There is a considerable lack of research on trauma, specifically war trauma and its properties and treatments. Furthermore, there is a lack of discourse involving gestalt therapy in the field of psychology due to its reputation and founder. This paper attempts to advocate for the both of these deprivations singularly and synergistically. This literature view uses seven sources related to gestalt therapy, war trauma, and trauma. It postulates that the utilization of gestalt therapy in trauma treatment for veterans is appropriate and likely effective. It is critical for the field of psychology to more frequently implement gestalt therapy in its discourse and practice so that further research can be done on its effectiveness.
Keywords: trauma, war, gestalt therapy, treatment
The Appropriateness of Gestalt Therapy as a Trauma Treatment for Veterans
Trauma is universal. It may vary in its operational definition and severity depending on a range of factors such as culture, experience, and subjective perception - but it is inarguable that it is a consistency of the human experience. The human response to trauma, aside from these factors, has certain similarities. It causes intense psychological and emotional pain, which in turn considerably affects the brain, the nervous system, and can then impair the body’s overall health through a disruption of many physiological processes. Trauma is generally stored in oneself by way of an automatic and unintentional repression or avoidance that can significantly impact a person’s ability to function healthily in the world. It affects perception, contact, relationship, communication, and many other essential ways of engaging with one’s surroundings. Because of the commonality of trauma, it should be understood that trauma work is an invaluable proficiency of the mental health clinician’s skillset. In order for clinicians to have a comprehensive understanding of trauma, and employ effective therapeutic techniques and interventions, there must be an abundance of research related to the subject.
Though there have been some groundbreaking revelations presented to increase our understanding of trauma, there is still much to be learned about it and appropriate treatments by closely examining it. Furthermore, there is much value in examining trauma in its most severe forms, as this provides the clearest but also possibly most complex observable manifestation of it. War can produce an amalgamation of some of the most devastating and complex trauma imaginable to the human being. Yet, there is a significant lack of both short and long-term research done on war and its effect on the human psyche. I am advocating for a greater emphasis on war trauma in the field of psychological research. It could have significant implications, not only for veterans, but for our understanding of trauma in all of its presentations.
Personal Justification for Advocacy
My interest in trauma and war began at a surprisingly early age. My father made no attempts at sparing me from an awareness of the harsh realities of this world, and in many ways, I am thankful for this. I had minimal restrictions as far as the type of material I was allowed to consume. Even prior to my adolescence, we watched movies like Terminator 2, Rambo, Predator, and Saving Private Ryan. I saw rape, death, killing, and acts of war portrayed on screen. I remember watching Black Hawk Down in middle school and being mystified by the experience of the American army rangers in the movie. They had names, they had families, they were human beings. In many ways they were very ordinary. They could be you or me - and they killed, watched their friends die, and many died themselves during a war tour that was supposedly intended to bring aid to Somalia. Somalia, at this time, was a country whose power was being consolidated by militia, and whose people were starving and dying during this struggle for power.
This brought upon a whirlwind of thoughts and emotions in me. There was so much that I did not understand. Was the United States involvement in this country justified? Was it helpful? How did these soldiers process what they experienced? How did Somalis feel about these rangers? I had many questions and felt an overwhelming emotional response to what I was witnessing, which fueled a desire to know more. Most of my chosen reading material from then on consisted of books on suffering and profound trauma, often specifically of war. The Things They Carried, Matterhorn, Black Hawk Down, Generation Kill and many more were influential during my process of exploration. I continued to gain insight into the personal trauma of those who experienced the battlefield, while also expanding my knowledge of the scope of war as it relates to politics, government, race, and power.
Later in life, as I developed an interest in psychology, I began to see the connection between this and my earlier interest in war. Suffering is an inevitability of human existence. Because people need assistance with enduring, processing, and healing from suffering, there is a need for the field of psychology. Part of psychology’s role is to gain insight into the nature of suffering and trauma, and then provide theories and treatments that can be used to assist in the alleviation of these elements of the human experience. Through my undergraduate studies in psychology, I developed an interest in gestalt therapy. I was attracted to its theory of human nature, and of the tangible way it appeared to facilitate emotional processes which created change and relief. It was not until now, however, that the specific interests of war, trauma, and gestalt therapy have come together.
Literature Review
There are many interrelations between the traumatic effects of war, and gestalt therapy’s theoretical orientation towards healing, which will be discussed throughout my suggestions for treatment. This supports the idea that gestalt therapy is an appropriate and likely effective therapy for treating war trauma. It should be understood, however, that in the scope of treatment, a significant amount of progress must likely be made with the client before the phenomenological and trauma techniques of gestalt therapy may be implemented to their maximum effectiveness.
