Psychotherapy with Adult Survivors of Complex Trauma

Undoing a person’s aloneness in the face of overwhelming emotions1

1 A phrase used by Fosha (2003, p.245), which, I believe, captures the essence of much of the literature reviewed here.

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

Abstract

This literature review aims to provide an overview of the current literature in the field of trauma therapy,

examining theory and treatment recommendations in the general field and concluding with an emphasis

on Gestalt specific writings. For a more current and comprehensive overview of Gestalt trauma therapy

literature, German language publications have been included. Gestalt concepts are reviewed against, and

links are made with, concepts and recommendations from the wider field. Based on the literature

reviewed, Gestalt therapy’s field-sensitive, dialogic, phenomenological and experiential practice is found

to be a highly suitable approach to working with traumatised individuals, especially when grounded in a

solid understanding of the figure-ground relationship between contact and support.

Introduction

The inspiration for this literature review has grown out of my desire to further integrate and translate into

practice my current understanding of psychotherapeutic approaches to working with adults who have

experienced early interpersonal trauma. My particular interest was to review Gestalt literature on trauma

to better understand the interface between the abundant contemporary trauma literature and Gestalt’s

theoretical and practical base. In my work with women who experience eating issues, trauma is often part

of my client’s early history and commonly becomes a relevant part of our work. At times the eating/not-

eating, purging or over-exercising begin to make more sense when seen in light of the benefits of

drowning out or numbing intense and overwhelming feelings, as an attempt to regulate overwhelming

affect (Van der Kolk, Perry & Herman, 1991). Whilst eating issues are not the focus of this review, they

provide the background for my personal interest in the topic as one of many potential secondary

manifestations of trauma.

Many authors and clinicians recommend a phase-oriented trauma therapy approach highlighting the

importance of stabilisation and building resources prior to addressing traumatic memories (Kepner, 2003;

Ogden, Minton & Pain, 2006; Steele, Van der Hart & Nijenhuis, 2005). I have recently witnessed the

immense impact and the extent of retraumatisation that can occur when the recommendations of creating

stabilisation, safety and support before processing traumatic memories are not followed. A particular

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

interest therefore was to identify the recommendations in the literature for providing safe trauma therapy,

which avoids retraumatisation and improves a person’s quality of life rather than leading to disintegration.

My hope is that beyond my own learning this literature review may provide a useful overview for other

practitioners in the field.

This literature review will be presented in three parts. Part one will provide some background to the

therapeutic focus of the latter sections by defining trauma and describing its potential consequences in a

person’s life. Part two will provide an overview of the recommendations for treatment in the wider field

of trauma therapy, whilst part three is devoted to examining literature on trauma therapy within the field

of Gestalt therapy.

Trauma – Definitions and Consequences

The word trauma originates from a Greek word, meaning wound (Gordon, 2007). People become

traumatised when their immediate ability to cope with and respond to a perceived threat is overwhelmed

(Bassuk et al., 2006; Hermann, 1992; Levine, 2008). Traumatic events generally involve threats to life or

bodily integrity, or a close personal encounter with violence and death (Hermann, 1992). A traumatic

event confronts a person with the extremes of helplessness, terror and loss of control and leads to

responses of catastrophe (Hermann, 1992). Traumatisation can occur from any event a person consciously

or unconsciously perceives as life threatening (Levine, 2008). The perception of the event is influenced

by a number of factors, including age (Levine, 2008), previous exposure to trauma, the duration and

severity of the exposure to trauma (Bassuk, Konnath & Volk, 2006), as well as early attachment patterns

(Briere & Spinazolla, 2005), and a person’s resources for resilience (Rothschild, 2003). Commonly

identified traumatic events include sexual or physical assault, terrorism, torture, domestic violence,

accidents, neglect in childhood, being diagnosed with a life-threatening illness, man-made and natural

disasters, being held hostage and sexual molestation of children (American Psychiatric Association, 2000;

Bassuk et al., 2006; Emerson & Hopper, 2011).

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

Many clinicians and researchers in the traumatic stress field distinguish between simple and complex

trauma (Becker-Weidman, n.d.; Hermann, 1992; Paivio & Pascual-Leone, 2010). The term complex

trauma is used to refer to complex adaptations to early onset, ongoing interpersonal abuse and/or neglect

that occur within a care-giving relationship (Van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola, 2005).

