Healing complex trauma PTSD and related addiction with Gestalt – why Gestalt should be incorporated in the treatment of PTSD

An essay by Ana Haynes

Towards my disappointment, upon researching the definition of trauma in the DSM-5 I have come to find a very non-inclusive one, one which by not acknowledging the wholeness of trauma, subsequently dismisses the lived experiences of those who battle PTSD every day. It goes as follows: “actual or threatened death, serious injury, or sexual violence” (Anushka Pai, 2017). How can we begin to heal it, if we do not accept it for what it is? I have to admit that I am much more inclined of working with Gabor Mate’s idea of trauma: “Trauma can also be inflicted not by what happened to you, but what doesn’t happen that should happen. So that when your needs aren’t met, that can wound as well. Even though you weren’t overtly hurt, you’re still wounded by not having your essential human needs met” (Mate, 2021). I prefer it not as much for the definition, as for the way in which he chooses to support his patients. A compassion-based approach. Which is what the DSM-5 seems to me is lacking. When we bring in discussion such complex issues, with potentially life altering mental health implications, it feels almost ironic to dismiss some of them. I find many similarities between Mate’s approach and gestalt, the most significant one for me being the deep approach he takes to incorporate body awareness in the process of working with trauma and addiction: “Trauma is not what happens to you, is what happens inside you.” (Mate, 2021)
One of the keys to understanding how to deal with trauma and support traumatised patients, is to understand what trauma is. Based on Mate’s description, trauma is not the adverse event which happens to you, is not an external factor. Instead, trauma is the reaction triggered by the brain during the experience of trauma (Mate, 2021). Human beings have a specific set of needs which ensure survival and unfortunately, even though our environments have changed, our instincts in the face of danger have not. We do not have to watch over our shoulder for lions anymore, however, the same reaction is triggered in the brain in the event of lesser dangers than let’s say being eaten by a lion, events such as physical or emotional abuse, and even the possibility of them. Fight, flight or freeze are just as alive in the new environment, as they were when we were hiding in caves from lions.
In the face of potential danger, as a threat to our survival need, the brain engages in a series of chemical and signal triggering reactions, meant to support the body defend itself from danger (Green, 1995, p. 107). This reaction happens on the hypothalamic-pituitary-adrenal axis. This axis is extremely sensitive to the environmental changes, and the ACTH and the secretion of corticosteroids can be triggered by even small changes in the environment. If the danger is diminishing, then the brain will stop the signal sent to the HPA axis, and the release of extra hormones will stop (Green, 1995, p. 105). However, replaying over and over the same memories of a traumatic event, and even the fear of this happen again alone, will engage the brain in the fight-flight-freeze response just as in the face of actual danger, therefore activating the HPA axis (Mate, 2019, p. 36). This replaying being the PTSD signature.
Now, if this function of the brain has been most helpful and ensured the first two on Maslow’s pyramid of needs (Life, 2022), continuous arousal of the HPA axis and the continuous release of hormones in the blood stream, will over time have toxic effects on the body (Green, 1995, pp. 105-106). There are many illnesses which can be associated to this, and Mate’s extensive research evidences some of the most significant ones, referring to auto-immune diseases, where the body is attacking itself (Mate, 2019, p. 7). If this is the case, then we cannot dismiss the potential that the body can suffer of many other problems caused by the brain’s response to trauma. Therefore, in the treatment of trauma, working with the body should not be just an addition, but rather an absolute must. This is why I believe that gestalt techniques being incorporated in the work with patients suffering of complex trauma PTSD is an absolute must. “For someone who has experienced severe trauma, there may be toxic levels of these stress related chemicals, which eventually become exhausted and depleted and no longer serve to protect the individual. Dissociation is driven in particular by a neurochemical reaction” (Taylor, 2014, p. 9). At the moment severe trauma occurs, a split between body and mind happens, which we can then spend lifetimes trying to bring back together (Mate, 2018, p. XXV). Bromberg calls this a “precipitous disruption of self-containment” (Taylor, 2014, p. 3). Mate refers to this split as an unfortunate dissociation (Mate, 2019, p. Note to reader). A split between what our bodies tell us to be true, and what the mind is willing to accept. This split happens because the experience is so heavy that the conscious mind cannot tolerate it. Since the trauma is felt in the body through the hormones released during the event, the split does not allow for the normal process to take part, therefore the physiological process remains imprinted in the body at a cellular level, and the mind cannot finish this process as it has disconnected from it. “The enduring mark of trauma is borne out of what is initially a healthy reaction, the survival instinct, to strikingly abnormal events. This is later maintained in the body’s attempt to resolve the trauma” (Taylor, 2014, p. 8). Continuous release of these hormones when the trauma is relived, leads to adults with issues. The adult seeks help in the therapy room, however more often than not, the issues bringing them in, are more than just the childhood trauma. This is because as children, when experiencing trauma, we develop coping mechanisms, or creative adjustments in order to be able to live with the trauma and still be able to participate in the society. In time, these creative adjustments might become more and more integrated in different areas of our lives. The problem is that even though these creative adjustments have played an important role in our survival, they will no longer be useful as adults (Matzko, 1997, p. 40). Most times is these creative adjustments which bring people in the therapy room. If we look at these creative adjustments in the here and now, rather than looking at the original trauma alone, and track down how they were developed in the first place, we can then uncover the trauma which lead to them.