The treatment process should proceed as follows. First, the clinician must understand the potential fragility of the therapeutic relationship. Research shows that there may be some hesitancy and caution in clients with posttraumatic stress disorder, and their engagement with therapy. Butollo et al. reported client dropout rates between 18.9% for eye movement desensitization and reprocessing therapy and 26.9% for cognitive behavioral therapy, which are two of the leading PTSD therapies (Butollo et al., 2014). This could also be evidence that suggests a need for different and more effective therapies. Additionally, Finley et al. found that veterans typically have some resistance to trauma focused therapy (Finley et al., 2020). Many people seek treatment as a last resort and they will likely be hesitant to engage in the vulnerabilities of therapy due to the difficulties that this produces. I can imagine that this hesitancy would be much more severe in the case of someone who has significant trauma that they have repressed. It is courageous and incredibly difficult to explore the experiences of searing trauma. This is why it is important for clinicians to be direct and honest about the nature of treatment.
Providers have stated that they prefer to inform veterans, in detail, of treatment options and then allow them to have input in the selection and course of treatment (Finley et al., 2020). By creating a more egalitarian foundation to the relationship, the clinician will strengthen the therapeutic relationship. Gestalt views trauma as disrupting the person’s ability to make healthy contact with their surrounding field. In other words, the trauma damages the person’s ability to relate to themselves, others, and the world around them (Perera-Diltz, et al., 2012). This will likely set the therapeutic relationship at a disadvantage, which places a high degree of importance on the clinician to operate in a manner that promotes connection.
After the client is briefed about the nature of treatment, a process of assessment should begin that allows the therapist to gain insight into the unique person and environment within which the trauma has occurred. Scurfield (1993) elaborates on this by stating:
No one went to war as a “blank tablet.” We all went as someone, as somebody. We all had personalities, strengths and shortcomings, values, beliefs, prejudices, relationships, successes, problems, issues and dreams. And you, this some-body, entered the military and went to war. And you brought inside of you to the war all of those personality characteristics, strengths and shortcomings, values, beliefs, prejudices, relationships, successes, problems, issues and dreams with you — we all did. And what we brought with us to the war somehow interacted with what each of us experienced during the war, resulting in unique combinations arising out of who we were before the war and during war. And so, there is no way to begin to understand the possible impact of war unless you have a clear sense of your personality before, during and following exposure to war trauma (as cited in, Scurfield, 2006, p. 97).
Scurfield makes it eloquently clear that the clinician must seek to understand and work through the context of the whole person. They must then attempt to help heighten the client’s own awareness and understanding of these factors. I cannot yet specifically say what this assessment would look like in terms of its structure and application to the client/therapist relationship. More research must be done in regards to this issue. It should be noted that construction and analysis of sensitive, effective, and appropriate methods of assessment are critical. It is likely that this stage of therapy may take a significant amount of time and much of it will consist of talk therapy.
Once a comprehensive understanding of the whole person is achieved, it could be appropriate to move into pretreatment and some cognitive work. By doing so, it would hopefully provide the client with the tools to build a solid foundation that is necessary for being able to undergo intensive trauma work. This is supported by Finley et al. who found that providers agree that supportive psychotherapy and pretreatment are essential to providing effective coping skills for subsequent treatment (Finley et al., 2020). Widera-Wysoczanska also supports this by stating that, “In order to be able to go back and resolve the trauma, an individual first needs to build a sense of support and strength inside and outside. Building resources that enable recovery processes provides the basis to healing from the consequences of trauma” (Widera-Wysoczanska, 2016).
After these skills are formed within the client, it is my belief that a combination of introductory gestalt and cognitive processing therapy could be effective. CPT is a cognitive therapy with significant empirical support in its ability to treat trauma (Konig et al., 2020). It is used in cognitive restructuring to help the client reduce avoidant or repressive tendencies. Scurfield found that an avoidance or detachment from the realities of war is vital to being able to survive it. He states that, “For both front-line combatants and support personnel in such roles as medical services, graves registration, truck drivers, in-country prison duty and intelligence, the primary means of surviving the risks, the constant threats and unpredictability of danger, is to learn how to detach oneself from the realities of what is happening” (Scurfield, 2006). This makes working towards preparing and opening the client to reliving their traumatic experience a critical element of trauma work.
Cognitive therapies have been questioned regarding their comprehensiveness in trauma treatment. They oftentimes reduce PTSD symptoms, but typically fail to provide any moral or inter/intrapersonal benefit beyond that (Butollo et al., 2014). Some clinicians believe there may be unresolved issues of contact that are being missed by these treatments. This notion is echoed by Pack who stated that sometimes clients can begin to form an identity of themselves through their pathology (Pack, 2008). She discusses the importance of then deconstructing and reauthoring client’s stories through gestalt properties of awareness, which allows them to recreate a sense of self that is separate from their trauma. As the therapeutic process unfolds, a stronger connection within the therapeutic relationship is established, and the client gains tools and comfort with the idea of doing more intensive trauma work. When the timing feels appropriate for the client and therapist, the last stage can begin.
