Gestalt work on traumas with refugees

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Emotional accompaniment

in their search of

Inner and Outer Integration

NVAGT Congress, Antwerp, Oct.16th 2015 Ivana Vidaković

ividakovic@ian.org.rs

Content

Drafting common background Gestalt model in theory and practice

Our main assets for working with trauma

Diagnostic considerations Gestalt trauma treatment How to integrate this in your work?

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Drafting a common background

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What is the most difficult part in trauma related work?

Hopelessness. To manage the hopelessness and not get infected by it

“Unreachable”. “Dependent in basic living needs” Difficulties related to trauma, complex, multi problems

Them being lonely and their isolation. How to support their struggle with Isolation and Solitude?

Their traumatisation. Re-traumatisation during the therapy work. Secondary traumatisation - being not accepted here. Not finding security, feeling anxiety,

Being present in the body. To be very precise in following the body language

How to cope with the pain. Help to contain the pain

What is the main question trauma or something else?

Powerlessness. Solitude. Lack of ground. Lack of belonging. Their inner tumult. Priorities.

Keep the balance. How to enter their story without causing re-traumatisation

Cultural background of the refugees. How to connect on that level of understanding

How to offer therapy? Would they accept therapy since it does not come to their culture?

How to create an opening to come to the trauma

Noticing when trauma “comes up” in discussions with refugees. What are “red flags”?

Knowing which aspect to discover together with the client and which better not in function of what is the most helpful for the person to normalize the life …

How to deal with it, so refugee feels “recognized”, free to speak, ask for help (other than from me) Working with illegals without perspective trying to give them any hope in the here and now life

To keep them without giving them money, work, house…

Working alone, not in a team. What to do when there is a crisis?

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What is the most touching, when you are in contact with immigrants?

The unique stories

I’m touched when people can feel so powerless

Empty hands

Multi problems, loss of family, displacement

The lack of family, friends; sorrow for those who are still in the country of origin

The difficulty for them to “anchor” somewhere, not finding place in the world, the local centers where they live as refugee. How to work on that as a local person being born here?

Grief in general, having no chances or power to make changes

How they succeed to survive and find their way

Their drive to survive, to fight for a better life

Their opening up and their gratitude when we are interested

That I can do so little

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What is useful in trauma work? What do you find helpful?

Human contact. Similarity. Small beginnings. Be there/Comfort. “I see you”. “Here and Now”. Hope, Perspective. Acceptance, Compassion.

The training in awareness. Awareness in “Here and Now”. Healing

“Being there”. Being present. Emotional freedom. I am listening and I am nearby.

Knowledge of the culture, attitudes, religion, …

Give a name together to what they have been through

To go very slowly.

Patience. Supporting them to find some stable ground in the sessions.

To look at the whole person. Attention to the strength of the person

Building up a relationship. Being supportive.

Personal attention and showing understanding. Building up relation of trust.

Stay with foot on the ground / try to stay objective

Trauma remedies (homeopathic). Releases pain (physical and emotional), giving acceptance and rest, room to start future.

Support of colleagues. Conversation with colleagues. That I get the possibility to do training. 6

When are you content with the outcomes in your work? What gives you a satisfaction in work?

When I can connect. When dialogue is possible.

When people see more clearly, feel oriented.

When the stress goes down and a way of life is founded

A person find his way, can have happiness again in life

When one gets chance and becomes legal, the happiness

Longing to live the life inspire of …

When people become “independent” persons in basic living needs

Helping moving on

Meeting interesting people.

With students – raising awareness. Welcome to refugees (Syrian Christians) our church

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Some difficulties in working with immigrants

Linguistic and intercultural barriers

Culture and religion plays a significant role in individuals cope with trauma

Range of urgent needs and multiple traumas

Context, external influences, insecurity and low predictability of the future

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Trauma

Trauma is an intensive and aversive event (sudden, unexpected, out of scope of usual experiences, out of ability to cope with...). Trauma can be complex or cumulative.

Most of affected people will not suffer from long term trauma reactions, depending on their personal characteristics, life experience and support available in the field, as well as the nature and consequences of the trauma itself. Some of them will develop persistent symptoms (app. 40-60% of refuges and people in war zone).

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Diagnostic considerations

Psychiatric diagnoses – symptoms oriented

(DSM IV V, ICD 10 11) The Western conceptualization of mental health and mental illness may not be

universally applicable

Still, why is diagnostic relevant if immigrants are our clients?

*Phenomenological descriptions

*Gestalt process diagnostic

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Phenomenological approach

What we can observe in our client / a concrete person?

