractions.
Halfway through the 20 th century, developments of certain views indicate
a shift of the paradigm. In sociology, the term "participatory observation"
becomes popular and with it a school of thought whereby it is assumed that
a simple observation changes that which is observed. In physics, the Heisen-
berg's uncertainty principle gives rise to a similar phenomenon. As for psy-
chotherapy, the developments centre on group dynamics, which denote the
progression of relationships within a group, as described by Wilfried Bion
amongst others. There are theories that stress the formative power of rela-
tionships even further: for example, Jakob Moreno's psychodrama, and later
systemic family therapy which does not concern itself with the individual,
but the system itself.
Describing the relationship between two main characters is not about
indicating a simple pattern of stimulus and reaction; this had previously
been offered by behavior therapy, which also concentrates on a single per-
son. It is rather about the complicated, interwoven nature of the actions and
reactions of the client and the therapist (or, in infant research, the child and
the mother), which simultaneously happen on several levels of communica-
tion: the level of meaning, but also the levels of affection, cognition, and
evaluation.
The past fifty years have doubtless shown a trend towards the inclusion of
both the people in the therapeutic situation, which has - similar to observing
both mother and child in infant research - developed into a micro observa-
tion of the intertwined interactions of patient and therapist. John Bowlby and
his colleagues looked at the bond between mother and child, while in the
1980s Daniel Stern came up with his theory of the competent child which
is intertwined - not symbiotic - with its mother, which he describes as a
theory, taking the senses of self as the driving force in the development. In
the field of infant research, the Swiss psychiatrist Dieter Buergin deserves a
mention: he refers to a triad between child, its mother and its father that
exists right from the start. He provides evidence suggesting that even during
its first year of life a child is able to perceive not only dyadic relationships,
but also the relationship between its parents. This could be interpreted as an
approach to more-persons-psychology.
T oday's View of the Significance of the Therapeutic
Relationship
While the "one-person-psychology" model is still justifiably prevalent in the
macro areas of medicine and other sciences, it has become very clear that in
the micro observations performed by psychotherapy, the reciprocity and

Notes on the Psychotherapeutic Relationship
247
mutual relationship of client and therapist are paramount. This assumption is
supported by science and especially infant research - which has grown enor-
mously over the past years. Infant research describes the extraordinarily in-
terwoven relationship between the baby and its mother as a significant factor
in the child's development. Trauma research purports that the reaction of a
person's environment can have a considerable impact on whether the trau-
ma is exacerbated or can be dealt with by the patient. Memory data prove
that the interaction of a child with its surroundings leads to an increase in the
nerve cell network.
Two further results of the infant research have a bearing on the understand-
ing of the psychotherapeutic relationship. They are:
- a growing realization of the importance of the non-verbal aspects in the
relationship, and
- the empirically proven hypothesis that the perception, realization, and
processing of information, i.e., the learning as well as a change in the pat-
terns and attitudes are closely tied to developing trust and the ability to
bond.
It is understandable that both the child and the client draw meaning for their
feelings from the emotional connotation of the mother/the psychotherapist,
especially when the child/the client feels that this context is authentic with-
out being easily manipulated or domineering.
Robert Stolorow produced an even more common view of the therapeu-
tic relationship in his theory of intersubjectivity. In it he presumes that the
two people constituting a therapeutic setting make up an intersubjective
field in which both contribute to the situation. This is not to be confused with
the systemic theory in which the system is the focus of attention. Rather the
emphasis is on observing the process whereby two subjectivities meet 3 , al-
though understanding the behavioral patterns remains an important part of
this.
Again, there is a tension between the observation of the individual (and
his intra-psychological make-up) and the reciprocal, interactive influence
within the relationship. Once the yardstick of an objective search for the
truth is no longer applied, this could of course be viewed as precisely the
change psychotherapy can affect: at the centre is the joint construction (or
co-construction) of a view of the patient's past and present, which allows
him/her more freedom and a more meaningful life.
Stolorow and his colleagues refer to "the organizing principles of experi-
ence" (Stolorow et al. 1987) both in the patient and in the psychotherapist
which become active in the two-persons-relationship of therapy: it is experi-
3 The psychoanalyst Ernest Wolf therefore generally referred to intersubjectivity as the
"dialogue of subjectivities" (Wolf 1988).

248
Gerhard Pawlowsky
ence which "organizes" every subsequent event, that is perceives, classifies
or moulds it. The recognition of these patterns in an experience and the or-
ganizing principles at work is only a transitional stage in the patient's devel-
opment towards a more conscious handling of these patterns, while the goal
must be to deal with them freely and unselfconsciously.
The Therapeutic Relationship in the Diagnostic Guideline
The therapeutic relationship takes centre stage in the diagnostic guideline
mainly because psychotherapy - and this is now the common view - works
with it. The method of diagnostics conforms to the method of psychothera-
py: it is necessary to find out in the first encounter between the (potential)
client and the therapist as to what issues and resources the client brings to
the therapeutic situation and whether client and therapist are suited to each
other and could work together.
One objection to this could be that psychotherapy turns into a very sub-
jective process: whether a client and therapist can work together might be an
arbitrary decision on one part or the other. Surprisingly, however, this is not
the case, which is due to the sophisticated education the psychotherapist
receives, including many hours of self-experience training, which leads to
the elaborate self-reflection and the ability to be empathic. Psychotherapy
therefore remains a scientific process which includes a limited component of
subjectivity.
This subjectivity is further reduced by the therapy-contract which in-
cludes the stipulation that the therapist must relinquish any right to making
decisions on behalf of the client. In psychotherapy it is only possible to work
with the patient's experiences and to offer him/her a general, constructive
framework for his/her development; but under no circumstances can the
therapist create a certain experience for the client. The question of compli-
ance is therefore largely irrelevant in psychotherapy (except in the rare cases
of working with dependent clients such as children) because it is the client's
decision to begin and/or to remain in therapy.
So what does the therapeutic relationship entail? It involves interaction
and the resulting experiences, the reciprocity, and the mutuality between cli-
ent and therapist which create the basis on which the client can effect a
change. The therapist's offers towards the relationship, which create the
framework for the development of the therapeutic relationship, are generally
differentiated according to the method: psychoanalysis talks of reticence and
abstinence, humanistic psychotherapy calls it engaging with the client, allow-
ing the therapist to be touched by them, behavioral or systemic therapists
describe it as a sympathetic yet neutral attitude. The relationship itself is often
comprehensible only through the use of the metaphors: the "bond" between

Notes on the Psychotherapeutic Relationship
249
people, a "connection", which contains conflict, consensus, loss and gain,
i. e., an increasing component of trust, and is therefore unique in its form.
The therapeutic relationship will change in the course of a long period of
therapy, it becomes more equal, the therapist's contributions may increase,
the psychological intimacy grows, and in some cases the client - who (per-
haps for the first time) feels himself/herself understood - may develop a de-
pendency on the therapist which has to be carefully undone. Professional
therapy must also take the emotional consequences of parting into account.
A therapy between a certain therapist and a certain client results in a
unique relationship which cannot be reproduced by another therapist in rela-
tion to the same client. The therapist's personality adds to this uniqueness.
Therefore the diagnostic guideline emphasises the dimensions of the thera-
peutic relationship, precisely because the uniqueness of the relationship be-
tween both "partners in therapy" is the biggest agent of therapeutic change.
References
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hungstheorien - Brucken zur Selbstpsychologie. problemata fromann-holzboog 132:
Stuttgart-Bad Canstatt 1994)
Balint M (1949) Wandlungen der therapeutischen Ziele und Techniken in der Psycho-
analyse. Int J Psa 31 (1950), pp 117-124. Also in: Primary Love and Psycho-Analytic
Technique. Tavistock, London (1965) (German publication in: Die Urformen der
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Bowlby J (1969) Attachment (Attachment and Loss, vol I). Basic Books, New York (Ger-
man translation: Bindung. Kindler, Munich 1975; Fischer, Frankfurt aM)
Burgin D (1998) Triangulierung. Der Obergang zur Elternschaft. Schattauer, Stuttgart
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mund Freud Studienausgabe, Erganzungsband: Schriften zur Behandlungstechnik.
Fischer, Frankfurt aM 1975, 171-180 (English translation in: Standard Edn, vol 12,
pp 111-120)
Freud S (1912) Zur Dynamik der Obertragung. In: Sigmund Freud Studienausgabe, Ergan-
zungsband: Schriften zur Behandlungstechnik. Fischer, Frankfurt aM 1982, 157-168
(English translation in: Standard Edn, vol 12, pp 97-108)
Kohut H (1957) Introspection, empathy, and psychoanalysis: an examination of the rela-
tionship between mode of observation and theory. J Am Psychoanal Assoc 7: 459-
483 (German translation: Introspektion, Empathie und Psychoanalyse. Zur Beziehung
zwischen Beobachtungsmethode und Theorie. In: Heinz Kohut: Introspektion, Em-
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und Forschung und zur Psychologie der Kunst. Suhrkamp, Frankfurt aM 1977, 9-35)
Kohut H (1977) The Restoration of the Self. International Universities Press, New York
(German translation: Die Heilung des Selbst. Suhrkamp, Frankfurt aM 1979)
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Gerhard Pawlowsky
Rogers CR (1951) Client-Centered Psychotherapy. Houghton Mifflin, Boston (German
translation: first: Die klientbezogene Gesprachstherapie. Kindler, Munich 1972; later:
Die klientenzentrierte Gesprachspsychotherapie. Fischer, Frankfurt aM 1994)
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und Anwendung. Klett-Cotta, Stuttgart
Stern DN (1985) The Interpersonal World of the Infant. A View from Psychoanalysis and
Developmental Psychology. Basic Books, New York (German translation: Die Lebens-
erfahrung des Sauglings. Klett-Cotta, Stuttgart 1992)
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jective Approach. Psychoanalytic Inquiry Book Series, vol 8. The Analytic Press,
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Selbstpsychologie. Suhrkamp, Frankfurt aM 1996)
Translation by Christine Pawlowsky

