These criteria or symptoms may be viewed as two dimensional polarities. One dimension is arousal, which may be seen as a continuum from extreme arousal and agitation to low arousal and numbness. The other dimension is approach-avoidance, which may be seen as a continuum from over involvement (with accompanying flashes of image, memories, and rumination)to total avoidance or fear of any stimuli that may relate to the experience.

From a Gestalt therapy perspective, these PTSD characteristics may be viewed as indications of "unfinished business." Specifically, the indicated symptoms of the trauma seem to demonstrate:

1. an attempt to assimilate an experience that is not assimilable
2. repeated unsuccessful attempts at completion of the cycle of experience
3. disatisfaction with one's responses to the unusual circumstances
4. an existential reminder of one's mortality

Melnick and Nevis (1992; 1998) offered an original attempt at viewing PTSD from a Gestalt therapy perspective. According to these scholars, PTSD is due to the inability of the individual to disengage from an experience and to absorb and digest it. They argue that PTSD symptoms are due to disturbances in the final stage of the cycle of experience, namely the demobilization phase. The demobilization stage, they suggest, includes four sub-stages:

1. turning away
2. assimilation
3. encountering the void
4. acknowledgement

Thus, the various PTSD symptoms represent inability to move through the stages. According to this formulation, therapy should focus, first, on enabling the client to turn away from the traumatic figure (perhaps the memory of a loved person, addiction, or the concept of invulnerability). In the second stage, therapy should take the client slowly through a process of assimilation in which emotions will be discharged at a proper pace simultaneously with the development of a proper repertoire for energy draining. Working through the third stage, encountering the void, is most difficult, but when completed, leads to acknowledgement of the emergence of something new about the self. Thus, according to Melnick and Nevis, after successful therapy, the client will not only be symptom free, but will also acknowledge a gain from the traumatic experience.

In addition, Gestalt therapy has many other characteristics that are beneficial for the treatment of PTSD. These characteristics include an I-Thou dialogue, a phenomenological approach, and focus on the here and now.

One of the unique contributions of Perls (Perls, Hefferline & Goodman, 1973) to psychotherapy is the invention of therapeutic techniques which help the individual to surface unfinished situations, traumas and trauma-related conflicts (Clarkson & Mackewn, 1993) from the past and resolve them in the present. These techniques include fantasy and visualization, creative enhancement of body language, two-chair work, graded experiments, psychodrama, and enactment. The enactment of trauma, which forms exposure to the trauma, is of special importance in the treatment of PTSD. Most manuals for the treatment of PTSD (Foa & Meadows, 1997; Meichenbaum,1994; Paunovic & Ost, 2001) focus on exposure as a major tool for treating PTSD patients. Indeed, enactment is in-vitro exposure of the trauma during the therapy session, while an experiment is an in-vivo exposure to trauma-related issues in the real setting.

Furthermore, a well-trained Gestalt therapist is well equipped to handle exposure successfully. Indeed, attending to the "here and now," to body movements and non-verbal behavior, can facilitate the impact of exposure. Leahy and Holland (2000), in a discussion on issues that prevent successful exposure during cognitive therapy, indicate failure to become anxious during exposure [through deflection], and failure to habituate, as major obstacles to successful exposure. All these difficulties can be facilitated and ameliorated by Gestalt techniques.

In views of these potentials, I decided to explore the professional literature and analyze the contributions of Gestalt therapy to the treatment of PTSD. A literature search of the PsychInfo data-base (up to November 2001) yielded 15 citations with the terms "Gestalt therapy" and "trauma" or "PTSD." Of these, five were chapters in books, one was a dissertation, and only nine citations were journal articles. Of these, only three related specifically to the treatment of PTSD by Gestalt therapy. Two were case studies (Serok, 1985; Slackin, Weller, and Highton, 1989) and one related in a general way to the treatment of PTSD among Vietnam veterans using Gestalt therapy (Crump, 1984). The rest of the articles related to eclectic approaches to treatment of PTSD where Gestalt therapy was also employed.

Of the nine journal articles, four appeared in Gestalt journals (The Gestalt Journal and Gestalt Review) while the remaining five appeared in journals of low impact index (the index is based on the number of times articles in a journal are cited by other journals). In addition, it should be noted that the most recent journal article that relates to trauma and gestalt therapy appeared five years ago (Oaklander, 1997).

