As this literature review was written as part of a Social Work Course, the place of Gestalt Therapy and PTSD in Social Work was considered. Saari (1996) wrote of the nature of social work "The practise of clinical social work involves a process in which assessment, goal setting, planned intervention, and evaluation are prominent features. The effectiveness of interventions is presumed to rely upon the strengthening and reordering of the organizational structures in the client's life, including those structures that have traditionally been seen as intra psychic, interpersonal, institutional and/or societal."This definition informs the reader that the social worker's involvement is with the whole client, not just parts. Payne (1996) emphasised the position of the client, "the client is clearly seen as a crucial actor in achieving whatever outcomes are desired in the social work process. Thus, social work must be more participatory, rather than therapeutic. This is the success of task-centred work. Social Work must also recognise the particular social and personal characteristics of clients rather than treating them all of a kind, or all needing the same model of practice. ..It must also recognise the way clients are treated in social systems, without denying the possibility of action."

Payne's definition added to Saari's, once again working with the whole client, adding that Social Work practice actively empowers the client to achieve his/her unique aims.
Post Traumatic Stress Disorder affects all aspects of a person, as will be described in more detail later in this literature review, and consequently Social Work Practice for a client who has experienced PTSD can also affect all aspects of a person.

The wide breadth of Social Work implies a wide breadth of curricula in Social Work Education. Some of the skills and knowledge necessary for Clinical Social Work are gained in the classroom and some in the field. Briggs and Cromie (2001), "The history of social work education has been marked by a never ending concern about the gap between education and practice, and the inadequate provision to students of skills and knowledge for healthcare practiceÖOver the years health services in Aotearoa New Zealand have demonstrated their commitment to the production of competent social work practitioners by offering fieldwork placement to students. Strategies that have been attempted in other countries to bridge the gap include internship and residency programmes."

Social Work and Gestalt Therapy meet each other happily as they also have the whole person in mind, not merely an aspect of a person to focus on. O'Leary (1995) wrote that there is no exact translation of the German word Gestalt. The closest translation is "whole". The whole cannot be understood by analysis of the different parts. Perls (1951) stated:

"The greatest value in the Gestalt approach perhaps lies in the insight that the whole determines the parts, which contrasts on the previous assumption that the whole is merely the total sum of its elements. The therapeutic situation, for instance, is more than a statistical event of a doctor plus a patient. It is the meeting of the doctor and the patient....Neither the full understanding of the organismic functions nor the best knowledge about the environment (society etc.) covers the total situation. Only the interplay of organism and environment constitutes the psychological situation. The isolated organism and its abstractions-mind, soul and body-and the isolated environment are the subjects of many sciences; e.g. Physiology, Geography. etc. they are not the concern of psychology."

Gestalt Therapy also enjoys a wide breadth of possibilities for those who have experienced trauma and may experience unfinished business or PTSD. Gestalt Therapy has similar challenges to Social Work in the quest to provide the broad training base Gestalt Therapists use in their work.

The Diagnostic Criteria of PTSD from DSM-1V TR, followed by consideration of PTSD from a Gestalt perspective.

DSM-1V TR (2000), published by the American Psychiatric Association provides clear descriptions of diagnostic categories to enhance diagnosis, communication about, study, and treat clients. A DSM diagnosis refers to the client's current presentation.

According to Melnick and Nevis (1998) "diagnosing prevents the Gestalt therapist from becoming isolated from those with different theoretical orientations. Consequently gestalt theorists still use traditional diagnostic labels such as schizophrenia, narcissism, and borderline personality disorder."

DSM-1V TR provides a list of diagnostic criteria for Posttraumatic Stress which are summarised as follows:

• The person has been exposed to a traumatic event.
• This traumatic event is persistently re experienced.
• Persistent avoidance of stimuli associated with the trauma
• Persistent symptoms of increased arousal.
• Duration of these disturbances is more than a month
• The disturbance causes social or occupational distress.