The Psychotherapeutic Relationship - an Explosive
Power in Principle
GERDA MEHTA
Introduction
Relationships shape people. Relationships influence, anchor, and re-confirm
people. They frame the content of stories and build history which preform
identity and biography for individuals as much as for groups, societies, even
nations and humankind in general. They become alive in community, through
which meaning is preformed, performed, and projected into the future.
The concept of diagnostics, the diagnostic instruments and their applica-
tion are intertwined with the dynamics of terminology and ideas. They are
being shaped by the zeitgeist and psychotherapeutic school traditions. They
are embedded in scientific, professional, communal, political, economic,
and pragmatic discourses as well as in their corresponding institutional
(power) structures. And so is the individual diagnosis by its application in
individual cases, when the diagnostician tries to capture, describe, and justi-
fies the necessity for cure or intervention for support to reach wanted/ex-
pected changes.
The psychotherapeutic relationship is - as any other work relation - lim-
ited in time and has a clearly intended purpose. It is and should remain a
tool to achieve a certain goal. It is a temporary, more or less short-lasting
relationship. When it is mastered well, it leaves hardly any traces but brings
forth good outcomes/effects. Through the therapeutic relationship, healing,
change and dissolution of suffering should evolve. The therapeutic relation-
ship should enhance postures and ideas that can be put into practice for
living one's own life in a more appropriate way and contribute toward a
more compatible living within one's social surroundings as well as to a con-
gruent contribution to the lives of others. Sometimes its goal is a better un-
derstanding of oneself and others, which also is a legitimate purpose.

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The therapeutic relationship needs a safe and a protective environment; it
needs to be safe in order to become a shelter in rough times, or when one is
working through rough times in his or her experience. To create and main-
tain essential confidence in psychotherapy and in psychotherapists, psycho-
therapists are guided by professional standards - by a binding ethical code
and, in many countries, also by a pertinent legislation.
The psychotherapeutic relationship is an essential part of psychotherapy
as well as an important tool. Specific ways of approaching and shaping the
encounter, its contents, postures and adjacent settings are essential to make
it work. The special ski lis of psychotherapists to create a space, atmosphere,
and a stage as well as the mastering of adjacent components of this relation-
ship ensure its effectiveness. This essential psychotherapeutic skill is learnt
over many years of supervised school and modality specific training. The
internalization and authenticity of this effective therapeutic posture and tool
are fostered in all psychotherapeutic schools.
The Dynamic Impact of Therapeutic Relationships
A general survey of psychotherapy around the world states the central im-
portance of the relationship in all psychotherapeutic treatments. JJThe basis
for treatment is the relationship between psychotherapist and patient or, in
a non-clinical setting, with the client. JJ (Pritz 2002, 13). Many years earlier
Sigmund Freud dealt in his work with the aspect of transference love and
emphasized that transference love in a psychotherapeutic relationship is not
true love. He mentioned the danger and potentially explosive impact this
professionally created love can have that it needs as careful handling as a
chemist engages in when handling chemicals (The dynamics of the transfer-
ence 1957).
The psychotherapeutic relationship is a professional, in many aspects
one-sided companionship. This relationship is set to make many things pos-
sible (again): psychological and social injuries as well as intimidated aspects
and denials should be healed; the patient should (re)gain courage and con-
fidence, actively engage in his/her life and interact with others to his/her
contentment; s/he should find and manage an expectable balance between
experiencing, enjoying, enduring, and active creating. The psychotherapeu-
tic relationship supports, in many cases even enables and brings forth the
change, by providing stability, by working on and establishing a justified
hope for change. Within this seemingly natural, yet artificial relationship,
patient and psychotherapist can experiment and co-create, (re)assess goals
and possibilities, check effectiveness and (re)adjust to circumstances. It can
become a platform to be prepared and equipped for adaptation in natural
surroundings.

The Psychotherapeutic Relationship
253
The psychotherapeutic relationship can be compared with a mother-
child-relationship which is just there, but in fact it is securely established.
This enables the child to find her way in this world, to get along in her sur-
rounding and "conquer" it by exploring and interacting with it, some even
say by co-creating it. Through this relationship the child can actively partici-
pate in the world and also experiment and develop. The therapeutic relation-
ship is set to provide the patient with a similar kind of support.
Characteristics of a Psychotherapeutic Relationship
Family and social networks, i.e., people who want to be able to live together
and have to do that day by day, manage to meet their needs and necessities
by living together or by doing it to a limited or even unacceptable extent.
One may assume that patients consult psychotherapists due to their ecologi-
cal/social/psychological imbalance or shortcomings. From their point of view
(or of others who have an influence on them), they cannot effectively and
sufficiently deal with the necessities of life, with themselves and social net-
works, with what is disturbing them or others; and there is a hope that it
could be different.
The psychotherapeutic relationship is a means to achieve a goal. It is a
fine tool that needs a lot of practice, care, professional engagement, and cau-
tion when administered. The therapeutic relationship ends when the set goal
is achieved. The psychotherapeutic relationship is successfully administered,
when intended therapeutic results emerge. Gradually the impact of the psy-
chotherapist on the patient's life will diminish. The patient will be enjoying
his/her own achievements and consider psychotherapy as a path already
walked, in the optimum case - without being attached to the psychotherapy
or psychotherapist with a feeling of thankfulness or dependency. Psycho-
therapy is claimed to remain just a service, having had its successful impact
without any further necessities arising from it.
The psychotherapeutic relationship is a special kind of encounter. Its
components are planned and its impact reflected. Each step needs fine tun-
ing and adjustment within a larger process and is adjusted with special pro-
fessional expertise. Each situation has its relationship-based offers and re-
quirements which are based on the circumstances and requirements of the
respective patient in that given moment and furthermore for the general, in-
tended process.
Therapeutic relationships are established in a way that they support heal-
ing, convalescence, and recovery for patients, and this is and should remain
the only reason for establishing and continuing such a relationship. It is a
specific professional relationship, even if it sometimes appears like a relation-
ship to a very close and reliable person. The psychotherapeutic necessity for

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Gerda Mehta
discretion guarantees that the relationship remains limited to the therapy ses-
sions and remains one-sided in its nature. The psychotherapists' effort is be-
ing covered by the payment or is part of their job. The patient's gain for the
payment should be contentment.
According to the professional and ethical standards, this relationship ends
when the therapeutic goal is achieved. The established necessity for discre-
tion ensures the protection of all the secret issues arising during psychother-
apy, so that the patients get to deal with their innermost issues without being
confronted with social consequences afterwards. According to psychothera-
peutic representatives of various traditions, this helps initiate and facilitate
changes in the patient's perception and behavior.
One needs to continuously administer diagnostics on the therapeutic re-
lationship and finely (re)tune it during psychotherapeutic treatment. It is not
a tool like the coat one wears when visiting someone in an intensive care
unit, which fits many visitors. Psychotherapeutic relationships need to be
specifically tailored to the person, her/his specific personality with his/her
ways of living, peculiarities and resources, potentials and biography, and
therapeutic goals that become relevant during psychotherapy. The relation-
ship has to be invented, tailored and molded with each individual, and on
top of it - it needs to be continually adapted and reshaped during the psy-
chotherapeutic process and progress; the psychotherapeutic relationship
needs to prove its effectiveness for the individual and his/her needs, poten-
tials and goals by the progress of the patient. Psychodiagnostics of the rela-
tional aspects itself helps to master that delicate dance between performing
and forming the basis for change and breakthrough to a better life and liv-
ing.
Psychotherapists work on the development of the relationship, its capac-
ity, support and efficiency, in order that the inevitable burdens of the psycho-
therapeutic work (confrontations, irritations, frustrations in order to motivate
to make change happen) can be mastered for the patients' benefit. Diagnos-
tics that becomes relevant for psychotherapy enables understanding and its
reshaping during the encounter, as Ulrike Borst states (2003, 210). Profes-
sional experience and knowledge are utilized within the very special and
specific therapeutic process. A functional psychotherapeutic relationship can
be recognized by the effectiveness of the psychotherapeutic interventions.
The desire for continuation and the hope for an eventual effective impact on
both sides, patients and psychotherapists, may be a further indication for a
positively mastered psychotherapeutic relationship.
Harald Goolishian and Harlene Anderson described human systems
(people) as language- and meaning-generating systems (1988). Meaning and
understanding are being constructed socially and inter-subjectively. The
problem, the request or the pathologic disorder are the reasons for entering
a psychotherapeutic relationship. They legitimize the use and maintenance of