Complex trauma leads to a loss of a coherent sense of self and therefore significantly disrupts a person’s

capacity to function in the world (McFarlane & De Girolamo, 1996). This can result in significant mental

health issues, which may be diagnosed as separation anxiety disorder, oppositional defiant disorder,

phobic disorders and attention deficit hyperactivity disorder in children (Van der Kolk, 2005), or later, as

depression, anxiety, borderline, antisocial or multiple personality disorder, bipolar disorder, agoraphobia,

panic disorder and/or posttraumatic stress disorder (Hodges, 2003; Lubin, Johnson & Southwick, 1996;

Panova, 2009; Wiley, 2010). When treated in isolation and with medication alone the underlying

traumatic events may remain unacknowledged and treatment may (at best) lead to symptom management

rather than healing (Ogden et al., 2006).

To acknowledge the severe impact of early prolonged interpersonal trauma a number of diagnostic

constructs have been proposed and researched over the years, including Complex Post Traumatic Stress

Disorder (C-PTSD), Disorders of Extreme Stress Not Otherwise Specified (DESNOS) (Jongedijk,

Carlier, Schreuder & Gersons, 1996; Wiley, 2010) and Developmental Trauma Disorder (Van der Kolk,

2005). None of these have as yet been accepted as official diagnostic criteria. Whilst some desire to keep

diagnoses neatly separated in non-overlapping categories, which can be medically treated (Kilpatrick, as

cited in Wiley, 2010), proponents of the complex trauma diagnosis point to the necessity to recognise the

underlying unity of the vast collection of supposedly unrelated diagnoses of complex trauma survivors

(Wiley, 2010). Van der Kolk (2005) argues that “approaching each of these problems [multiple

diagnoses] piecemeal, rather than as expressions of a vast system of internal disorganization runs the risk

of losing sight of the forest in favor of one tree” (p.2).

The consequences of trauma, apart from the above-mentioned potential array of psychiatric diagnoses, are

manifold and may extend into all areas of a person’s life. Often the initial effects lead to secondary and

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

tertiary effects as the person attempts to adapt to the initial impact (Lubin & Johnson, 2010). Primary

effects include significant changes in physiological arousal, sensory processing, affect regulation,

cognitive functions, memory and interpersonal relating (Hermann, 1992; Lubin & Johnson, 2010). Each

of these effects can impact people’s lives significantly in the following ways:

Hyperarousal is the body’s natural response to threat. Ideally this energy is utilised and

discharged in successful and vigorous fight or flight, which then restores the body’s equilibrium.

When this is not possible physiological arousal may remain altered moving between states of

hyper- and hypoarousal, both of which over time disrupt cognitive, affective and sensory

processing (Emerson & Hopper, 2011; Ogden & Minton, 2000).

Dysregulated sensory processing interferes with the perception of internal body states, leading to

either highly sensitised internal experiences of chronic pain and somatisation or desensitisation

and bodily numbing. It also interferes with the capacity to perceive external stimuli and leads to

reexperiencing (intrusive memories, flashbacks) or dissociative symptoms (Lubin & Johnson,

2010).

Emotionally the person may experience flat affect, numbness and/or anger and rage mixed with

feelings of helplessness, hopelessness, panic, confusion or despair (Bassuk et al., 2006; Van der

Kolk, 2005).

Cognitive functioning is impaired through dissociation, depersonalisation and confusion/thoughts

that the traumatic event is happening again (Van der Kolk, 2005). Cognitions become less

differentiated leading to exaggerating or minimising and overgeneralising thought processes often

referred to as black-and-white thinking (Lubin & Johnson, 2010).

During hyper- or hypoarousal state-dependent memory retrieval leads to either increased access to

traumatic memories leading to further hyperarousal or amnesia leading to further numbing and

hypoarousal (Ogden & Minton, 2000).

Boundary violations and neglect lead to ongoing alterations in interpersonal relationships and

attachment style, especially if experienced chronically and within a care-giving relationship. This

may find expression in clinging, compliant, oppositional or distrustful attachment behaviors

(Becker-Weidman, 2009; Van der Kolk, 2005).

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

Not only does trauma affect and change the above areas of functioning, it severs these otherwise

integrated functions from each other (Herman, 1992). Without support, a vicious cycle is created

described as a “biopsychosocial trap, in which one level of impairment prevents self-regulatory healing

mechanisms from occurring on other levels” (Shalev, 1996, p. 95).

Secondary effects develop as the person attempts to manage the above primary effects in an unsupportive

interpersonal environment where disclosure seems too dangerous or has been met with ridicule, disbelief

or further abuse (Lubin & Johnson, 2008). A variety of coping mechanisms may be employed in an

attempt to dampen, avoid or contain the distressing experience. These include amongst others: social

withdrawal, risk-taking behaviors, self-harm and eating disorders, drug and alcohol abuse or perpetrating

violence against others, some of which will inevitably increase the risk for retraumatisation (Farber, 2002;

Lubin & Johnson, 2008). Over time the environment may align further with the traumatic schemas (e.g.

social withdrawal leading to reduction in friendships; difficulty concentrating or acting out behavior in

school leading to being sent to a school for ‘difficult’ children) and the person becomes further

encapsulated in a life structure dominated by the effects of the traumatic past (Lubin & Johnson, 2008).