And now the real and hard work begins. We tracked down the trauma. Now we have to work with it. How do we do that without the risk of re-traumatising the client? Gestalt means at the core “in the here and now” (Kohen, 2003, p. 42). Applied to trauma, this translates to bringing the trauma to awareness and dealing with it in the present. Considering that we deflect and dissociate from trauma for good reasons, because it’s not tolerable, the therapy room becomes a safe container for the client. The idea is to bring the trauma to awareness in easy-to-tolerate bite-size chunks and work with what happens in the here and now in the room, not what happened in the past. In other words, assessing the ways are we reliving the trauma in the field in the present. In the here and now trauma can be seen in how we creatively adjust in the environment or found in the felt experiences. To understand the first one better, we need to assess the relationships in the field. The second one is what is the client feeling in the here and now in the therapy room. This can be emotions. And these emotions can most likely be found in felt sense in the physical body. And at this stage, gestalt therapy is differentiated from traditional psychotherapy. If we know that trauma is not only an illness of the mind, but biology is telling us that trauma is an illness of the body as well, it then makes sense to work with the mind and physical body simultaneously in order to support the client in the ultimate way, giving them the best chance to heal and transform from within. If trauma has negative physiological effects on the body, then the opposite can be true, and this opens a new world of possibilities.
As we have seen until now, there is a physiological element to trauma. This gives it almost a tangible form, and if something is tangible, material, then change can happen. If we go back to the idea that trauma is something which happens within us, then an element of accountability is involved in order for healing to occur. Accountability not for the event, but rather acknowledgement that something happened in me at the time of the event, and that something is still there (Mate, 2021). And if that something has a tangible form, then I can work with it. I take over control and transform it into a new way of being. “You are predetermined just to cope with events in one way, namely, how your character prescribes it to be.” (Perls, 1971, p. 7). For example, if I have endured repeated trauma, in the form of PTSD, then I have developed ways to deal with it. Such ways can be deflection or dissociation, etc. In the safety of the therapy room, I can bring this to surface and notice it, knowing that if for example I choose to dissociate, it’s ok to do so. And this is how change begins. By making an informed and conscious choice. The creative adjustment is not in control anymore, I am. I chose for example to remember a certain event and talk through it in the therapy room. I notice what is happening step by step. I might notice that I am feeling angry. And instead of deflecting, I stay with the anger. I might notice that the anger is physically felt in my stomach. And I stay with it. And this time, nothing bad actually happens to me from the outside. I get to recreate the situation in a state of awareness, with the choice to deflect from it if I choose to do so. I would be rewiring my brain to understand that trauma is what happened inside of me, and that makes it something I can take control of and change of I chose to do so. “Because if trauma […] if trauma is the fact that you were abused as a child, you will never be a person who wasn’t abused as a child. But if that was the trauma of what happened to you, guess what, it will never unhappen. But if trauma is what happened in you, the wound that you sustained, the meaning you made of it, the way you then came to believe certain things about yourself or the world or other people, and if trauma was that disconnection from the authentic self, well guess what? Good news. That can be restored at any moment” (Mate, 2021).