The Psychotherapeutic Relationship
255
this tool. Psychotherapy then becomes an engagement in a continuous dia-
logue, in which new meanings are generated continuously, until it finally re-
sults in the dissolution of the problem as well as of the therapeutic relationship
(problem-dissolving system, 190). Similarly, De Shazer (1988, 218) describes
everything a psychotherapist deals with as a construction of the way patients
construct their reality; based on this, both patient and psychotherapist create
a therapeutic reality. Meaning and attributions are shaped and sharpened,
sometimes replaced and changed by language and negotiations, as words can
generate novel meaning through intentions, interpretations, and social im-
pact, through their use and in the dialogue and interaction with others.
Psychotherapists are part of the therapeutic system and feed the process
with differentiation and opening views by introducing new aspects. They
participate in the quest for differentiation and change in perspectives or
change in positioning so that the irritating, the disturbing, the "symptom", the
"personality aberration" can be let go or becomes irrelevant. This way of
describing has been borrowed from the systemic family therapy coding;
members of other psychotherapeutic modalities would use a different vo-
cabulary.
Within the therapeutic process an authentic, familiar and yet special lan-
guage develops, which is useable for the inner and outer life of the patient.
On the basis of a stable relation the therapist stimulates the client to bring
forth progress. Moments of clarity and deepening of understanding are inter-
rupted by puzzlement, curiosity, enthusiasm, and amazement that call for
integration in one's understanding and biography. Distancing becomes pos-
sible for the too close, traumatized and traumatizing and hurting aspects,
and play with possibilities and new decisions arises. The search for the cor-
rect wordings sharpens the perception, differentiation, and meaning. The
shift of keywords can indicate change. Helm Stierlin writes (1994, 16) that as
long as the relationship remains alive, contradictions and contrasts are being
generated but are also balanced at the same time. He describes this dynam-
ics as relationship dialectics and requests a dialectic description of this dy-
namics. In psychotherapy, that dynamics is in the service of reaching the
therapeutic goal.
The psychotherapeutic posture is characterized by oscillating between
the empathy for the way the patients perceive and describe their world and
a slightly different, more distancing and reflecting approach, setting other
kind of interventions, based on methodology and theory. The reactions to
these interventions are additional psychodiagnostic information for further
relationship-based offers and interventions. The various critical moment-
based observations indicate relationship-based clues on various levels (cog-
nitive, emotional, physical, expressive promotion of one's self and public
image, appearance, relation to others, etc.). The psychotherapist directs his/
her attention towards how the patient presently talks about his/her experi-

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Gerda Mehta
ences, how s/he phrases his/her concerns, how he/she presents him/herself
in general, how s/he invites or excludes the therapist from collaborating/en-
tering on the very point and moment in time, etc.
The psychotherapist's attitude towards the process of change is guided by
the enhancing and encouraging trust. Exceptions are only made when it is
not considered appropriate from a professional point of view. In general the
attitude towards patients is benevolent and the therapists are empathically
interested in the persons and their concerns, but they ignore and discard
conversations and issues irrelevant for the therapeutic process.
The way the therapeutic relationship can and should be realized in a
therapeutic process is to actively encourage and bring forward a change,
which eventually also can be experienced in the way the patient responds
within this relationship during the psychotherapeutic process. The fine tuning
of the materialization of the therapeutic relationship is established within
planned modality- and school-specific approaches. Changes within the psy-
chotherapeutic setting can be emphasized and utilized, sometimes even
deliberately brought forward, as they can reinforce and bring confidence.
The change within the therapy session eventually can become a model for a
change also outside the therapy setting.
Reflections on Participatory, Continuous Diagnostics
Psychotherapists consider themselves as an influential part in the psycho-
therapeutic process, starting with the initiation of the psychotherapy till its
termination. Therefore they are also an essential factor in the psychothera-
peutic diagnostics. The capability of a professional reflexive encounter for
the purpose of being helpful towards healing with nearly any patient is the
product of a professional development of psychotherapists over years of su-
pervised and guided training. There are no specific general schemes that
could be clearly and usefully described and objectified for any case without
distorting the relevant information for the therapeutic endeavor itself. It is the
active unique encounter that makes an effective therapeutic process. Thera-
pists correspond to the immediate experience and the very local meaning-
making co-created with the patients. In the therapeutic process the patient
and therapist are intertwined with each other. Isolating the therapist aspects
or patient aspects would detach them from the effectiveness in the immedi-
acy of the local interaction; it would lessen their usefulness for guidance and
planning the interventions. So far developing manuals of conduct have had
limited effect (Hubble, Duncan, Miller 1999).
'Objective' measurement influences that encounter. But the discussion
with colleagues and other professionals for the purpose of collaboration
needs other categories for description, another more distanced and descrip-

The Psychotherapeutic Relationship
257
tive language. It is another context where other language and principles be-
come relevant, and transformation of information into other languages are
needed for relevant communication on that level.
During their training, psychotherapists need to experience a multitude of
encounters with patients and engage in supervised reflections on their ac-
counts of these processes to acquire a wide repertoire of psychotherapeutic
skills and reflective self-criticism. Such skills include immediate re-acting and
observing the impact of one's actions: reflecting on the present interactions
and at the same time finding alternatives of interacting when indicated, and
more. During their practical training, psychotherapists are able to gather a
wide range of experience with professional contexts and people from various
backgrounds. They learn how to interact with people with different histories,
origins, upbringings, cultures, problems, psychic stress, illness, or emotional
misery. They learn how to tune into their ways of communicating and set the
stage of interacting on what is especially relevant to them, as the therapists
need to effectively and adequately use that encounter for the healing process
or for helping them deal with their issues. In their training, they gather ex-
plicit and implicit standards for the assessment of local necessities, for form-
ing relationships as well as competence for realizing malignant processes
and engaging in helpful alternatives. They need to become able to observe
their specific impacts and, at the same time, engage and make prognoses of
the possible impacts, of possible alternatives and choose the more helpful
ones.
Psychotherapists also learn to recognize and to check their own emerging
interests, personal needs, upcoming thoughts and emotions in the psycho-
therapeutic encounter and to deal with them; they might be irrelevant and
counterproductive for the very psychotherapeutic goal. This specific ability
of reflecting and dismissing one's own needs, passions, and wishes within the
therapeutic session as well as the one-sidedness of this particular relationship
are essential quality standards of psychotherapeutic ways of forming relation-
ships. Supervision and intervision (among colleagues) are the right places for
discussing such personal issues that happen to even experienced therapists.
The specific engagement and behavior of the patients in their attempt to
approach psychotherapists and the encounter with the therapists are valua-
ble psychotherapeutic diagnostic criteria: recognizing how patients react to
the invitations of the therapist, what patients find interesting, how they set
the stage from their side, what they reject, ignore, sometimes not even per-
ceive, the reactions to verbal or nonverbal invitations, the way of presenting
themselves at the first time, their stories they bring with them, their ways of
using space and much more. These conceivable/observable parameters are
potential indicators as well as parameters for changeability, particularly in
their aberration of the expected, and become useful within the therapeutic
process.

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Gerda Mehta
Visiting a Psychotherapist; Initiation of the Psychotherapeutic
Relationship
Relevant diagnostic considerations on forming a specific psychotherapeutic
relationship start even before the patient and the psychotherapist meet. Con-
siderations to undergo therapy contribute to a JJspace for encountering JJ , so
do exchanges about experiences of other people with the therapist and psy-
chotherapy in general, announcements of psychotherapists, and contact
modes (website, folders, official lists as well as referral modes). Also the first
telephone contact and location of practice give indications.
As most patients actively search for a psychotherapist, and there is usu-
ally no shortage of therapists, it can be assumed that patients are self-moti-
vated, have chosen to meet a psychotherapist on their own free will. Most of
them have already gathered some information about the psychotherapist
before they approach him/her. Patients activate their own previous psycho-
therapeutic experience in a new psychotherapeutic encounter, and this
shapes the relationship between the patient and the psychotherapist. Some-
times these influences can be detected only later and they may even become
issues in the course of the psychotherapeutic process.
In the beginning, the psychotherapist approaches the patient with being
open, non-judgmental towards values, morals, lifestyles, and expectations.
The psychotherapist notices the patient's invitations and demands and gets
involved in the process, in which - depending on the psychotherapeutic
modality - special aspects are stressed and featured that seem to be useful,
others that seem to be irrelevant or even counterproductive to achieving the
psychotherapeutic goal are ignored.
Reduction of complexity becomes necessary for understanding the pa-
tient and his/her goals, for designing and building a relationship accordingly
and for planning interventions. Each psychotherapeutic school sets its own
specific methodical emphasis.
One category for systemic family therapists, for example, is to distinguish
between clients, visitors, and complainants. With this categorization, sys-
temic family therapists want to capture their patients' motivation as well as
their expectations, in order to become capable to respect and meet the pa-
tients' compliance. This tool rests on the theory that the assessment of the
patient's own motivation as well as his/her readiness to comprehend them-
selves either as active partners of the process of change or passive victims of
destiny, are very important tools for planning interventions for systemic fam-
ily therapists. That motivation and readiness for his/her engagement need to
be reassessed continuously - even within a session and for each topic and
goal, as we assume, psychotherapy is inherently a dynamic process that is
principally open to change at any moment. Systemic family therapists prefer
to direct their attention towards and especially look very carefully for clues