Tertiary effects are the resulting disturbances in the systems of meaning and the constriction of the

person’s sense of self, leading to cynicism, hopelessness, loss of vitality and dreams, existential fatigue,

suicidal ideation (Levine, 2008; Lubin, Johnson & Southwick, 1996) and posttraumatic decline

(Titchener, as cited in Lubin & Johnson, 2008). It becomes clear that over time trauma can have a

detrimental impact on a person’s health and wellbeing (Wiley, 2010), education, work, family and peer

relationships and can lead to involvement with the legal system (Van der Kolk, 2005).

Trauma Therapy – Recommendations from the Wider Field

“Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection

and meaning” (Herman, 1992, p.33). Trauma therapy therefore aims to reestablish a sense of control and

safety (Herman, 1992), to undo a person’s “aloneness in the face of overwhelming emotions” (Fosha,

2003, p.245) and to facilitate integration and meaning making (Herman, 1992). Trauma therapy aims to

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

support people to locate the traumatic events in the past, to integrate implicit and explicit memories, and

to learn to regulate arousal (Rothschild, 2000). Successful treatment therefore may be seen as “the

resolution of the effects of the traumatic past on the client’s current organisation of experience” (Ogden et

al., 2006, p.235).

Many trauma therapy approaches promote a phase-oriented treatment model beginning with establishing

safety and support, followed by processing traumatic memories and closing with integration (Herman,

1992; Kepner, 2003; Ogden et al., 2006). The severity of trauma, the age of onset and duration, single

versus multiple traumas, the person’s current resources and support, and pre-trauma functioning all

influence the direction of treatment and determine the amount of time spent in each phase (Kepner, 2003;

Rothschild, 2000). Assessing these factors is an important step in planning for treatment. Figure 1 outlines

a way of conceptualising different client types and implications for treatment.

Figure 1:Trauma Types and Implications for Practice (based on Rothschild, 2003; Rothschild, 2000)

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

Type I and IIA have a stable background and sufficient resources to be able to engage more quickly with

the traumatic event(s) that led them to seek therapy. With Type IIB clients, rebuilding resources through

the therapeutic relationship is essential before moving into second phase work of addressing traumatic

memories. Type IIB(R) clients’ access to previously held resources is temporarily overwhelmed and

sufficient time needs to be spent with phase one work of rebuilding safety, grounding and support. Type

IIB(nR) have had limited opportunities to build resources for resilience due to ongoing abuse, violence

and/or neglect and therefore commonly present with complex adaptations to trauma. They may present

with borderline personality features or, in the extreme, with dissociative identity disorder. In such

instances phase one work remains the most important part, if not all, of therapy, providing a slow,

continuous process of stabilisation and building safety and trust within the therapeutic relationship

(Ogden et al., 2006; Rothschild, 2000). Not all clients benefit from working directly with traumatic

memories and some can become significantly worse (Rothschild, 2010). It is therefore important to take a

thorough case history before engaging in trauma work and to continuously reassess the level of

functioning throughout the therapeutic work to avoid regression and retraumatisation (Rothschild, 2003).

Pierre Janet may have been the first clinician formulating a phase-oriented approach to working with

traumatised clients more than a century ago (Van der Hart, Brown & Van der Kolk, 1989). He proposed

the following three stages as a heuristic approach, recognising the need for continuous adaptation to each

individual case:

1. Stabilisation and symptom reduction

2. Modification of traumatic memories

3. Personality reintegration and rehabilitation (Van der Hart et al., 1989).

Since then many other clinicians have proposed similar models. Table 1 compares and contrasts the

different stages of various methods highlighting the emphasis across models of ensuring stabilisation prior

to memory work. Although some approaches propose four or five stages, thematically the extra stages can

be seen as sub-stages of either phase 1 or phase 3; for the sake of comparison they have therefore been

named phase 1a/b and phase 3a/b respectively.