Post traumatic Stress Disorder from a Gestalt perspective is understood by Gestalt Therapists as "Unfinished Business". Perls, Hefferline and Goodman derived this term in the 1950's from gestalt theory, and Perls introduced the theory of "Unfinished Business" to Gestalt Therapy. O'Leary (1993) wrote of Perls' contribution "When we perceive a figure that is incomplete, the mind acts to perfect it and view it as ended. Perls extended this principle to therapy. Incomplete experiences and feelings persist in the memory of the perceiver. It is a tendency of the organism to conclude any situation or transaction that is unfinished."

A literature search of Gestalt literature on "Unfinished Business" found 19 references. Several referred to a definition by Polster and Polster (1993) "All experience hangs around until a person has finished with it. Nevertheless, although one can tolerate considerable unfinished experience, these uncompleted directions do seek completion and, when they get powerful enough, the individual is beset with preoccupation, compulsive behaviour, wariness, oppressive energy and much self-defeating activity. Closure must come either by a return to the old business or by relating to parallel circumstances in the present."

Cohen (2002) wrote "PTSD is due to the inability of the individual to disengage from an experience and to absorb and digest it." Cohen saw symptoms of trauma as manifestations of attempts to assimilate experiences that are not able to be assimilated, repeated unsuccessful attempts at completion, dissatisfaction with the person's own responses to the unusual circumstances and an existential crisis.

These glimpses of Gestalt literature which span four decades demonstrate consensus about the term, concept and theory of Unfinished Business. Perls, Hefferline and Goodman (1951) wrote about the therapeutic work necessary for the client to complete his/her "Unfinished Business." "Avoidance is the means individuals use to prevent themselves from completing 'Unfinished Business.'.. They then become stuck, blocking their possibilities of growth. Working with these blocks is both difficult and painful. Avoidance exists for good and sufficient reason, and hence the task is to become aware of the reasons for its existence."

The ways in which clients are experiencing avoidance, subsequent to a traumatic event, will determine the focus of the clinical social work intervention.

Cohen (2002) explored the history of Gestalt's contribution to PTSD. He wrote of the invention by Fritz Perls of therapeutic techniques which helped to bring up unfinished situations, traumas, and conflicts from the past and resolve them in the present. Fantasy and visualisation, creative enhancement of body language, two-chair work, graded experiments, psychodrama and enactment were therapeutic techniques used by Perls and are currently used with people who are experiencing trauma. Cohen reviewed the work of Foa and Meadows (1997) and found exposure, enactment and experiment are the major tools for treating those with PTSD. He also wrote of an attempt to view PTSD from a Gestalt Therapy perspective by Melnick and Nevis (1992:1998) who argued 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, included four sub-stages:

• turning away
• assimilation
• encountering the void
• acknowledgement

This formulation determined the focus of therapy at first enabled the person to turn away from the traumatic event, followed by guiding the person through assimilation in which emotions were discharged and the ability to cope was built. Support through the void was given and the acknowledgement of new gains from this new traumatic experience was facilitated.

Other contributions Gestalt has made to the treatment of PTSD which have also been useful, according to Cohen, include an I-Thou dialogue, a phenomenological approach, and focus on the here and now.

Literature Review of the Gestalt Treatment of PTSD

According to O'Leary there has been little research into gestalt therapy, counselling and /or psychotherapy hindering recognition of the effectiveness of gestalt therapy. O'Leary wrote of Smith, Glass and Miller (1980) who identified that Gestalt was as effective as other approaches. To do this they completed a meta-analysis of 475 controlled studies of psychotherapy and obtained an average effect size for 18 therapy types.