The Psychotherapeutic Relationship
259
of change and novelties in thinking and perceiving and languaging: by de-
picting change in views and language use and also (re)shifting of goals.
The special mode of the school and modality the therapist belongs to
shape the psychotherapeutic relationship. The ability of self-reflection, ex-
perimenting with and testing the effect of alternatives or of his/her own con-
tribution to the actualization of the therapeutic relationship patterns are
continuous essentials in the diagnostic process.
The therapeutic relationship can, however, turn into a process that makes
progress difficult or impossible. It can even be counterproductive and harm-
ful - a reason for ending the psychotherapy. Moreover, the psychotherapeu-
tic relationship can slip into another relationship and transform into an ex-
ploitation for personal advantage, as it is also in the JJserviceJJ of the therapist,
like friendship, competition, fight, emotional closeness, intellectual chal-
lenge. It can even slip into uncontrollable dependency or grow into an
erotic relationship. Ethical guidelines, psychotherapy laws, criminal laws,
quality standards, and professional knowledge are reminders and warning
lights for this not to happen or to be continued. Supervision and intervision
with colleagues help to not prolong such malignant encounters, and to dis-
rupt and redirect these developments.
Requirements for Psychotherapeutic Service
As mentioned above, the individually tailored way of forming a psychothera-
peutic relationship, its constant reassessment and reshaping in the service of
reaching the psychotherapeutic goal are based on professional knowledge as
well as practical skills. Patients bring their desire for the change and urge for
the dissolution of the troublesome. Psychotherapists display their professional
competence: their knowledge, their skills for precise perception, their empa-
thy for people with their needs and desires, their curiosity, positive thinking,
hope for change, their engagement in the language of the patient, creations,
life styles and capabilities to modulate, and a big repertory of interventions in
the relational space, their routine questioning and examining of their own
perceptions, hypotheses, and intentions and checking their actual impact,
their ability and readiness to reflect on the overall therapeutic process and
take supervision, while keeping up with the ethical standards (of their profes-
sion). The psychotherapist makes an assessment of his/her own competence
for the specific patient and problem and his/her willingness for referral when
his/her limits are reached or further competences are required.
About notions of setting, contents and goals of the psychotherapy or the
prospect of it, an overlap between the patient and the psychotherapist is re-
quired. Furthermore, availability of time, space, financial capabilities, toler-
able circumstances of life, ability to keep appointments, a sense and willing-

260
Gerda Mehta
ness of expressing oneself as well as the ability to think and verbalize and
consider possible alternatives, a willingness to get involved and collaborate
are among the basic requirements that need to be present from the begin-
ning, or they have to be fostered.
Before, after, and within the first couple of therapeutic sessions psycho-
therapists reassess the patient's willingness to commit to the psychotherapeu-
tic process as well as reassess its possibilities of becoming effective. These
considerations are essential for deciding whether to terminate or to continue
the process. The need of deciding about continuation arises especially in the
initial phase, and fades as the therapy progresses. Basic - but not blind - trust
on the patient's side in the psychotherapist's engagement, capability and
methodology is required. However, they don't have to agree in their outlook
towards the world and people and way of being. If the patient's self-percep-
tion and social responsibilities are impaired, it may be necessary that the
psychotherapist sets intermediate goals to strengthen the therapeutic rela-
tionship and the collaboration. S/he may also include other professionals and
family members in order to meet basic therapeutic cooperation.
Before a psychotherapeutic agreement over a prolonged period of time is
established (long term therapy), more assessment is necessary. Early on in the
process, psychotherapists make a decision about their own willingness and
capability whether a planned, methodology-based relationship seems princi-
pally manageable and conceivable with this particular patient for him/her
and if a potential for collaboration on the desired outcome can be assumed.
Furthermore, it has to be assessed if entanglements with other social roles
can be excluded and if the patient's appearance and views of the world and
people can be generally tolerated by the psychotherapist.
Psychotherapists make an effort to initiate a therapeutic process that is
eligible for the specific patient. It is one of the finest, the most desired quali-
ties of psychotherapy to diagnose what it needs in the very moment for the
overall process and to continuously (re)set a stage that can effectively shape
and form the psychotherapeutic relationship in order to use it as an effective
tool for achieving a psychotherapeutic goal. Patients are principally accepted
as they are and how they present themselves, how they live, and how they
manage their lives. Their personal capabilities, social behaviour as well as
their psychic plight are especially acknowledged.
Ending the encounters with termination of the therapy guarantees that
no other social interactions develop from this very intimate process.
Through this very intense and one-sided psychotherapeutic encounter, ex-
pectances, dependency patterns, and misinterpretation may be carried on.
These past ways of one-sided interacting do in general lead to difficulties in
every-day relationships. The therapeutic relationship is a natural-looking but
highly technical encounter. The patient cannot be asked to distinguish
between them. When no special care is taken this may lead to detrimental

The Psychotherapeutic Relationship
261
and malignant misunderstandings in case of continuation outside the ther-
apy.
Psychotherapists reflect on their psychotherapeutic-diagnostic findings
and results within professional settings, e. g., by writing protocols, engaging
in supervision, case studies, and continuous education. Their own behavior,
their assumptions and perceptions are also periodically re-questioned and
enlarged/deepened within professional learning settings. It could be that the
very assumptions of the therapist make the patients' problem persist (e.g., a
schizophrenic man or a depressive woman becomes a stigma, that freezes
them in this role, as how the therapist conceptualizes a problem has an ef-
fect on the gathering of information and on the interventions. His/her recon-
sideration might lead to better results).
Relationship-based diagnostics for the exclusion of the patients from psy-
chotherapy can be found in chapter 1, A./IA.
The requirements for psychotherapy on the patient's side:
The basic setting can be managed and met (e.g., appointments, punctual-
ity, payments);
Patients engage voluntarily in psychotherapy, in principle;
Patients have hope and trust in the psychotherapeutic outcome;
The process is established and remains within the preset limits of the psy-
chotherapeutic relationship (usually sitting and discussing issues and con-
cerns within a preset time limit, or an agreement when aberrations take
place).
References
Anderson H, Goolishian H (1988) A view of human systems as linguistic systems: pre-
liminary and evolving ideas about the implications for clinical theory. Family Process
27: 371-393
Borst U (2003) Diagnostik und Wissen in der psychiatrischen Klinik: bis wohin nutzlich,
ab wann hinderlich? Familiendynamik 2/28: 201-218
DeShazer S (1988) Therapie als System. Entwurf einer Theorie. In: Reiter L, Brunner E,
Reiter-Theil S (eds) Von der Familientherapie zur systemischen Perspektive. Springer,
Wi en New York, pp 217-230
De Shazer S (1991) Putting difference to work. WW Norton, New York
Freud S (1957) The dynamics of the transference. In: Collected papers, Vol II. Hogarth
Press and I nstitute of Psycho-Analysis, London
Hubble M, Duncan B, Miller S (1999, German 2001) The heart and soul of change. What
works in therapy. APA, Washington
Pritz A (2002) Globalised psychotherapy. WUV Verlag, Vienna
Stierlin H (1994) Ich und die anderen. Psychotherapie in einer sich wandelnden Gesell-
schaft. Klett Cotta, Stuttgart

Crises and Risk Potential
HEINER BARTUSKA
A wide range of literature deals with psychological crises and how they
should be perceived and psychotherapeutically dealt with - issues we could
subsume under the title 'crisis intervention'.
What the authors and the other experts who contributed to the Diagnos-
tic Guideline for Psychotherapists still miss in the technical literature is the
factor of diagnostics that relates to the professional assessment of a patient's
susceptibility to crises.
The Diagnostic Guideline is the first attempt to define the criteria for the
assessment of this risk potential (RP).
The necessity of engaging in the issue of the risk potential during the
elaboration of the Diagnostic Guideline first arose from the perspective of
indications, an issue psychotherapists are quite familiar with (see chapter
A.l1.3.2. of Diagnostic Guideline). It also emerged from the need for referral
and from the obligation to collaborate with other health professionals, par-
ticularly physicians and health care institutions (medical specialists, outpa-
tient clinics, hospitals, etc.). Before this definition had been undertaken in the
field of psychotherapeutic diagnostics, the criteria for the necessity for refer-
ral used to be vague and were left to the psychotherapists and to the best of
their knowledge.
For this reason these criteria had to undergo redefinition.
Another stringent reason for the redefinition of the RP came up during the
discussions by the study group. The issue of assessing the propensity to suffer
a crisis is of particular importance where intended and deliberate confronta-
tions provoke (call forth) a crisis in a patient, which he, prior to this confron-
tation, may in most cases anticipate, but which he can also easily ignore,
shift or deny. This usually happens with patients whose lack of stability or
ego-strength at first does not allow them to work on their latent crises, not
even with the assistance of their psychotherapists. During the psychothera-

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Heiner Bartuska
peutic process, recovery, growth, and the developmental potential usually
will be enhanced to the extent that the dormant crisis, held back hitherto, is
rendered manageable. As the developmental process proceeds, this working
through apparently becomes a necessity, because the forces confined in the
latent crisis have to be loosened and set free in the psychotherapeutic dis-
course, tested as to their applicability in real social situations and as to their
adequacy when life has to be mastered. This is the only way the patient's will
power will be strengthened further. To that end, the stability of the patient
must be estimated as reliably as possible, and also whether he is sturdy
enough to face the precipitation of a crisis covert thitherto. The Diagnostic
Guideline was the first occasion to endorse crises with a more accurate
definition.
A more appropriate word for a patient's leaning towards crises would
probably be 'critical potential', since this term more clearly points to the
forces and dynamics of how a crisis comes about and whether it tends more
towards chances or risks. It is particularly important to assess the patient as
to which critical potential she exhibits in the intake interview.
Menninger's (1968) deliberations were helpful in this respect when he
expounded his basic approach to illnesses according to the risk potential
they involve.
References
Bronisch T, et al (2002) Krisenintervention bei Personlichkeitsstorungen. Klett-Cotta,
Stuttgart
Dros M (2001) Krisenintervention. Hogrefe, Gottingen
Menninger K (1968) Das Leben als Balance. Piper, Munich
Riecher-Rossler A, et al (2004) Psychiatrisch-psychotherapeutische Krisenintervention.
Hogrefe, Gottingen
Son neck G (2000) Krisenintervention und Suizidverhutung. UTB, Stuttgart
Willenweber E, Theunissen G (2001) Handbuch Krisenintervention. Kohlhammer, Stutt-
gart
Translated from the German by Luna Gertrud Steiner