I believe that the most complete form of healing through trauma is by accessing and reliving it in the safety of therapy, and with the skills necessary to process it during the re-experiencing. Gestalt views therapy as helping work through “unfinished business,” which is a term used to describe blockages that affect our ability to healthily make contact with the world (Perera-Diltz et al., 2012). Crump (1984) stated that through the gestalt process of reliving their traumatic experience in the present moment, veterans showed a decrease in struggle and anxiety (as cited in Perera-Diltz et al., 2012, p.80). He also stated that “giving the symptom or the emotion a voice brought awareness and closure to the unfinished business” (as cited in Perera-Diltz et al., 2012, p. 80). To me, this shows evidence for gestalt techniques supporting the healing process. I think trauma is primarily an emotionally affecting experience that manifests itself deeply within the body and mind. As a result, I find that gestalt therapy’s emphasis on emotional awareness, expression, and resolution provide a sound theoretical framework for trauma therapy and trauma therapy for veterans.
Discussion
In the writing of this paper, I found limited amounts of research on gestalt therapy and its effectiveness as a trauma treatment. Many of the articles I read called for a need of further research on the subject. Also, some of the articles were written by the same authors and referenced each other, which shows a lack of available research. Additionally, most articles were unanimous in their agreement that gestalt therapy is, at least, equally effective when compared to the leading evidenced based trauma treatments – and could provide significant benefits beyond reduction of symptoms for the healing of the whole person. Perera-Diltz et al. summarizes this sentiment when they state that “Although Gestalt therapy is the treatment of choice for PTSD theoretically, strategically, and tactically, it fails to achieve its proper status and recognition among the various approaches for the treatment of PTSD. . . .The current rules of the game in psychotherapy are documented “proofs” of efficacy” (Perera-Diltz et al., 2012, pg. 82).
Research that specifically addresses war trauma and the psychological health of veterans is even scarcer. Scurfield emphasized this in his book by specifically identifying a severe lack of longitudinal research done on long-term psychiatric assessment of veterans (Scurfield, 2006). There is significant overlap between trauma, PTSD, and war trauma. However, war is an incredibly unique traumatizing experience. As a result, it should be understood that there is a need for specific research and strategies for treating veterans. Scurfield has done significant amounts of work in this regard, and made note of several non-traditional therapies that have been found to be effective. They are: visiting memorials, grief and loss rituals, Outward Bound adventure-based activities, helicopter-ride therapy, and returning to the war zone during peace time.
With further regards to treatment development, gestalt therapy is aligned with more contemporary approaches to psychotherapy and development. These approaches emphasize that neurosis, trauma, and development must be specifically understood through the lenses of people’s unique systems and environments. Furthermore, these modern approaches seek to place the individual as the expert of their experience and culture. They not only include the individual in the understanding of and construction of appropriate treatments, but they encourage them to lead the way. This method of developing theories and creating treatments must be applied to veterans and those who have experienced war trauma. In the field of psychology, we can use theoretical orientations that seem to be the most fitting or appropriate, and verify them through research. However, why would we not begin with the experts – the veterans themselves? I feel similarly now to the way I did when I was young and watching and reading about war. There is so much that I cannot now and will never be able to understand. Because of this, I will strive to listen to, advocate for, and elevate the people who do. Psychology needs to do more to help those who experience war trauma, and it needs to begin this mission by listening to those who have lived it.
References
Butollo, W., Konig, J., Karl, R., Henkel, C., Rosner, R. (2014). Feasibility and outcome of dialogical exposure therapy for posttraumatic stress disorder: A pilot study with 25 outpatients. Psychotherapy Research, 24(4), 514-521, https://doi.org/10.1080/10503307.2013.851424
Finley, E. P., Ramirez, V. A., Haro, E. K., Garcia, H. A., Mignogna, J., DeBeer, B. (2020). Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the veterans health administration: A thematic analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 251-259, https://doi.org/10.1037/tra0000477
Konig, J., Unterhitzenberger, C. C., Kohout, P., Rosner, R., Karl, R., Butollo, W., (2020). What was helpful in today’s session? Responses of clients in two different psychotherapies for posttraumatic stress disorder. Psychotherapy, 57(3), 437-443, https://doi.org/10.1037/pst0000295
Pack, M., (2008). “Back from the edge of the world”: Re-authoring a story of practice with stress and trauma using gestalt theories and narrative approaches. Journal of Systemic Therapies, 27(3), 30-44, http://search.ebscohost.com/login.aspxdirect=true&AuthType=ip,sso&db=edsbl&AN=vdc.100069495398.0x000001&site=eds-live&scope=site
Perera-Diltz, D. M., Laux, J. M., Toman, S. T., (2012). A cross-cultural exploration of posttraumatic stress disorder: Assessment, diagnosis, and recommended (gestalt) treatment. Gestalt Review, 16(1), 69-87, http://search.ebscohost.com/login.aspxdirect=true&AuthType=ip,sso&db=edsbl&AN=RN316783350&site=eds-live&scope=site
Scurfield, R. M., (2006). War trauma: Lessons unlearned from Vietnam to Iraq: Vol. 3 of a Vietnam trilogy. Algora Publishing.
Widera-Wysoczanska, A., (2016). Trauma treatment: Factors contributing to efficiency. Cambridge Scholars Publishing.