A literature search of the contribution of Gestalt Therapy to the Treatment of PTSD produced one record. This was research written by Isotupa (2000) "PTSD as a social wound: Do social wounds require social healing?" A 6 week inpatient program for chronic PTSD was examined by outcome, and process evaluation data collected on 157 individuals who were attending the Program for Traumatic Stress Recovery. Overall this program was successful in ameliorating a variety of difficulties experienced by trauma survivors and gains made were both statistically and clinically significant. A literature search of Therapy for PTSD and/or Trauma in general which included the one record of Gestalt Therapy, produced 2,725 records showing that while literature on Gestalt, trauma and PTSD is scarce, literature on the treatment of PTSD and Trauma in general is abundant. Cohen, a Gestalt Therapist from Israel, stated his disappointment that with all the ways in which Gestalt has contributed to the treatment of PTSD so little has actually been written. He challenged other Gestalt Therapists to write about their work. Fodor (2002) added that while many of us in the Gestalt field work with trauma, we do not have a Gestalt Literature on trauma as such.

As Gestalt Therapists understand PTSD and Trauma as "Unfinished Business", I searched the literature for "Unfinished Business" and found 180 records. Most of these were not concerned with Gestalt Therapy. A search for "Unfinished Business" and Gestalt produced 19 records. Three of these articles had a research component. The first of these was written by Jacoba Joubert, "A Gestalt aid program for the child with enuresis from a social work perspective." Joubert worked with the child to increase his/ her awareness of him/herself. The work also included increasing the child's awareness of his/her environment with the aim that unfinished business from the past was resolved enabling the child to live in the present. Six children in middle childhood were observed in play therapy with a gestalt approach in 10 individual sessions. The research was qualitative and quantitative with the researcher observing case studies. Self esteem, emotional experience, perception and occurrence of enuresis were researched and an aid program which has an assessment guideline and intervention program was developed for social workers to implement for children with enuresis.

The second of these was written by Robert Witchel titled, "Gestalt Therapy: Development, Theory and Techniques." Research to demonstrate the effectiveness of Gestalt Therapy in group settings was carried out alongside Gestalt Therapy techniques such as games of dialogue, unfinished business, playing projections, reversing behaviour, body movement and expression, the contact withdrawal rhythm, and dream work.

The third was Woldt and Stein who wrote, "Gestalt Therapy with the elderly: On the coming of age and completing Gestalts." The authors aimed to apply Gestalt theory, practice and research into the field of providing psychotherapy for the rapidly increasing elderly population. They saw the elderly population as experiencing self absorption, unfinished business, loss of control, living in the past, unresolved polarities, and closure. Their research was part of their plan to initiate the process of applying Gestalt therapy theory to these issues for this population.

My original hypothesis had been that Gestalt literature on PTSD and trauma was scarce, and after the September 11th tragedy there was a watershed, and this literature had increased markedly. After embarking on this assignment, I realised there was literature on PTSD and Trauma from a Gestalt perspective called "Unfinished Business" which was lost amongst other literature also called unfinished business. The literature written after September 11th uses the terms Trauma and PTSD as well as the term Unfinished Business, hence the inaccurate assumption I had reached to form my original hypothesis. Perhaps the more frequent use of the terms "Trauma" and "PTSD" by Gestalt Therapists, in addition to the more familiar term "Unfinished Business", will increase the dissemination of the ways Gestalt is seen to be able to contribute to the field of Trauma and PTSD.

One of the initiatives the Gestalt community published was a special issue of Gestalt!, which is an electronic journal about the theory and practice of Gestalt Therapy. In the introduction of "Gestalt!" Brownell (2002) introduced this publication which focused on "the way in which Gestalt Therapy, through the presence of Gestalt therapists in and around ground zero, has made an impact and still has a potential influence to contribute."