Reflection - Self-Reflection - Self-Awareness
HEINER BARTUSKA
The role of reflection is frequently addressed within psychotherapeutic diag-
nostics, and most prominently so in the Diagnostic Guideline. All issues re-
viewed therein unmistakably presuppose the psychotherapists' ability to pro-
vide self-reflective answers. If we inspect the reflective and self-reflective
abilities more closely, the first question we have to ponder is how the com-
petence of reflection is related to self-reflection. Before looking into this
more deeply, we should clarify which shades of meaning are implied in the
term 'reflection'.
I personally translate 'reflection' primarily as 'casting or mirroring back',
which is a strange expression since it is partly tautological or redundant; in
physics, the act of mirroring is, however, the radiating back as opposed to
absorption or scattering. Not every mirroring implies that the reflected rays
go back to their original source or issuer of the light. The reflected rays may
also hit a completely different object, in case the mirror is not level or plane
or aligned properly. If the mirror consists of a strip of metal, it is easy to
transform it into a concave or convex one by bending it slightly, thus causing
either the focusing or the diffusion or dispersion of rays.
The extent of the reflected part depends on the quality of the medium.
Opaque objects reflect part of the incoming light and absorb the other.
Some objects are transparent, some translucent. Depending on the material
and on the thickness of the object, the light partly passes through, or is re-
flected, scattered, or absorbed. The extent of the reflected part depends on
the quality of the medium. It is quite obvious: an image is formed by the
reflection of light rays. Real and virtual images accrue in the course of mir-
roring processes. Real images can be made visible on a white screen, for
instance, whereas virtual ones are not optically visible on it.

266
Heiner Bartuska
The dispersion of light rays into a spectrum produces the verifiable distri-
bution of the variety of colors contained in normal white light, and they are
radiations of different wave lengths.
To add one more facet, the relative openness and receptivity of the object
which the reflected light will hit has to be taken into account. If, for instance,
we observe a high degree of absorption (obscuration) in the receiving object,
the reflected information has to be structured provisionally and according to
its goal, in order to heighten the probability of this information to arrive cor-
rectly.
In doing so, we should also be aware that the reflected rays are in them-
selves bits of information which, according to the information theory, are
structured in a more or less redundant or complex way. For the recipient to
process this information, it certainly has to be simple in structure, less com-
plex, and as little contradictory in itself as possible, which implies that the
different parts of the reflection must not be inconsistent with each other.
If the participating objects have agreed on an appropriate and codified
information system and accustomed to it by practice, the reflection and the
feedback of the needed messages will happen smoothly and automatically
and not require any further effort. If, however, the reflection of non-codified
information is required because there is a corresponding need for action,
complications will arise and effort will be needed, since each information
that is reflected both ways has to be subjected to the above described pro-
cedure of adjustment and recodification. This is, for instance, the case when
the course of a dialogue has to be coordinated lest the two partners speak
or listen simultaneously. As a self-evident example the Morse alphabet
comes to our mind, which is a defined structure of letters or characters and
which, hence, corresponds to a script. Naturally, any other definitions of
these characters are imaginable. Since we have to assume that there is a
large number of signal or character definitions and, moreover, lingual mean-
ings, understanding seems most unlikely to succeed at all. Admittedly, we
are aided by the similarities of the languages and common meanings, so that
understanding via different signal or character definitions and also lingual
meanings works or is at least approximated. Precisely from this, we may de-
duce the error probability score, which directly correlates to the degree of
similarity between the signal definitions and the lingual meanings. We may
only tentatively assume the sameness of the signal definitions and lingual
meanings, and we have to check the success of information transfer and
correct and/or even recodify it. Since we have to assume that a 1000/0 trans-
fer of information is not feasible by human communicative means (digital
data transfer such as the copying of a CD is the only 100% successful way),
corrigibility and improvability will always remain relative.

Reflection - Self-Reflection - Self-Awareness
267
Application of these Analogies to the Reflection Training of
Psychotherapists
According to Random House Webster's Unabridged Dictionary, reflection
means reverberation, and the verb 'to reflect' means 'to cast back' (light,
sound, heat, etc.) from a surface; reflection is also: the fixing of thoughts on
something - the careful consideration or a thought occurring in considera-
tion or meditation. 'To reflect' further means 'to give back or show an image
of'; 'to mirror; to think, ponder, or meditate; 'to ruminate, deliberate, muse,
consider, cogitate, contemplate'. The verb was testified in Middle English
(reflecten) as a loan word from Latin reflectere 'to bend back'.
As for the psychotherapeutic self-awareness training, two main goals may
be distinguished: (1) the improvement of one's handling of conflicts and
problems, and (2) enhancement of the ability to differentiate more clearly
between one's own and the other's contributions to relationship matters.
In order to look more closely into the reflection training as such, we draw
on another analogous example, this time from basket ball. For developing
and learning a practical skill, if we resort to the case of an ordinary basket
ball training unit, we come to realize that it is obviously goal- and success-
oriented. Every ball that finds its way into the basket is valued as a success,
whereas the numerous attempts and learning steps towards this are taken
little notice of. In such a process many mistakes are, however, appreciated as
important feedback (whether the ball has been thrown too short, too high or
too vigorously, whether too much thrust had been applied, etc.), and their
correction is undertaken immediately. In doing so, the failings - their causes
or their quality - usually remain unnamed because it is assumed that the
player himself and all the trainers/bystanders have noticed anyway what the
mistake was. In a few cases only the trainer or, more frequently, the training
partners will give a few hints, or utter words of support or criticism. Training
within a group setting thus is a reinforcement factor, in form of encourage-
ment in case of success, and of intensified advice, supportive statements,
and constructive criticism or, occasionally, depreciation by the colleagues.
Trainings are evidently run according to the trial and error principle and do
not follow the steps as prescribed by text books or theories.
In complete analogy to this model, the reflection training of personal
growth is practiced along the lines of trial and error methods - the success
being noticed and reinforced, the failures frustrated. Thus, a theory is not
necessary yet during the training. Specifications of theory may, however, en-
able the coach to be more accurate and unambiguous in his ideas on the
course taken and on the techniques used and to offer a more tangible meth-
odology of language, advice, and instructions which, in their turn, will pro-
duce better results (training effects).

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For the purpose of improving the quality of the reflection training, the
theory of reflection will be elaborated by conclusions drawn from analogies.
In so doing, we use the following concepts from the physics of reflection:
alignment, permeability, strength/intensity, absorption, deflection, diffusion/
accumulation, straightforwardness, information processing, codification/un-
ambiguousness and consistency of information channels.
Correspondence between Psychotherapeutic and Physical
Reflection
The alignment in the physical sense corresponds to the full and 'broadly dis-
persed' attentiveness towards the patient in psychotherapy, which belongs to
the benevolent attitude. It has to be 'dispersed broadly' because if the atten-
tion is focused on the client all-too too clearly from the very start, he might
easily get the impression that the psychotherapist is conducting an active
interrogation or inquisition, which are both undesirable because they would
put the patient in a passive position or give him a sense of being reduced to
his problem, suffering, or symptom rather than accepted as a human being
who has limitations but also resources and a particular life history. If the top-
ics and the framework are presented and pinned down by the therapist, the
patient is denied the position of an equal dialogue partner. It is the purpose
of psychotherapy to strengthen the patient and to support the development
of his will-power and self-determination.
The permeability for incoming information is an important issue in psy-
chotherapy. The psychotherapist has to be relatively permeable in order to
take in as many messages from the patient as possible and to let them have
an impact on her. She, furthermore, has to adjust her permeability or to
shield herself in cases where the patient reacts very aggressively or resorts to
offensive forms of acting-out. Since both modes, Le., being more or less per-
meable, are not practicable at the same time, the psychotherapist has to be
very flexible, to either reduce her guards and open up to a relatively high
degree, or close up again. Besides, she has to assess the patient's permeabil-
ity and his degree of self-protection, otherwise she would not be able to re-
spond appropriately. This also involves selective receptivity and relative
openness.
The strength/intensity is enormously meaningful for the benevolent basic
attitude. The psychotherapist is required to be fully alert and, for the most part,
keep the intensity of her own messages toward the patient as low as possible.
Consequently, a receptive kind of attentiveness is asked for. Only in those as-
pects which set the framework of psychotherapy she has to convey calm and
self-confident messages, otherwise the patient would not understand the set-
ting as safe and he would thus not be willing to conform to it. The patient