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

Table 1: Comparison of Phase-Oriented Trauma Treatment Approaches

Authors Phase 1: Stabilisation

Phase 2: Processing of Trauma Memories

Phase 3: Integration Comments

Hermann (1992) a) A Healing Relationship

b) Safety

Rememberance & Mourning

a) Reconnection

b) Commonality

Classic text in the field of trauma

Steele et al. (2005) Stabilisation & Symptom Reduction

Treatment of Traumatic Memories

Personality Reintegration and Rehabilitation

Based directly on Janet’s model

Ogden et al. (2006) Developing Somatic Resources for Stabilisation

Processing Traumatic Memory and Restoring Acts of Triumph

Integration and Success in Normal Life

A sensorimotor approach to psychotherapy

Trauma-focused CBT (TF-CBT)(Feather Ronan, 2010; Kliethermes, 2007)

a) Strengthening Psychosocial Context

b) Enhancing Coping Skills

Processing Trauma Through Gradual Exposure

Addressing Special Issues/ Preventing Relapse

Promoted for use with children & adolescents, presented here only to highlight similarity of stages proposed2

Kepner (2003) a) Developing Support

b) Developing Self-Functions

Undoing, Redoing & Mourning

Reconsolidation A Gestalt approach, discussed further in part 3

Butollo, Kruesmann & Hagl (1998)

a) Safetyb) Stabilisat

ion

Confrontation Integration A Gestalt approach, see part 3

Each approach moves through similar stages although the specific strategies and interventions vary based

on overarching principles. It is beyond the scope of this literature review to provide detailed descriptions

of each approach other than Gestalt (see part 3), yet it becomes obvious that across modalities

establishing safety, stability and support is paramount before processing traumatic memories. Depending

on the level of functioning and the severity of the trauma this may take from one initial assessment

session to forming the entire therapy (see Figure 1).

The need to pay attention to body process in trauma therapy has become more widely recognised

(Rothschild, 2000; Rubin, 2006; Van der Kolk, 2009). As neuroscience advances and continues to provide

2 Whilst CBT trauma therapy approaches for adults do not specifically recommend a phase-oriented approach, treatment guidelines specify that prior to implementing exposure therapy it may be useful to provide training in affect and interpersonal regulation for people who find it hard to tolerate trauma focused interventions, e.g. after chronic trauma (International Society for Traumatic Stress Studies, 2012).

Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

further insights into brain responses to trauma, the importance of therapists noticing body process and

acting “as an auxiliary cortex, interactively modulating clients’ levels of arousal” (Ogden & Minton,

2000, p.11) becomes clearer. Working with the body also gives access to implicit memory, which talking

therapy on its own cannot, and provides a vehicle for the mobilisation and expression of incomplete

action tendencies (Burley & Freier, 2004; Ogden et al., 2006) seen as essential for effective treatment

(Van der Kolk, 2006a). Tracking of body process provides relevant information for supporting clients to

remain within an optimal arousal zone for integration (Wallin, 2007). Figure 2 outlines a model to

understand the regulation of nervous system arousal.

Figure 2. Window of Tolerance (adapted from Ogden & Minton, 2000; Siegel, 1999 cited in Ogden & Minton, 2000; Wallin, 2007)

Hyper- and hypoarousal are protective strategies activated by the amygdala as a survival response to

fight/flight or, if this is impossible, freeze (Wallin, 2007). After experiences of trauma these defensive

responses commonly become activated more quickly; the tolerance levels for experiences that can be

assimilated and integrated without triggering a survival response decrease (Ogden et al., 2006). As the

prefrontal cortex3 and hippocampus4 shut down during survival responses, both hyper- and hypoarousal

3 The prefrontal cortex is responsible for “body regulation, attuned communication, emotional balance, response flexibility and fear modulation” (Costin, 2012, slide 30). During normal functioning it can regulate emotional impulses generated by the amygdala, the body’s alarm system. However, neuroimaging studies have shown traumatised individuals to have less active higher cortical brain areas and a perpetually activated amygdala interfering with the above functions (Beauregard, n.d.).4 The hippocampus, which transmits information to the cerebral cortex, is suppressed during traumatic experiences. This prevents processing of the traumatic event to become a memory located in time and space (explicit memory). Remaining in implicit memory only, unresolved traumatic memories can provoke images, sensations and emotions, perceived by the body as the event occurring again. Without engaging the explicit memory system, the experience cannot be cohesively understood or retold (Rothschild, 2003).

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

interfere with a person’s capacity to integrate experience and make meaning (Ogden & Minton, 2000),

both of which are key tasks of trauma therapy that aims to relocate traumatic experience in time and place

as separate from current reality (Van der Kolk, 1994). The therapist’s task therefore is “to hold the

client’s arousal at the optimal levels of the Modulation Model, accessing enough traumatic material to

process but not so much that clients become too dissociated for processing to occur” (Ogden et al., 2006,

p.11). Over time, as integrative capacity increases, tolerance levels expand leading in turn to further

integration (Ogden et al., 2006). Paying close attention to the bodily signs of arousal (see Figure 2) helps

the therapist to know when to co-regulate arousal as clients may initially lack awareness and capacity to

communicate signs of flooding or dissociation (Wallin, 2007).