In Gestalt! Bowman, who managed a Fortune 500 Corporation's Employee Assistance Program in New York City and was Co-President of the Indianapolis Gestalt Institute, wrote of his heavy involvement in the trauma and debriefing work at ground zero. He had provided critical incident debriefing for thirteen years and challenged current debriefing techniques. Following Bowman's challenge, I searched the literature for debriefing groups and produced 5 records. Two were written by Regehr, a social worker from Toronto who also challenged crisis debriefing groups and reviewed the crisis debriefing model. In her research she found that initial reports, which supported the efficacy of crisis debriefing groups, relied on anecdotal evidence, client satisfaction surveys, and clinical impressions of group leaders. Subsequent research has found the model does not reduce, and may exacerbate PTSD. Her research concluded there is some empirical backing for the social support and the psycho-educational components of the model but that vividly reviewing details of traumatic events may increase intrusion symptoms through vicarious traumatisation.

Critical Incident Stress Debriefing (CISD) is being extensively challenged. Gist and Devilly (2002) reviewed literature and research on CISD and concluded that debriefing yielded no demonstrable effect in subsequent resolution of traumatic exposure, and may inhibit or delay resolution for some people. The control group showed natural resilience to be more helpful than CISD. Alternative interventions did better than CISD. The authors concluded that intervention should be tailored to the needs, context, and course of individual resolution. Another conclusion which is particularly relevant to this literature review is Harris, Baloglu and Stacks (2002), who found no relationship between debriefing and PTSD.

As Gestalt Therapy had contributed to CISD with exposure, enactment and experiment, this literature review searched to determine the place of Gestalt in this debate. Greenburg had completed two studies and one of these is summarised in this review. In an article titled "Resolving Unfinished Business. Efficacy of experiential therapy using empty-chair dialogue," Paivio and Greenburg studied 34 clients who were experiencing unresolved feelings towards a significant other. They were randomly assigned to either experiential therapy using a Gestalt empty-chair dialogue intervention or to a psycho educational group offering information about unfinished business. Treatment outcomes which targeted general symptomology, interpersonal distress, target complaints, unfinished business resolution, and perceptions of self were evaluated after 4 months and again after a year. The results showed that the experiential therapy achieved gains for most clients and significantly greater improvement than the therapy group. The treatment gains of the experiential group were maintained at follow-up.

Bowman, Regehr, Gist et al., Harris et al., and Greenburg, amongst others, have independently questioned the efficacy of debriefing, concerned about possible vicarious traumatisation as opposed to the efficacy of Gestalt techniques such as the empty chair to resolve unfinished business. Two issues arose in this Literature Review: (1) discounting Gestalt in general and (2) failing to use Gestalt therapy, both of which limited options available for the client. These Gestalt techniques were recommended previously in this Literature Review for people who are experiencing PTSD, not as a fundamental part of debriefing. An accurate assessment of the client's situation and what he/she needed was the starting point. It was the timing that was important; there was no dispute about the efficacy of Gestalt techniques. The debate concerned when to use the particular techniques.

Fodor (2002), a Gestalt Therapist who worked with her established clients after the September 11th tragedy wrote of the discussion on how best to deal with the immediate aftermath of trauma as well as treatment for those who develop PTSD subsequently. "Most researchers are saying the best short-term response to trauma during the early phase is to enlist and facilitate the natural supports of the person and community. People in shock need to talk about the events with the people they know and are close to, and may have experienced the events. Strangers and mandated counselling may be unhelpful. Trauma specialists remind us that people are resilient, and over time most will recover. While many of us in the Gestalt field work with trauma, we do not have a Gestalt Literature on trauma as such."

Bowman (2002) observed what people want:

1. First, people feel significant relief from spending time and sharing stories with others with similar feelings and experiences.
2. Second, people relish the opportunity to rest and reflect.
3. Finally, people value getting information that normalises their personal responses to the trauma (e.g. sleeplessness, nightmares, anxiety, and phobias).

Fodor wrote that most therapists in New York felt unable to cope with the tragedy of September 11th and subsequently "trauma experts are conducting seminars for those of us in the mental health field bracing us for a second wave of perhaps 100,000 people turning to therapists with post traumatic symptoms in the next year." She suggested a Gestalt approach within the community, setting up crisis support teams and training and work for the community at large. "Having someone with whom you have a relationship to articulate the experience seems most crucial We may get back to, or learn how to, hang out in the community and provide needed services."