Reflection - Self-Reflection - Self-Awareness
269
hence has to learn to distinguish between the clear regulations and the space
which is open to self-expression and autonomous creation, from which he
will learn to benefit. The therapist has to be alert that the intensity of her
responses and interventions does not push, bedazzle, persuade, or sway the
patient, so as not to call forth aversion or resistance, but they still have to be
intensive enough to raise realistic hopes on the success of treatment. This
balance has to be adjusted to the patient's receptiveness and capacity. Shy
patients, for instance, require a rather gentle voice and a slow pace.
The absorption of the received messages is a key factor of de-escalation,
primarily in those cases where the patient repeats or actualizes his basic
conflict with the psychotherapist and wants to carry it out directly with her.
The tendency of 'wanting to be the victor' is a frequently used strategy of
conflict-solving on the patient's part and requires highly-developed de-esca-
lation skills and, naturally, endurance on the psychotherapist's part for the
conflict to be resolved constructively.
The usage of analogies or metaphors, for instance, corresponds to deflec-
tion; they are needed when the patient's thinking is fixated onto accustomed
but inadequate and thus failing resolution attempts, due to strong emotions.
It is most advisable to choose words and examples from the patient's life or
images closely related to his actual day-to-day living, since he will then more
easily understand and accept them.
The diffusion/focusing mainly correspond to the formation of a focus or
focal point, a concept frequently used in psychotherapy. Episodes of a wider
focus of listening, receiving, and exuding an empathetic attitude alternate
with closer inspections of the problematic issues and their details. The con-
sideration of the factor that suffering and learning are universal belongs to
diffusion. This entails that we, as psychotherapists, have to point to the fact
that the pain of, e.g., separation or loss is inevitable, and that we have to ac-
cept and to endure it, as opposed to the avoidable pain of, e.g., self-harm.
Using the term 'school of love' might bring home to the patient that humans
have to continually learn how to satisfy their need of loving and being loved
in a way that suits themselves and others.
The straightforwardness corresponds to the much needed transparency of
how the therapist acts, including transparent explanations of why her per-
sonal penchants and problems have to be left aside, and an reasonably sin-
cere attitude that enables the patient to accept the psychotherapist and to
have trust in her competence.
The processing of information and the codification of signals correspond
to the psychotherapeutic unambiguousness and to the consistency of infor-
mation. To align and to coordinate the transfer of information, i.e., the non-
verbal (gestures, facial expression, pitch of the voice, etc.) and verbal mes-
sages in a way that accordance and clarity are reached, is a considerable
challenge to many people, which gets even harder in difficult situations, and

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Heiner Bartuska
an even higher degree of authenticity and clarity may be required. As widely
known, nonverbal expressions are far more related to the handling and the
control of one's own emotions than verbal utterances. The psychotherapist
is, therefore, called upon to deal with her emotions concerning her personal
penchants, conflicts and problems in a way that she preferably does not
make any nonverbal gestures that are inconsistent with her verbal declara-
tions (by reflecting and controlling them self-reliantly). We, furthermore,
have to be careful that the codification of the information to be transferred
comes in a lingual code that the receiver is most likely to grasp and make
sense of. For a maximum reception of the information, we firstly must be
aware of how the dialogue partner encodes his meanings, and analyze how
much they correspond to the expected usage of terms.
Perfect communication is therefore impossible to achieve among hu-
mans. In case of minor or major disturbances it becomes even more de-
manding, but a purposely and methodically enhanced reflection training of
the mentioned abilities and skills may improve it to a considerable degree.
The various scientific and certified psychotherapeutic methods thus have
been assigned the role of codifying lingual meanings coherently and of meet-
ing the requirement of the best-possible receptivity towards those cues from
the patients which are encoded differently.
Reflection in psychotherapy is mainly about perceiving oneself and others.
If we, again, use our analogous example from physics, we have to acknowl-
edge, though, that the reflective activity of the psychotherapist is far more
complex. She has to be permeable in order to take in impressions, she has to
picture them within herself as in a mirror, has to feed some portion of her
comprehensive picture back to the patient in an appropriate, inspiring, and
non-judgmental way, while absorbing everything else. Like a prism, she
should be able to offer a dissection or disassembly in order to analyze and
differentiate the components which are confounded in the various expres-
sions (which, in our physical metaphor, corresponds to the white light that is
a merger of all colors of the spectrum). Thus, our 'reflection' is closer to the
Latin meaning of 'bending or turning back' than to the process of mirroring in
physics, a technical term very common in some psychotherapeutic schools.
There are many further distinctive features by which the ability of reflec-
tion could be described, but neither can we study them more deeply in the
present paper nor have analogies from other sciences been found for them.
Interrelation between the Abilities of Reflection and
Self- Reflection
Since we humans are incapable of looking upon ourselves from outside, we
rely on feedback (reflection) from our fellow-men and -women, whenever

Reflection - Self-Reflection - Self-Awareness
271
we want to learn how we come across to them. Naturally, any feedback in-
cludes material, selected perceptions and messages from the other person
that are stripped of their contexts. From these ponderings (reflections) which
have to be analyzed and integrated in a system (method), the trainee may
internalize experiences that are systematic representations of the results of
his reflections. Thus, the ability to reflect independently, i.e., without the
help of others, is being wrought.
It is only by the sufficient practice of the standardized forms of reflection
(which, in psychotherapy, are: self-analysis, self-awareness, and personal
growth trainings, exercises that enhance self-experience, etc.) that secured
knowledge and skills are acquired which are apt to form the basis of self-re-
flection practiced on one's own account.
If the reflection training is confounded with the theory of a particular
method and unless we stick to methodically correct denominations, the train-
ing effect will decrease considerably because this form of reflection trainings
involves instructions and enhances knowledge rather than advancing per-
sonal growth and self-perception. If elements of supervision are interspersed,
the training will be partly instructive but deflect the attention away from one-
self towards future patients and thus bring down the reflection process.
On the other hand, it is possible to integrate self-reflective elements (self-
awareness training) in theory, technique and supervision seminars to impart
tangible knowledge, and this will not harm the reflective process.
The Issue of Self-Awareness and Personal Growth in the
Various Psychotherapeutic Schools
Different psychotherapeutic schools offer different methodic approaches re-
garding the goals and purposes of the self-awareness trainings. The following
have crystallized so far:
- self-awareness targeted towards maturation and development of the per-
sonality,
- self-awareness targeted towards conflict management, finding alterna-
tives, and improving resolution skills,
- experiencing and practical learning of methods and techniques,
- self-awareness as meditation or diary entries alternating with the reading
of a meaningful book without any instruction, and
- systematic reflection and self-reflection trainings for all psychotherapists.
In 1 and 2 the targets are clear and in accordance with the reflection training.
Regarding target 3, which addresses the practical acquisition of the meth-
od, we should be aware that some schools act on the assumption that the
future psychotherapists, the trainees in other words, do not have any clini-

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Heiner Bartuska
cally significant disorders such as neuroses or neurotic conflicts, which is
why they are not patients by definition.
Some specific methods when setting up their training curricula obviously
presumed that self-awareness serves the practical acquisition of the method
or the learning by demonstrations. If these demonstrations are administered
in an individual setting, the only possibility for the coach (teaching therapist)
is to demonstrate this method on the training candidate or on himself.
If the method is effective, a circumstance evidenced by efficacy studies
(which have to be submitted by the training schools for their method to be
conceded the status of a science), the demonstration will take effect in the
trainee or in the teaching therapist himself. Even if this is a role play only, the
identification with the applier and the test person cannot be precluded,
which thus, implicitly or explicitly, sparks personal development. The trainee
will test the demonstrated technique as to its usefulness for his own prob-
lems and conflicts, or for the improvement of his hitherto applied solutions
and in case of success adopt them.
Regarding target 4 (self-awareness as meditation or private diary entries),
our thoughts developed so far reveal that this cannot be called a reflection
training in the sense discussed above because it does not involve instruc-
tions, in-depth engagement, and feedback contributed from without.
What is new about target 5 is the systematic approach to reflection and
self-reflection training that should be undertaken by all therapists. To the au-
thor's knowledge, such an approach is not laid down explicitly in any of the
psychotherapeutic syllabuses, but only implicitly and at varying degrees so.
Settings
Self-awareness trainings can be conducted within various settings.
Individual self-awareness training: A trainee works with an experienced
teaching therapist one to four times a week, for a fifty minute period at each
session. He is either lying on a couch without any eye contact with the
therapist, or sitting diagonally opposite.
In a small group: 8 to 12 trainees work with one or two teaching thera-
pists in a circle, with everyone being able to watch everyone else. One pe-
riod lasts for at least 90 minutes. Sessions may be held regularly once a week
over a long period of time (one year group), or within the framework of a
seminar as 10-20 sessions on a number of consecutive days.
In a large group: 20 to 100 trainees work with two or three teaching
therapists seated as in a plenary meeting where the eye contact with every
other person is restricted. One session lasts for at least 90 minutes. Such
large group meetings are usually held in the course of several day seminars
(3-8 days), either once a day, or as a blocked course of 8-10 periods.

Reflection - Self-Reflection - Self-Awareness
273
Peer groups: trainees meet for group sessions without the guidance of a
teaching therapist.
Benefits and Potential Training Mistakes
Individual Self-Awareness Training
Individual self-awareness is solely customized to the training candidate. She
is the absolute focus of attention. The target of learning to handle one's con-
flicts better is within realistic reach. Seeing the trainee through her process
may, under certain circumstances, also lead to a state of dependency on the
teaching therapist. Exclusive individual self-awareness trainings may invoke
the problem of inflated self-estimation with all its implications, as the teach-
ing therapist's concentration on the candidate may be mistaken for the rein-
forcement of his, i.e., the candidate's, achievements. Another risk is the ami-
cable rapprochement of the teaching therapist toward the trainee which,
because of the mutual reassurance, might take off from the world outside
and assume folie-a.-deux proportions.
The candidate practices her permeability with the aid of and via the
teaching therapist. This lessens the probability of confrontations, and en-
hances the disclosure of the candidate's resources, problems, and conflicts
and sets up the space for confidence.
The intensity/strength of feedback is also adjusted to the psychological
condition of the candidate. She is supported in handling the intensity/
strength which has been attuned to her and which she in turn attunes to
the teaching therapist. Unscheduled confrontations are unlikely to occur. It
is, hence, easier for the candidate to engage in the present intrapsychic is-
sues (problems, disorders, and conflicts), in recollections and one's own
psychic structures and in the planning of her future, and to process them
thoroughly.
Where absorption is concerned, the de-escalation strategy and tolerance
well rehearsed by the teaching therapist will relieve the candidate and pro-
tect her from the necessity to employ de-escalation techniques herself.
Deflection: The reflection training which is built up via the usage of
analogies and metaphors reinforces versatility, creativity, and spontaneity.
The reflective activity can, however, also remain lopsided and oriented to-
ward the teaching therapist's educational background and social class, with-
out the patient developing much of her personal style or originality because
she leans too strongly towards the role model of the psychotherapist.
The diffusion/focusing and its relatedness to the universality of suffering
as opposed to the possible avoidance of self-harm may be focused and thor-
oughly worked through with the assistance of the teaching therapist.