Gestalt Trauma Therapy (GTT)

The final part of this literature review is concerned with reviewing Gestalt literature on working with

trauma. Both Cohen (2002) and Hardie (2004) point towards the scarcity of such literature and Fodor

(2002) comments “while many of us in the Gestalt field work with trauma, we do not have a Gestalt

literature on trauma as such” (p. 85). It comes as a surprise that none mention Kepner’s (2003)5 classic

text Healing Tasks, which provides an in depth description and to date the most developed Gestalt

approach to working with adult survivors of childhood abuse (Wirth, 2008). Kepner presents a trauma

treatment model whose phase-oriented approach clearly aligns with many of the contemporary

recommendations from the wider trauma field (see Table 1). He presents in depth descriptions and

examples on how to work in each of the phases (developing support; developing self functions; undoing,

redoing and mourning; reconsolidation) using an approach firmly based in Gestalt therapy practice

(Kepner, 2003). He also provides a valuable assessment instrument with direct implications for his

treatment model (Wirth, 2008).

Nonetheless, apart from Kepner’s detailed account only limited English material could be sourced, which

included: Serok (1985), who presents experiential, phenomenologically based reenactment work adapted

5 First published in 1996

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

to each individual, stating that “most important is for the individual to reach maximum expression” (p.88)

to complete unfinished events. In contrast to more recent publications, which emphasise a resource-

oriented approach prior to expressive work (Hartmann-Kottek, 2004), little attention is given to the

establishment of safety and resourcing prior to exposure, though this may simply reflect the focus of

writing rather than the entirety of the therapeutic work. Melnick and Nevis (1997) describe PTSD as an

interruption at the demobilisation phase as part of a comprehensive paper proposing formal diagnosis

from a Gestalt perspective. Tobin (2004) encourages the integration of EMDR (eye movement

desensitisation and reprocessing) and relational Gestalt therapy. Finding EMDR to be an “excellent

adjunct” (p.16), he highlights the importance of the therapeutic relationship as the container/ground,

especially when working with complex trauma. Haarburger (2006) presents his work with male survivors

of sexual abuse, exploring gender and shame as part of the field, promoting a dialogic and

phenomenological approach influenced by Kepner. Sapriel (2012) emphasises mindfulness and body

awareness “embedded in a safe and secure therapeutic relationship” (p.107) as tools to facilitate the

development of a “sense of agency, contain previously uncontainable affect, and become capable of

nourishing contact” (p.107). All highlight Gestalt’s usefulness as an approach to working with trauma,

specifically naming the dialogic stance/therapeutic relationship (Haarburger, 2006; Sapriel, 2012; Tobin,

2004), experimentation (Kepner, 2003; Serok, 1985), field sensitive practice (Haarburger, 2006; Kepner,

2003) and phenomenological exploration/awareness of body processes (Haarburger, 2006; Sapriel, 2012;

Serok, 1985) as important trauma-specific competencies, which will be elaborated on further.

Sapriel (2012) explains: “Gestalt therapy has always emphasised field theory, but historically, the

technology of awareness was more figural, field theory more ground” (p.111). This historical shift is

apparent also in the above collection of articles with Serok’s (1985) focus on reaching “maximum

expression” (p. 88) to complete unfinished events, whereas later articles emphasise field sensitive

practice, highlighting the importance of support and the therapeutic relationship whilst sensitively

facilitating awareness of contact modifications.

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

The German speaking Gestalt community has a significant collection of recent publications on GTT and

for a more comprehensive and up-to-date review, these are now included alongside the above-mentioned

material. Trauma publications from other experiential approaches influenced by Gestalt therapy could have

been considered to identify relevant GTT principles; e.g. Paivio and Pascual-Leone’s (2010) Emotion

Focused Therapy for Complex Trauma6 or Ogden, Minton and Pain’s (2006) Trauma and the Body7.

Alternatively, Gestalt literature on working with secondary manifestations of trauma8 may also have been

included. Both alternatives promise a rich exploration and could form an entire literature review of their

own. Even though not chosen as the main focus here, they have provided some background to the overall

text.