Professionals from disciplines outside Gestalt therapy are having similar discussions. Roberts (2002) from the Interdisciplinary Program in Criminal Justice at Rutgers University wrote, "throughout the world: mental health educators and practitioners must develop the following: training and certification programmes for crisis interveners and trauma specialists: systematic and empirically tested procedures and protocols for crisis response, crisis intervention, and trauma treatment in the event of a future mass disaster or terrorist attack." Roberts developed the "ACT Intervention Model for Acute Crisis and Trauma Treatment" There are 3 stages:

1. Assessment/ Appraisal of immediate Medical Needs Threats to public safety and Property Damage
2. Connecting to support groups, the delivery of disaster relief and social services and Critical Incident Stress Debriefing
3. Traumatic Stress Reactions, Sequelue, and Posttraumatic Stress Disorders (PTSD)

He recommended research on the effectiveness of crisis intervention over the five to ten years following Septemeber 11.

After the September 11th tragedy, Kim, a Gestalt Therapist, and Kramer, who has a PhD in Learning and Change in Human Systems, published their ideas integrating aspects of Cognitive and Gestalt therapy into "Mindfulness Meditation". Mindfulness meditation is another tool that could be used with those who have experienced trauma. Mindfulness meditation is a method by which one might calm down a disturbed mind."..we simply observe our thoughts as they come and go. We don't engage in them. We just let them arise and fade. We treat our thoughts as a process, not as content." (Kim and Kramer, 2002).

The final area in this Literature Review is "Managed Care." One of the developing concerns for the helping professions is the ethical considerations for Managed Care. Literature on this subject is growing. Lazarus and Sharfstein (2002) wrote of the difficulties of working from a sound ethical base while receiving financial assistance from a funding provider. The authors wrote of difficulties with confidentiality, conflicts of interest, informed consent, double agentry, honesty and interference in the therapeutic relationship. An example of this is in New Zealand where Counsellors receive funding from the Accident Compensation Commission for providing counselling to survivors of sexual abuse. Gestalt Therapists, as others, have to work with the needs of the client and meet the requirements of the funding provider. When considering the history of Gestalt Therapy, in the 1960's Perls was rejected by the Psychoanalytical Institute because of his own personal approach to psychotherapy, showing this tension is not new. However, concerns about Managed Care affect the Helping Profession as an entity, not exclusively Gestalt Therapists.

Conclusion

Clients who are experiencing symptoms of PTSD or "Unfinished Business" are able to use the wide breadth of knowledge and skills which are inherent in both Clinical Social Work and Gestalt Therapy.

Literature on Gestalt Therapy's contribution to the area of Trauma and/or PTSD is scarce; however, there is a wealth of literature written on "Unfinished Business." Unfortunately, specific Gestalt Therapy literature on unfinished business has been lost amongst literature which is called "unfinished business." That is because the term has become generalized throughout the discipline of psychotherapy.

Initiatives taken to increase the profile of the Gestalt contribution to the field of PTSD were to challenge Gestalt Practitioners to write about their work, to use the terms PTSD and Trauma as well as Unfinished Business, and to publish a special edition of Gestalt! which described some experiences of the September 11th tragedy and consider how Gestalt Therapy could further be involved in this field.

The issues which arose in the area of Trauma, PTSD and Gestalt therapy commenced with research on Critical Incident Stress Debriefing (CISD). The possibility of vicarious traumatisation was increased by techniques used to re-experience the traumatic event. This concerned Gestalt Therapists, as some of the techniques used in debriefing originated from Gestalt Therapy; however, it is the timing of when to use these techniques that is being questioned in the research, not the techniques themselves.

All the helping professions, not just Social Workers or Gestalt Therapists, were concerned about what to do immediately after a trauma. Research and observations showed that people who have experienced trauma want social support from those close to them. Family, friends and those who have been through the experience with them were preferred.