Describe with an phenomenological stand:

Just what is appearing at the surface, as concrete as possible

Avoid classifications

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Trauma syndroms

Intrusions - persistent re-experiencing of a traumatic event (reminders, memories, dreams, flashbacks,...) with distress

Avoidance of stimuli associated with trauma

Negative alternations in cognition and mood (Numbing of affects, low general responsiveness and interests, negative expectations, blame of self or others, detachments, inability to feel positive emotions)

Hyperarousal – alterations in arousal and phisical and emotional reactivity (irritability, anger, self-destructiveness,

sleep and concentration problems)

Dissociation, derealization, depersonalization 15

PTSD symptoms in polarities (Cohen, 2002, 2003)

Trauma symptoms may be viewed as TWO-DIMENSIONAL POLARITIES:

AROUSAL

EXTREME AROUSAL LOW AROUSAL

and AGITATION and NUMBNESS

APPROACH–AVOIDANCE

OVER–INVOLVEMENT TOTAL AVOIDANCE

WITH THE TRAUMA and FEAR of any stimulus

intrusions, flashes of images, associated with the trauma.

memories, and rumination

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The assets of Gestalt theory and therapy

Holism. Field theory. Organismic self-regulation. The whole person including thoughts, feelings, behavior, body sensations, and dreams. Everything is part of the common field, in flux, interrelated, and in process. The creative adjustment that the organism (person) makes in relation to the environment.

Phenomenology, awareness, here and now

The phenomenological approach leads to the slow, minute-by-minute process of examining the original experience, and to the process of assimilating it, together with identifying how the patient interrupts the process. The possibility of activating and including in the therapeutic process all elements existing in the environment. "The phenomenological here and now“ (Zinker, 1977).

Relational experience, dialogue

the I-Thou dialogue includes presence, inclusion, commitment to dialogue, and confirmation (Buber, 1965; Friedman,1991)

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Trauma as fixed gestalt

“Uncompleted situations from the past” and “fixed perceptions” (Perls, Hefferline, & Goodman, 1951)

Unfinished experiences, fixed gestalts, inability to

disengage, interfere with novel experiences (Polster &Polster, 1973; Zinker, 1978).

Disruption in demobilization phase, (4 sub-stages & therapeutic tasks with trauma clients: Turning away, Assimilation, Encountering the void, Acknowledgement.)

(Melnick and Nevis,1992, 1997,1998)

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4 phases of Trauma therapy (Butollo et all, 2000; 2014)

Safety (Orienting, Feeling safety, Establishing therapeutic relationship,

Listening about trauma, Explaining and addressing symptoms, Learning techniques of relaxation, breathing, Activation of existing internal and social resources),

Stability (Expressing emotions, developing better control of inner

processes, reestablish Self-boundaries in relationships, Self-reflections in contact with others),

Confrontation (Emotional and cognitive processing of trauma,

Dialogical exposure – empty chair techniques)

Integration (Getting in touch with own aggression, acceptance of

what happened, grieving for losses, acceptance of change,

perspectives for the future).

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The main milestones in refugees’ trauma therapy (Vidakovic, 2015):

Creating safe and stable working alliance

Re-establishing self-regulation, respecting personal boundaries

Self and context awareness,

Relieving trauma symptoms,

Recognizing (multiple) losses,

Building social support and interaction with host communities,

Facilitating inner integration and transformation of meanings.

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Relational aspects in trauma therapy

Pain and suffering (as well as love and joy) as universal human experiences.

Healing is in the relationship

The value of the human contact, goes beyond the words, cultures, religions, therapeutic backgrounds, etc.

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Relational aspects in trauma therapy

The relational dimension in the therapy refers to the capacity for contact, relationship, trust and intimacy, but also to the projections, transference and counter-

transference in the client-therapist interpersonal experience.

The therapist has to be alert to them since they could bring trauma elements into the here and now and make them available for exploration.

The common relational issues in therapy with trauma clients are stability / instability, trust / mistrust and

power/helplessness.

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Risk of Burn out in trauma work

Working with traumatized persons is often very complex and demanding: you connect with a powerlessness, hopelessness, despair, injustice, isolation…

Your own trauma experiences are triggered

You might go to far across your own limitations risking burn out

As a parallel process, working with marginalized people could lead therapist to feel marginalized him/herself, with low social recognition and support for that kind of work.

Remember your self about your support systems, regain life/work balance, call for peer support or supervision

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Some (gestalt) techniques for trauma work

WORKING ON SAFTY&STABILITY *useful for symptoms of Hyper arousal and reactivity The use of fantasy and visualization (Establishing a “safe place”, Creating

an “inner supporting team”, Feeling the ground and the roots, etc ) Introduce distance from the traumatic event and regain control (looking

through the screen, managing remote controler)

Focusing to the “here and now” with life-assuring “I statements” (I am safe, I survived, I am here and I am alive)

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WORKING ON CONFRONTATION

*useful for symptoms of Intrusions and Avoidance

Revisiting the traumatic scene –

- Think about traumatic events only 10 min each day with “acceptance and let it go”. Introduce exercise during the session, progressively starting from 2-3 min than use also as a home work(useful for symptoms of intrusion)

- Retelling narrative on the traumatic event, in detail with sensations, emotions, as if it were happening in the present.