274
Heiner Bartuska
Straightforwardness/transparency: the role model of the teaching therapist
and its usefulness may be experienced and rehearsed. Thus, the role model
will eventually unfold its function and ease imitation.
Information processing: accurate instructions by the psychotherapist in all
the essential areas of reflection promote the careful processing of all issues
(problems, disturbances, and conflicts). The learning effect will, however,
only be as good as the competence of the teacher. We, therefore, cannot
deny the risk of the stimuli or suggestions being biased because the depend-
ence on the teaching therapist may lead to blanking out certain aspects or to
superficial compliance with him. It, furthermore, makes a difference whether
the teaching is theory- or practice-based. Theory-based teaching does not
involve the reflection of practical work.
If the training has been sufficient, a very high standard of reflection abili-
ties in regard to the individual or the dyad may be expected, while deficits
of reflection may remain in other social concerns.
Small Group
A small group is totally oriented towards the group itself and the participat-
ing trainees. The entire space and the total time are at the candidates' dis-
posal; they must compete though for the orientation the group takes and for
the focuses it assumes. Also, it is indispensable that the group oscillates be-
tween the group as a collective and its individuals. The attendance of and
the concentration on the group and on the candidates imply a far lesser de-
gree of dependency on the teaching therapist, since the group reinforces
the expression of independent and critical opinions, differentiations, and
relativizations. In groups, the required trust and the openness are more dif-
ficult to achieve than in the individual self-awareness trainings, but they will
be more closely related to reality than the very specific situation of individ-
ual self-awareness training. In the beginning, it is more difficult to open up
in grou ps.
The risk of overestimating one's capabilities is naturally smaller since the
group always lends itself as a corrective mechanism and there cannot pos-
sibly be any exclusive concentration on the teaching therapist. Peer pressure
can, however, become a problem and consequently hamper the learning
progress of the whole group or of individual candidates. Another danger is
the higher susceptibility to secretion and abuse; as the threshold of confiden-
tiality is higher, secrets could more easily be held back, agreements made
outside the group sessions kept secret from the (formal) group and the teach-
ing therapist, and sexual relationships, due to the intimacy among candi-
dates, or candidate and teaching therapist, could under certain circumstanc-
es impede the training to such an extent that the reflection is foiled alto-

Reflection - Self-Reflection - Self-Awareness
275
gether. On account of the mutual reassurance they give each other, the ami-
cable rapprochement between the teaching therapist and the candidates
may lead to the complete detachment from the world outside and mount up
to sectarian proportions. There is a possibility that certain individuals con-
stantly take a back seat and, hence, conflicts and immaturity are overlooked
and not submitted to appropriate reflection.
The group certainly practices a broader scope of permeability because of
the necessity to keep an eye not only on the current conversation but also on
the nonverbal reactions of the whole group, the teaching therapist, and other
group members. If the perception remains constricted, problems of orienta-
tion, unpleasant surprises, and a loss of acceptance will be the consequence.
The only antidote against this would be to totally split off of the group's
atmosphere, its topics and the occurrences therein. The group, of course,
exerts a certain amount of social control. It judges everything that takes
place and classifies it into acceptable/unacceptable and it grows by doing so.
During this process, the participants will strive to broaden and deepen their
acceptance which was absent in the beginning.
Intensity/Strength: the manifold encodings of the language and meaning
the participants bring with them provide versatile opportunities and also ne-
cessities of learning, some of which are not developed yet. There is a high
demand on the autonomy, initiative, and on the endurance towards confron-
tations and peer pressure. Notably, these demands may potentially put more
strain on the candidates than they are ready to take.
Absorption: confrontations and the imponderability challenge and in-
tensely train the skills of de-escalation on the one hand and, on the other, the
reflection of one's (own) contributions; this is done via provocations which
are not noticed as such immediately.
Deflection: every presentation of problems, disturbances, or conflicts
brings up similar concerns in the other participants, thus continually causing
deflections and refractions. This leads to exercising the reflective abilities
and, equally, provides ample opportunities to distract from one's own prob-
lems or from conflict awareness and to hide from them.
The broad diffusion/focusing is an inevitable factor in groups when the
emotions are running high because similar experiences and thus the univer-
sality of strong emotions will occur as a natural corollary to problematic or
conflict-ridden social situations. The diffusion (i.e., the universality of suffer-
ing and learning) occurs almost automatically when the other participants
voice similar experiences. Finding the focus has to be practiced continuously,
because also the participants have to set theirs.
The straightforwardness/transparency of the participants as well as of the
teaching therapist is practiced constantly, otherwise the co-trainees would
not embrace the meaning of the messages of the moment. The interest and
the need for recognition and understanding are a continuous challenge to

276
Heiner Bartuska
adopt a straightforward attitude and to thus safeguard the best possible trans-
parency.
Processing of information: time and space are shared by all training can-
didates, which is the reason why either the whole group, or a certain indi-
vidual, or competing participants are in the center of attention. The encour-
agement by the teaching therapists in essential areas of reflection facilitates
the workup of all issues, a process which is more delicate in a group, due
to the higher level of complexity, and which thus necessarily should be
structured with greater care than in individual settings. The reflection may
be enriched and improved by other group members, but the demand on
the teaching therapist is much greater since he has to simultaneously assess
the entire network. The risk of biased developments cannot be denied. A
group is too complex for anyone to completely overview the way every
participant processes his or her information. Each group member hence re-
lies on her autonomy and on her own initiative. In such a process, there is
always a danger that essential areas are omitted or concealed thus defying
processing and reflection. The more theory- or technique-based the teach-
ing (to which some methods are more prone than others) the higher the risk
that the reflection training becomes restricted and is narrowed down to
standardized routines and thus sidesteps the multiform reality in the reflec-
tive process.
Generally, the participants of a personal development group are more
able to reflect on themselves in a vaster variety of ways and more intensely
and to handle their personal problems, disorders, and social conflicts rather
well. However, the intrapsychic issues and the related implications are less
thoroughly worked over than in an individual setting.
Large Group
Initially and for quite some time, the group is oriented towards the crowd,
which is experienced as superior and unmanageable since the control of all
facial expressions and nonverbal utterances is not viable; large groups are
thus more complex and orient themselves toward the group as a whole. It
may focus on an individual for a short period of time, incidences which stir
up unstructured experiences (e.g., from early childhood) in a variety of ways.
There is also a sociopolitical level, which prompts the engagement in politi-
cal questions.
Such a process is usually an ordeal for the permeability for the individual,
inflicted on him or her from many sides, which contributes to an intense
training in her reflective skills. The strength/intensity of the emotions of a
large group is far higher than of a small group; the responses to the state-

Reflection - Self-Reflection - Self-Awareness
277
ments are heard and received immediately and thus they multifunctionally
reinforce the reflective training.
The absorption must be learnt more intensely and multilaterally, other-
wise an individual's balance cannot be restored. Overstrain and impasses are
the disadvantages likely to be met on this way.
Deflections occur frequently and provide ample training opportunities,
the utilization of which depends on the skills previously practiced.
Diffusion/focusing are also ample and changeable, and constitute the way
to practice flexibility.
The straightforwardness/transparency is considerably difficult for the
teaching therapist, too. Its immediate effect on clarity, intelligibility, self-con-
fidence, and steadfastness cannot be ignored. There is a high demand on the
participants' self-reliance.
Information processing is put to a hard test because of the variety of op-
tions. Space and time belong to so many trainees that mutual sharing and
understanding is hardly imaginable with this group size. The focuses of the
current statements are always in the center of attention.
The results of a large group training are manifold, such as intense self-re-
flection by the participants and a better handling of their goals, penchants
and disturbances in the social field; unstructured intrapsychic issues ignored
hitherto may also be faced and dealt with.
Peer Group
The direction is determined and the topics are chosen by the participants
themselves without any guidance or supervision by a teaching therapist.
Usually, the skills previously acquired are practiced, consolidated and en-
hanced. Often, a large amount of creativity is released. One cannot expect
a sufficiently accurate proficiency in the methodological procedures in the
trainees yet because none of them is in possession of the required teaching
qualification.
The permeability is, furthermore, developed and practiced in areas that
have been learnt previously, but more complex impasses and resistances are
seldom clarified because of the missing guidance or leadership, which is why
they have to be coped with elsewhere.
The strength/intensity can be high, which testifies to a high level of com-
mitment. In general, the participants' expectations are far higher in the pres-
ence of a teaching therapist, whereas the density and concentration are
lower in her absence.
For safety reasons, there is a higher degree of absorption because the
emerging conflicts have to be sorted out without any guidance, which is why
they will most likely be avoided altogether.