Gestalt therapy views traumatic experience as being confronted with a situation in which one’s current

level of integrative capacity and support are overwhelmed (Wirth, 2008). Dissociation is a self-protective

survival mechanism that interrupts contact with an experience of terror (Schoen, 2008; Wirth, 2008). The

splitting off, whilst aiding survival, interferes with integration, and an unfinished situation remains

(Votsmeier-Roehr, 2005). The person is unable to disengage from the experience, and even though the

moment has passed, the traumatised person has become fixed at this point in time (Melnick & Nevis,

1997; Schoen, 2008). Over time contact modifying strategies become habitual, fixed responses aimed at

avoiding further danger. If required over long periods of time, as in experiences of complex trauma, these

strategies can become part of personality structure (Votsmeier-Roehr, 2005). The many secondary

manifestations of trauma (see part 1) are understood as, “creative adaptations to inhospitable situations in

a person’s life” (Crocker, 1999, p.134) and the best possible response available at the time based on a

person’s prior life experiences and levels of support (Burley & Freier, 2004).

6 The development of the extensively researched Emotion-focused therapy (Paivio & Pascual-Leone, 2010) has been significantly influenced by Gestalt methodology (Votsmeier-Röhr, 2011). Contributions named include “explicit emphases on the role of emotional arousal, on bodily experience, and on the adaptive, organismic wants and needs associated with emotional experience as motivators of action” (Paivio & Pascual-Leone, 2010, p.85), which becomes apparent in the therapeutic stance and working with inner dialogues/parts (Votsmeier-Röhr, 2011).7 Ogden’s sensorimotor approach is strongly influenced by Hakomi (Beauregard, n.d.), a body-centered mindfulness based psychotherapy, which in turn was influenced by Gestalt principles (Hakomi Institute, n.d.). Her book is acclaimed as an outstanding contribution to trauma therapy by many of the current experts in the field (eg. van der Hart, 2006; Van der Kolk, 2006b; Schore, 2006) and uses an experiential here-and-now, phenomenological, relational approach supporting awareness and completion of unfinished ‘fixed’ patterns through a holistic body-inclusive approach.8 e.g.: addictions (Brownell, 2011; Leung, 2010), personality disorders (Greenberg, 2005; Greenberg, 2002), bipolar (Van Baalen, 2010), self harm (Williams, 2010), eating disorders (Gillie, 2000; Kappeler, 2004)

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

“Contact is the life blood of growth, the means for changing oneself and one’s experience of growth”

(Polster & Polster, 1973, p.101). However, experiences of trauma significantly alter a person’s capacity

for contact; without sufficient resources to complete the gestalt of the traumatic event, a person uses all

their energy to ward off danger and therefore is unable to notice their own sensations (Kepner, 1996;

Wirth, 2008). No clear figures can be formed, as a disturbance at the sensation stage of the cycle of

experience will affect all remaining stages (Melnick & Nevis, 1997). The person moves continually

between extreme arousal and numbness, from over involvement to avoidance (Cohen, 2002) with

insufficient ground/support to assimilate the experience into a meaningful whole (Schoen, 2008).

Being a humanistic-existential approach, Gestalt theory understands humans as constantly striving to

realise their creative potential. This occurs as a continuous process of integration and differentiation at the

contact boundary between organism and environment within the organism-environment-field (Schoen,

2008). Even though at times challenging, with sufficient support these contact episodes can be

experienced as exciting and as opportunities for growth. With insufficient support these experiences lead

to varying degrees of existential fear, contact is modified and, when confronted with extreme situations

(or reminders thereof), split off completely to maintain an intact sense of self (Kerner, 2008; Votsmeier-

Roehr, 2005).

The window of tolerance (Figure 2) is a theoretical construct defining a person’s tolerance level of arousal

(Ogden et al., 2006). Similarly, the Gestalt concept of the I-boundary9, which consists of a collection of

contact boundaries (Polster & Polster, 1973), is defined as the currently permissible contact processes a

person can engage in without dissociating to self-preserve (Kerner, 2008). The window of tolerance

expands as internal and external resources grow (Wallin, 2007). Likewise, the range of permissible 9 “For each of us there is a point at which fear crosses the line into trauma, causing severe disturbances in the integration of cognitive,

sensory, and emotional processing” (Cozolino, p.262). The I-boundary defines this point; contact within the boundary is experienced as safe,

routine and strengthens one’s sense of safety, at the boundary it is experienced as uncertain/new, but also as exciting/differentiating, growth

promoting. Contact outside the I-boundary is felt as existential fear that threatens one’s identity, as overwhelming or catastrophic (Schoen,

2008; Votsmeier-Roehr, 2005)

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

contact processes and a person’s “experiential range” (Zinker, 1977, p.118) expands, as self- and field-

support increase throughout the therapeutic work (Kepner, 2003; Votsmeier, 2005). For integration to

occur it is important that therapeutic work remains within a therapeutically useful level of arousal, enough

for relevant material to be brought to the fore but not so much that dissociation occurs (Kepner, 2003;

Ogden et al., 2006). Through dialogue and experimentation Gestalt therapy creates opportunities for “safe

emergencies” (Perls, Hefferline & Goodman (PHG), 1951, p.336ff), experienced as emergency because,

“the patient [feels] the behavior in its very emergency use” (p.65), but “felt as safe because the patient is

at a stage adequate to invent the required adjustment” (p.338)10, i.e. has sufficient self skills and field

support to risk change within the safety and support of the therapeutic relationship (Joyce & Sills, 2010).