Emotional habituation exercises (as extensive repeating of emotionally loaded word/s)

Write, read, burn (for intrusive recollection)

Recurring nightmare & bad dreams – standing, acceptance of past with anchoring in here and now

Re-script nightmare & bad dreams (ask client to change end and outcome, client has to do something different in the dream)

Dialog with perpetrator (empty chair dialogue)

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WORKING ON INTEGRATION

*useful for symptoms of Negative alternations in

cognition and mood

Working with gilt, shame, self accusation. Acceptance of authentic feelings, thoughts, particularly aggression Dialog among before/after trauma Self (empty chair dialogue)

Dialog and other appropriate symbolic options for closure (letters, releasing balloons for those who were unable physically to bury their loved ones)

Use of metaphor and symbols to get more meaning.

Writing, drawing. Personal narrative; mandala; the path of my life - for containing, expressing, celebrating successes of being alive

Defining new goals for self - Letter to self from the future

At the community level the intervention could be considered a collective story. The cultural elements of “stories, rituals and legends... the relationship to the spiritual realm.

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Other useful Trauma Treatment Techniques

Physical engagement, visuo-spatial tasks. (Performing manual or visuo-spatial tasks (worry or prayer beads, knitting, etc) while seeing or hearing about trauma may reduce intrusive memories of the event. (Emily A. Holms, Trauma Films, Information Processing and Intrusive memory development, in Journal of Experimental Psychology: general Vol.133, No.1.))

Relaxations / Self calming techniques (Autogenic, Open focus, Abdominal breathing, Progressive relaxation, Mindfulness, etc)

Support resilience - How client responded to trauma/mistreatment (Wade)

Focus on survival moment vs. catastrophic moment (Solomon)

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Create safe and predictive environment

Listen carefully, find what client want. Find out if the client is asking for help for his trauma or for something else

Go slowly

Help client to get control

Be realistic, support client’s realistic expectation Look for internal strengths and resources

Empower, Support small efforts and achievements for re-building self esteem and self-acceptance

Build external support network

Trauma Work - resume

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Dealing with “Complex (multiple) Trauma”

Go even more slowly

With several traumatic events, sort out what is most significant for client, find out what client want to have different

Deal with more recent traumatic event first

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Existential Perspective in Trauma Healing

Profundity of existential reconsiderartions during the trauma and in the post-trauma coping period; a process and not just an outcome (Linley & Joseph, 2002). Man's Search for

Meaning (Frankl, 1946)

Believe in clients and their capacity to overcome trauma and adversity in life. ... Not only to be symptom free but also able to acknowledge a gain from the traumatic experience (Melnick &Nevis 1992; 1998).

Post Traumatic Growth – positive transformative dimensions, appreciation of life, shift in priorities, deepening of spiritual life, fostering positive attitudes and emotions. (Hobfoll, et al. 2007; Grubaugh & Resick, 2007).

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Integration

“Completion and integration are achieved when life before the

trauma, the traumatic event itself, its meaning, the responses to

it and life after are perceived as parts of a meaningful

continuum, rather than as fragmented, disconnected segments.” (Alon & Levine Bar -Yoseph, 1994,)

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References

Butollo , W., Karl, R., Köning, J.& Hagl, M. (2014) Dialogical exposure in Gestalt –based treatment for postrtraumatic stress disorder, Gestalt Review

Butollo, W., König, J., Karl, R., Henkel, C.& Rosner, R. (2013) Feasibility and outcome of dialogical exposure therapy for posttraumatic stress disorder: A pilot study with 25 outpatients, Psychological research, Vol 24, No4, 514-521

Cohen, A. (2003) Gestalt Therapy and Post Traumatic Stress Disorder: The Irony and the Challenge, Gestalt Review, Vo.7, No.1, pp.42-56

Melnick, J. & Nevis, S. M. (1992). Diagnosis: The struggle for a meaningful paradigm. In E. C. Nevis (Ed.), Gestalt Therapy. New York: Gardner Press

Melnick, J. & Nevis, S. M. (1997). Diagnosing in the here and now: the experience cycle and DSM-IV, British Gestalt Journal, Vo1.6, No.2

Melnick , J. & Roos , S. (2007) The Myth of Closure, Gestalt Review, 11(2)

Serok, S. (1985). Implications of gestalt therapy with post traumatic patients. Gestalt

Journal, 8

Vidaković, I. (2013)The Power of “Moving on” - a Gestalt Therapy Approach to Trauma Treatment, in Francisetti, G., Gecele, M.& Roubal, J. (eds): Gestalt Therapy in Clinical Practice, FrancoAngeli, pp.317-328

Alon, N. & Levine Bar-Yoseph, T. (1994). An approach to the treatment of post-traumatic stress disorders (P.T.S.D.) in Clarkson, P. and Pokorny, M. The Handbook of

Psychotherapy. London. Routledge.

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ADDITIONAL ON LINE RESOURCES

www.istss.org – International Society for Trauma Tress Studies

www.estss.org - European Society for Traumatic Stress Studies

www.trauma-pages.com – David Balwin’s Trauma Information Pages

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Thank you for your attention

Ivana Vidakovic

ividakovic@ian.org.rs

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