Another issue that is developing alongside the concern about how to work with clients who have experienced trauma, is the tension of balancing the needs of the client and the needs of a funding provider. Gestalt Therapists are amongst those preparing themselves to be better equipped in the area of PTSD and Trauma.

References

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994
• Bowman, C, (2002) To Ground Zero and Back. Gestalt! Vol. 6 No.1 N.P. Available online at http://www.g-gej.org/6-1/gzeroandback.html
• Briggs and Cromie (2001) Current Issues in Mental Health Social Work. In New Zealand Social Work: Contexts and Practice. Auckland: Oxford University Press.
• Cohen, A. (2002). Gestalt Therapy and Post-traumatic Stress Disorder: The potential and its (lack of) Fulfilment. Gestalt!, Vol.6; No.1 N.P. Available online at http://www.g-gej.org/6-1/gestaltptsd.html
• Fodor, I., (2002) Reflections on September 11: When therapist and client participate in the same trauma. British Gestalt Journal, Vol.10, No.2 pp.80-85
• Gist, R. and Devilly, G. (2002). Post-trauma debriefing. The road too frequently travelled .Lancet. Vol. 360 (9335), pp.741-742.
• Harris, M., Baloglu, M., Stacks, (2002) J. Mental health of trauma-exposed fire-fighters and critical incident stress debriefing. Journal of Loss and Trauma. Vol. 7(3), pp 223-238.
• Isotupa, C. (2000).PTSD as a social wound: Do social wounds require social healing? Dissertation Abstracts International: Section B: The Sciences and Engineering. Vol. 161(6-B), Jan 2000, pp.3280.
• Joubert, J. (1999), A Gestalt aid program for the child with enuresis from a social work perspective. Dissertations International Section A: Humanities and Social Sciences. Vol 60. (1-A), Jul 1999, pp.0248
• Kim, J. and Kramer, G. (2002). Insight Dialogue Meditation with Anxiety Problems. Gestalt! Vol.6; No.1 N.P. Available online at http://www.g-gej.org/6-1/insightdialogue.html
• Lazarus, J. and Sharfstein, S. (2002), Ethics in managed care. Psychiatric Clinics of North America.Vol 25(3), pp.561-574.
• Melnick, J. and Nevis, S., (1998) Diagnosing in the Here and Now. A Gestalt Therapy Approach. In Greenburg, L., Watson, J., and Lietaer, G., Handbook of experiential psychotherapy. (pp.428-446.) New York. Guilford Press.
• O'Leary, E. (1995). Gestalt Therapy. London: Chapman and Hall.
• Paivio, S., Greenburg, L. (1995). Resolving "unfinished business". Efficacy of experiential therapy using empty-chair dialogue. Journal of Consulting and Clinical Psychology. Vol. 63 (3), pp. 419-425.
• Payne, M. (1997). Modern Social Work Theory. London: Macmillan Press Ltd.
• Perls, Hefferline and Goodman (1951). Gestalt Therapy. Excitement and Growth in the Human Personality. New York. Dell Publishing Co., Inc.
• Polster E. and Polster M. (1973). Gestalt Therapy Integrated. New York, Vintage Books.
• Regrhr, C. Crisis debriefing groups for emergency responders: Reviewing the evidence. Brief Treatment and crisis intervention. Vol 1(2) pp.87-100
• Roberts, A., (2002) Assessment, Crisis Intervention, and Trauma Treatment: The Integrative ACT Intervention Model. Brief Treatment and Crisis Intervention 2:1, Pp 1-21.
• Saari, C. (1996). Clinical Social Work Treatment. New York: Gardner Press Inc.
• Witchel, R. (1973). Gestalt Therapy: Development, Theory and Techniques. Paper presented at the American Personnel and Guidance Association Meeting, 23-27 May 1973, Atlanta, Georgia
• Woldt, A. and Stein, S. (1997). Gestalt Therapy with the elderly: On the coming of age and completing Gestalts. Gestalt Review