Phenomenological tracking allows for noticing signs of hyper- or hypoarousal (see Figure 2), indicating

the risk of retraumatisation and the need for co-regulation (Haarburger, 2006). When experiencing

flooding or numbing, the client’s prefrontal cortex and hippocampus have shut down and integration

cannot occur (Ogden et al., 2006). Such dissociation can be understood as “right figure [before] wrong

ground” (Kepner, 2003, p.94). Consequently it is important to reconnect the client with the safety in the

here-and-now, to strengthen the here-and-now ground of the therapeutic relationship rather than

heightening contact with the traumatic figure (Kerner, 2008). In the early phases of treatment grounding

strategies, which support current here-and-now relational processes, are used to regulate arousal and bring

the cortex back ‘online’ (Beauregard, n.d.; Wolf, 2001). If the relationship itself is experienced as

activating, bringing attention to and naming sensory impressions of the environment can help to ground

clients prior to attending to the relationship (McIndoe, 2007). Once sufficient relational and

self-support/ground has been built, memories can become more figural in the work (Kepner, 2003).

10 It is important to highlight here that PHG’s text was written for work with neurosis rather than specifically working with trauma or the often ensuing fragile self process (Wirth, 2008). PHG thus continue “felt as safe because the patient is at a stage adequate to invent the required adjustment, and not deliberately ward it off” (p. 338, italics added). Philippson (2012) highlights the impact of early trauma and neglect on a person’s “neurological capacity to move flexibly into new perceptions and relations to the environment”, which as a consequence becomes very limited and “can only be remedied by slow accretion from a caring relationship” (p.90). In other words, the warding off may not be very deliberate, but rather a neurologically wired response, which fortunately we now know can be healed in “a safe and empathic relationship [that] establishes an emotional and neurobiological context conducive to neural plasticity” (Cozolino, 2010, p.342).

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

“Most trauma occurs within the context of interpersonal relationships” (Van der Kolk, 2006, p.xxiii) and

leaves behind experiences of isolation and shame. In situations of complex trauma where a child’s needs

have been consistently neglected or met with abuse, a child learns early on to dissociate or remain

unaware of their inner experience/sensations and attunes to the caregiver’s needs instead. This results in

the loss of a sense of agency leading to hopelessness and despair and internalisation of the negative affect

from caregivers as an expression of one’s intrinsic defectiveness and unlovability (Sapriel, 2012). As

stated earlier, without awareness of sensation no clear figures can be formed (Melnick & Nevis, 1997),

which means, “without an authentic self, there can be no nourishing contact with another. One never

learns to be authentically oneself and with another at the same time” (Sapriel, 2012,p. 109, emphasis in

original). Furthermore, Schore (cited in Philippson, 2012) has shown that in cases of severe early trauma

“the neurological capacity to move flexibly into new perceptions and relations in the environment” is

disrupted and healing needs to occur “by slow accretion from a caring relationship” (p.90). This may be

facilitated through Gestalt therapy’s dialogic approach, which strives for “an attitude of genuinely

feeling/sensing/experiencing the other person as a person (not an object or part-object), and a willingness

to deeply ‘hear’ the other person’s experience without prejudgement” (Hycner & Jacobs, 1995, p.xi,

emphasis in original). GTT aims to mobilise client’s resources, which enable entry into dialogic

relationships through the consistent offer of authentic meeting alongside the strengthening of self-

functions necessary for a mutually authentic exchange (Butollo, Kruesmann & Hagl, 1998). This requires

close attendance to repairing therapeutic ruptures (Sapriel, 2012) as clients’ neural functioning and

implicit memory may initially distort the perception of the interactions with the therapist (Philippson,

2012). It is in the slow, continuous process of noticing and naming ruptures and attending to the repair,

that new implicit memories are created and authentic contact becomes a possibility (Burley & Freier,

2004; Mann, 2010). To sustain the capacity to initiate repair, the capacity for contact, even when faced

with projected rage or complete withdrawal, requires adequate levels of self- and field support for the

therapist as well. Regular supervision and self-care practices therefore are essential when working with

complex trauma survivors (Butollo, Kruesmann & Hagl, 1998).