278
Heiner Bartuska
Deflection may be applied in areas which have been successfully learnt
at previous occasions.
Diffusion/focusing with an autonomous formation of focuses runs a high-
er risk of being either over- or under-challenging.
The straightforwardness/transparency will hardly exceed the current train-
ing level, but rather facilitate the adjustment to the group.
Information processing: peer groups encourage autonomy, particularly
when previously learned issues are to be applied. Since sub-groups are likely
to form and the codification of information is usually tailored to these small-
er groups, they are less suitable for many participants. There, ideals and the
tendency to tell others how they are supposed to do things will form, and the
participants will, to a lesser degree, attend to the contents of the other indi-
viduals' statements and thus less broadly increase their self-reflective skills.
The peer group is therefore suitable as an additional training and exercis-
ing opportunity, besides a minimum of reflection training units in several
areas of the apprenticeship; the peer group cannot possibly make up for any
missing training units under instruction.
Peer groups are a good basis to build up the collaboration with col-
leagues, which is required in the psychotherapeutic profession.
Summary
From all the foregoing thoughts we may conclude that it is only the sufficient
and all-round reflective training within different settings that will lead to a
high standard of self-reflective skills. This standard is crucial for an independ-
ent management of diagnostic issues (as much as for the autonomous struc-
turing and shaping of the therapeutic process), otherwise it would be the
patient only who, in his illness-ridden and restricted ways, could contribute
information and feedback.
Reflection Training within the European Certificate for
Psychotherapy (ECP)
The ECP (finalized by the European Association for Psychotherapy (EAP) in
Rome, 1997) includes the acquisition of and the graduation in a particular
method after a minimum training period of 3200 hours, which is equivalent
to the requirements of the Austrian Psychotherapy Act. There is, however,
one delicate phrase in this regulation. As opposed to the Strasbourg Declara-
tion on Psychotherapy (1990), the mandatory number of at least 250 self-
awareness training units is counterweighed by an equivalent alternative.
What does this equivalent involve?

Reflection - Self-Reflection - Self-Awareness
279
Does it imply that there are various possibilities of crediting other training
modules, because the psychotherapeutic methods are similar and akin? This
cannot be the case, since the teaching contents can only be credited ac-
cording to the expert opinions which determine the teachings by observing
certain criteria; these must have been elaborated by the respective training
institutions, and the contents, the volume and the qualification of the respec-
tive teaching therapists must be equivalent. If the criteria and contents of the
self-awareness certificates submitted for crediting are partly identical or at
least alike, self-awareness trainings in a different psychotherapeutic method
can be credited. These problems of crediting can thus not possibly have
been referred to by that paragraph in the Declaration.
Or, is it that the provisional recognition of a psychotherapeutic method
has not been sufficiently defined yet (i.e., by submitting a specific theory that
is satisfactorily independent from other scientific and certified methods, by
supplying an anthropological image of man, a nosology, sufficient efficacy
studies, a consistent curriculum, and qualified teaching therapists)?
This would be the opportunity to partly acknowledge methods which are
currently in the stage of development and on the way to being recognized as
a science; in this regard, we need to be aware that the individual psycho-
therapists who are elaborating new theories have very often been trained in
other methods, either partly or fully. Problems will arise with only those psy-
chotherapists who have been trained solely in that new method which is still
awaiting recognition.
Or, are we dealing with one of those elastic clauses which allow award-
ing the ECP to those individuals who do not fulfill the criteria of skillful self-
awareness? If this is the case, the paragraph is in urgent need of modification,
since it is no longer defendable from a scientific point of view.
How did it slip into the Declaration then?
There is a historic background to it: during the years 1994 and 1995,
skepticism prevailed against the project of setting up a European certificate
in the European Association for Psychotherapy, and we owe it to the arduous
engagement of Emmy van Deuerzen, Digby Tantam, Alfred Pritz, Heiner
Bartuska, and the extended board that in the years 1996 to 1997, the discus-
sions in the study groups had developed to the stage that the criteria for the
ECP could be finalized (Rome, 1997). However, the board's approval did not
go as far as to delete the debatable paragraph that addresses the 'equivalent'
to self-awareness. The present version is the result of a political compromise
with all those who, at that time, could not or only partly prove that they had
attended self-awareness trainings in one of those methods which had been
acknowledged and certified as meeting scientific standards.

280
Heiner Bartuska
References
The European Association For Psychotherapy, Beschluss des ECP GV (1997) Rom, www.
europsyche.org
StrafSburger Deklaration zur Psychotherapie (1990) Teil der EAP Statuten, 1992
Translated from the German by Luna Gertrud Steiner

5. Psychotherapeutic Status
Based on the Diagnostic Guideline for
Psychotherapists
Created by Official Experts of the
Federal Ministry of Health and Women's Affairs
April 19, 2005
Summary of Guidelines
For Psychotherapeutic Diagnostics

Psychotherapeutic Status
The following survey is designed to establish a general psychotherapeutic
diagnostic impression consistent with the Diagnostic Guideline for Psycho-
therapists, formulated by the Federal Ministry of Health and Women's Af-
fairs, where all items mentioned in the present document are defined and
described at length.
This survey documents the decisions made at the beginning as well as
during the course of the psychotherapeutic proceedings.
Psychotherapist
Patient (Code number)
o Intake Interview _th session
Date
I. Diagnosis
I. 1. Symptomatology in Relation to Personality Aspects
Clinical picture of disorder (ICD/DSM)
Ascertainable personality traits 0
Degree of severity of symptoms
or identifiable symptoms 0
slight 0 medium 0 serious 0
Disturbance in existence since
Somatic discomfort
Personal resources
Social resources
Environmental resources
no 0 yes
missing 0
missing 0
missing 0
o
scarce 0
scarce 0
scarce 0
sufficient 0
sufficient 0
sufficient 0
1 Lines offer space for comments (optional)

284
Psychotherapeutic Status
I. 2. Psychotherapeutic Relationship
1.2.1. Assumption and Formation of the Relationship
given 0
given 0
Therapy Motivation not given 0
Cooperativeness not given 0
Pattern of interaction
Relational abilities
Other relational dimensions
1.2.2. Target Orientation
The patient is oriented towards
reduction of symptoms 0 change in personality 0 increase in insight 0
Significance/meaning of disorder for the patient
Subjective explanatory models
discordant 0 concordant 0
with therapist
Jointly elaborated prospects and goals
1.2.3. Process-Oriented Diagnostics
Is the beginning/the continuation
Possible no 0
Justifiable no 0
Beneficial no 0
yes 0
yes 0
yes 0
Is the current psychotherapeutic focus relevant to the patient's overall problem
no 0 yes 0

Indication
285
The psychotherapeutic intervention has to be optimized in accordance with
process
no 0
yes 0
1.2.4. Assessment of Ongoing Work (Reflection/Supervision/lntervision)
Which focus and which therapeutic steps will enhance the psychotherapeu-
tic relationship
Beneficial
Inhibitory
To what extent does the patient benefit from the psychotherapeutic process
as to his/her overall problem?
Expansion of potentials
Partial stagnation
I. 3. Risk Level, Degree of Severity
1. Minor disorder 0
2. Moderate disorder 0
3. Moderately severe disorder 0
4. Severe disorder 0
5. Immediate endangerment of self and/or others 0
1.4. Method-Specific Notes
II. Indication
II. 1. Indication of Psychotherapeutic Treatment
Disorder classifiable as disease
Social constraints
Relational constraints
Life quality constraints
Indication of psychotherapeutic treatment (recapitulated)
no 0
no 0
no 0
no 0
no 0
yes 0
yes 0
yes 0
yes 0
yes 0

286
Psychotherapeutic Status
II. 2. Recommendations and Additional Examinations
Somatic 0
Psychiatric 0
Clinical-Psychological 0
Hospitalization 0
Recommendation of further treatment 0
Social support (various) 0
II. 3. Indication of Specific Psychotherapeutic Option
Urgency immediate 0 psychotherapy to be taken up within
Duration, as far as assessable
Frequency (approx.)
Recommended methods
I npatient psychotherapy
Framework:
Setting individual 0 group 0 couple 0 family 0
Therapy financed by patient 0 third party 0 institution 0
Agreement reached no 0 yes 0
11.4. Method-Specific Notes
References
Bartuska H, Buchsbaumer M, Mehta G, pawlowsky G, Wiesnagrotzki S (2005) Psycho-
therapeutische Diagnostik. Springer, Vienna New York
http://www.bmgfj.gv.at/cms/site/attachments/6/8/3/CH0026/CMSl144348952885/man u-
al.pdf, 29.08.07
Translated from the German by Luna Gertrud Steiner

'r' I
Heiner Bartuska, born in 1950; involved in initializing
legal regulations of psychotherapy such as the Austrian
Psychotherapy Act, the Strasbourg Declaration, the Euro-
pean Certificate for Psychotherapy, etc. for 25 years;
protocolist of the study group which elaborated the psy-
chotherapeutic diagnostic system.
:c--..
Manfred F. Buchsbaumer, born in 1961; put his efforts
into implementing psychotherapy in the societal context
by persistently participating in discussions and reflec-
tions, and by developing support schemes; engaged in
the subject for twelve years.
. '.
4 - Gerda Mehta, born in 1955, contributed her long-stand-
ing experience, her professional, and political know-how
to revive the stalled dialogue between individuals and
groups.
''\
Gerhard Pawlowsky, born in 1943, contributor to the
'Worterbuch der Psychotherapie' - the Dictionary of
Psychotherapy; authored essays on psychotherapy; mem-
ber of the Advisory Board for Psychotherapy where he
held various functions for ten years; working as a psy-
chotherapist for 30 years.
,. 
....
. ."
....- c
"
"
r........
'
.
Stefan Wiesnagrotzki, born in 1944, psychiatrist, psycho-
therapist, working at the Psychosomatic Department of
the Vienna General Hospital for 25 years; member of the
Advisory Board for Psychotherapy since 1991; chairman
in various expert committees.

SpringerL sycc 'J!rtrir
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