As a frame of reference, we note that the combinations of the terms "PTSD" or "trauma" and "cognitive therapy" yielded 202 journal articles of which 166 appeared in non-cognitive-therapy journals.

While these findings do not necessarily indicate that Gestalt therapists fail to treat patients with PTSD, they may indicate that Gestalt therapists do not bother to report about their work and refrain from sharing it with their colleagues. Such lack of publication may be the reason for the insufficiency of consideration of Gsestalt therapy as a treatment of choice for PTSD. Thus Foa (1999), in her "Expert consensus treatment guidelines for post traumatic stress disorder," excludes Gestalt therapy from her list of the most common therapeutic approaches to PTSD. This exclusion by Foa is apparent again in a special issue on PTSD by the Journal of Traumatic Stress (Foa, 2000).

We note that the low publication rate of studies relating to Gestalt therapy of PTSD as also its lack of inclusion in discussions of therapeutic issues in PTSD, is not just a matter of prestige. It may lead to financial implications for therapists who practice only Gestalt therapy.

We suggest, as documented above, that Gestalt therapy has a lot to offer to the treatment of PTSD from a theoretical point of view as also in its technical aspects. One of the main goals of Gestalt therapy is to enable growth and self-actualization. It is ironic that it has failed to actualize its own potential and impact on the field of PTSD treatment.

The current trend in social science is for greater acceptance of qualitative research, including case studies (Yin, 1988), case report, and phenomenological reports (Cohen & Daniels, 2001; Hein & Austin, 2001). This gives therapists who are not familiar with the mysteries of psychometrics and statistics an opportunity to report about their therapeutic experience. I hope this article will encourage Gestalt therapists to respond to this challenge.¹

1. Please consult the qualitative study in this issue of Gestalt! on just such a subject (Airline Crash Survivors, Vietnam Veterans, and 9/11)

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Crump, L. D. (1984). Gestalt therapy in the treatment of Vietnam veterans experiencing PTSD symptomatology. Journal of Contemporary Psychotherapy, 14, 90-98.

Cohen, A., & Daniels, V. (2001). Review of literature: Responses to"Empirical and hermeneutic approaches to phenomenological research in psychology. A comparison." Gestalt! 5 (1), available on-line http://www.g-gej.org/5-2/reviewlit.html

Clarkson, P., & Mackewn, J. (1993). Fritz Perls. London: Sage.

Foa, E. B., Keane, T. M., & Matthew, J. F. (2000). Guidelines for treatment of PTSD. Journal of Traumatic Stress, 13, 539-555.

Foa, E. B., & Meadows, E. A. (1997). Psychological treatments for post traumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480.

Hein, S., & Austin, W. (2001). Empirical and hermeneutic approaches to phenomenological research in psychology. Psychological Methods, 6, 3-17.

Leahy, R. L., & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders. New York: The Guilford Press.

Meichenbaum, D. (1994). Treating posttraumatic stress disorder: A handbook and practical manual for therapy. Chichester, UK: Willey .

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. (1998). Diagnosing in the here and now: A gestalt therapy approach. In L. S. Greenberg & J. C. Watson (Eds.), Handook of Experiential Psychotherapy (pp. 428-447). New York: The Guilford Press.

Oaklander, V. (1997). The therapeutic process with children and adolescents. Gestalt Review, 1, 292-317.

Paunovic, N., & Ost, L-M. (2001). Cognitive- behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behavior Research and Therapy, 39, 1183-1197.

Perls, F. S., Hefferline, R., & Goodman, P. (1973). Gestalt therapy: Excitement and growth in the human personality. Harmondsworth: Penguin.

Rothbaum, B. O., Meadows, E. A., Resick, P., & Foy, W. (2000). Cognitive behavior therapy. Journal of Traumatic Stress, 13, 558-563.

Serok, S. (1985). Implications of gestalt therapy with post traumatic patients. Gestalt Journal, 8, 78-89.

Sluckin, A., Weller, A., & Highton, J. (1989). Recovering from trauma: Gestalt therapy with abused child. Maladjustment and Therapeutic Education, 7, 147-157.

Yin, R. K. (1988). Case study research: Design and methods. Newbury Park, CA: Sage.

Call for Papers for Gestalt!:

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