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Looking at the phase approach, the beginning phase(s) aim(s) to stabilise clients to be able to regulate

arousal sufficiently to remain in contact with their own experience and their environment more often

(Butollo, Kruesmann & Hagl, 1998; Kepner, 2003; Wolf, 2001). When contact is habitually interrupted at

the sensation stage, levels of sensation may initially need to be lowered and containing strategies are used

rather than expressive or confrontational, sensation increasing techniques (Hartmann-Kottek, 2004;

Melnick & Nevis, 1997). Kepner provides detailed descriptions of the stabilising work of the first, or in

his case first and second, phase. Therapeutic interventions after establishing support aim to reinstate self-

functions (pacing, grounding, boundary, self-support and self-soothing, mindfulness and affect tolerance

skills).

This preparatory work lays the ground for second phase work in which the traumatic material is

confronted in small doses, just enough so the client can remain in contact with the images, sensations,

feelings and thoughts alongside the support of the therapist and integrate these (Wolf, 2001). As self- and

field-support have increased due to the work of phase one, the traumatic material can now be revisited

(Wolf, 2001; Kepner, 2003). Not for the sake of cathartic expression of feeling per se, but to enable

“experiencing oneself differently” (Kepner, 2003, p.109) in relation to the trauma, to restore a person’s

“full capacity and range of possibilities with which to meet the environment” (p.109).

Van der Kolk (2009) points out “After confrontation with helplessness, it is essential to take effective

action” (p.12). Gestalt therapy through its experimental approach is ideally suited to surface unfinished

past situations enabling exploration of different responses within the present field (Clarkson & Mackewn,

1993; Serok, 1985). Phenomenological exploration brings implicit memory into awareness for

experimentation in the here-and-now (Burley & Freier, 2004; Wirth, 2008). The possibilities for creative

experimentation are many, including “fantasy and visualization, creative enhancement of body language,

two-chair work, psychodrama, and enactment” (Cohen, 2002, p. 2). However, “the intervention that is

more healing is a function of whatever is most assimilable, most readily integrated at the client’s current

stage of development” (Kepner, 2003, p.113) and experiments therefore need to be graded. This kind of

exposure and enactment work with traumatic memories can only be integrated if the current field

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conditions outweigh those of the past (Kepner, 2003), measurable by the client’s capacity to stay present

with the experience rather than dissociating due to being overwhelmed (Haarburger, 2006).

The final phase supports integration/reconsolidation and involves “the reorganisation and growth of one’s

perceptions, one’s sense of self, and one’s understanding of the larger world and one’s place in it, as well

as reorganisation and growth in how one makes meaning of experience” (Kepner, 2003, p.131).

Mourning, exploring questions of forgiveness, redefining one’s identity beyond survivorship (Kepner,

2003) and integration of the traumatised and non-traumatised parts of self are named as important tasks

(Butollo et al, 1998). Group therapy to break isolation and support interpersonal growth, as well as

reconnecting with the body through activities such as yoga, martial arts, feldenkreis or dance are

encouraged during this phase (Wolf, 2001; Kepner, 2003).

Conclusion

Definitions, consequences and treatment approaches from the field of trauma therapy, and more

specifically Gestalt therapy, have been reviewed. The importance of a phase-oriented approach, which

ensures clients are sufficiently resourced before trauma memories are processed, has been highlighted in

the literature across modalities. Gestalt therapeutic concepts have been discussed against the theoretical

backdrop of contemporary trauma theory. Based on the literature reviewed, Gestalt therapy has been

found to be a highly recommended approach for working with trauma, as long as practice is based in a

thorough understanding that contact can only be sustained with sufficient support. The majority of authors

therefore explicitly advise against contacting trauma memories prior to establishing sufficient support,

against making memories figural before the ground provides the necessary structures and processes to

support integration. Attention to body process and phenomenological exploration were identified as

important tools for noticing and co-regulating client arousal useful both for grounding and deepening

therapeutic work. Both also facilitate access to implicit memory based action tendencies and relational

patterns, which once brought to awareness can be explored through graded phenomenologically based

experimentation. This resurfacing of unfinished business allows for experimenting with new responses in

the here-and-now with current resources and within the incrementally built safety and support of the

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therapeutic relationship. Thus new implicit memory and neural functions that allow for flexible responses

and authentic exchange with the environment are created and a person’s deeply felt sense of

disconnection and aloneness can slowly be undone.

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Isa Pfluger Psychotherapy with Adult Survivors of Complex Trauma

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