Apart from traditional bodywork, there aren’t many therapy branches who work with the body. To understand the benefits of working with the body in psychotherapy, I suggest having a closer look at Miriam Taylor’s work. Taylor brings together the neurobiology of trauma and approaches it from a gestalt perspective. Considering the shortage of literature evidencing the benefits of gestalt when working with trauma and addiction, Taylor brings these subjects together, completing a much-needed gestalt. “Gestalt body process work is predicated on trusting the body to know what it needs; for trauma clients this basic trust needs to be restored” (Taylor, 2014, p. 8). What trauma does, it destroys the sense of safety and security and leaves the person vulnerable. This vulnerability has physical consequences on the body, and in contrast a healthy relationship based on safety and security is favourable to the healthy development of social and physical health elements. “All mammalian mothers – and many human fathers, as well – give their infants sensory stimulation that has long-term positive effects on their offspring’s brain chemistry” (Mate, 2018, p. 190). In order to have a full understanding of how to work with trauma and addiction in Gestalt, we furthermore need to understand how addiction is viewed from this perspective. Giancarlo Pintus describes two types of trauma. First, the addiction behaviour developed as a response to trauma caused by stressful life events. In this case, the addiction is developed in order to reduce tension and “maintaining the ability to feel rewarded” (Pintus, 2017). If we look at this from a split perspective, we see how this addictive behaviour is meant to repair that split, as it can induce feelings of “feeling at home” (Pintus, 2017), behind it being the idea that in the childhood the bond sense of safety and security has been broken as a response to trauma (Mate, 2018). In the early stages of development, the child and environment will co-create a style off attachment. If the style of attachment is positive, the child will develop essential skills which later in life can translate in healthy relationship with the contact boundary (Taylor, 2014, p. 76). In contrast, if the patterns of attachment are unhealthy, the child will lack the feeling of belonging, causing a continuous need to have their needs met in the environment, leading to uncompleted gestalts, in which addiction can come as a solution to temporarily satisfy the need for a contact (Matzko, 1997, p. 39). This is a way in which the individual manipulates the “biochemistry of bonding and attachment” (Pintus, 2017, p. 225). The second type refers to a predisposition towards addictive behaviours, most often associated with personality disorders (Pintus, 2017, p. 224). For the purpose of this essay, we will only look at the first type of addiction. Amongst the two types, the first one is more likely to have a positive outcome when engaged in the therapy process, as most of the patients suffering of addiction have also experienced traumatic events, which most likely lead to addiction. Addiction in the case of this patients tents to amplify “the emotional-cognitive dissociation of these patients” (Pintus, 2017, p. 224). It is worth to note that addiction down not only refer to substance abuse. Another key point in understanding how to support clients in healing trauma induced addiction is understanding how we creatively adjust as a response to trauma. Creative adjustments happen at the contact boundary. Creative adjustments are no longer useful in the present; however, we continue to use them. Therefore, the change needs to happen at the contact boundary. Continuous attempts to complete a gestalt, just to stop over and over at the contact boundary, leads in time to a desensitisation of the contact with the self (Matzko, 1997, p. 39). The experiences can no longer be integrated by the self, and the individual is caught in a vicious circle, in an attempt to close the gestalts. This is where addiction can give one the sense the individual a moment of respire, due to “the feeling of released tension” (Pintus, 2017, p. 223) and the biochemical avalanche of hormones to which they have over time become addicted to (Pintus, 2017, p. 223). These creative adjustments become normal a part of the individual’s relationship with the environment, and as such they are not considered a threat. The idea of taking them away is unthinkable, as this would leave them vulnerable to the same pain they are trying to numb, they would be put face to face with the trauma to which they have adapted, and for good reasons. This is where the field co-created in the therapy room becomes invaluable (Pintus, 2017, p. 229). If we were to consider the creative adjustments as being a crutch supporting the individual, it is important to not go straight to removing it. We need to understand how the need for the crutch appeared and how it has supported the client until now. The addictive experience has a numbing effect, and the client might not even be aware of the incomplete gestalt anymore (Kohen, 2003, p. 47). This is where the therapist comes into play. The therapy room offers the client a new environment, in which the client can bring themselves fully, and an “other” who can contain them. Through empathic resonation, the therapist can enable the processing of past traumas, making engaging with the trauma possible (Matzko, 1997, p. 42). Going back to the idea that addiction is used as a means to desensitise the traumatic experience, which is felt continuously as an incomplete gestalt, we can understand that in order to change the pattern we need to unveil the gestalt which needs finishing (Matzko, 1997, p. 43). There will be resistance in doing so, as the pain of the trauma is to grave. However, the resistance can be met with empathy and acceptance. Therefore, the therapist needs to hold space for the client to understand how addiction “has become an integral part of their life as a secondary creative adjustment” (Pintus, 2017, p. 225). Perls, Hefferline and Goodman describe the self as the total system of contacts at any moment and during the experiencing of contacts the individual must “be sensorially available in a lively contact and interaction with the environment in the ongoing present” (unknown). If we view addiction as an interruption to contact in the present, we can deduct that the first step in addressing this is to support the individual in staying present in the here and now with the experience. We need to support them into exploration and bringing the trauma to the present moment, to be relieved in the here and now in a safe environment. Per the description of self as being the total sum of systems the individual is part of (Matzko, 1997, p. 39), we can deduct that in traditional psychotherapy methods such as psychodynamic, they fail to address other factors than the mind, therefore being only partially effective. This is where Gestalt can come into perspective, as addressing the total of the factors in the environment, which lead to the creative adjustment being created, and furthermore used in the present life situations (Pintus, 2017, p. 229). By considering the first stage of the circle of experience as sensation, if sensation is numbed at the initial stage in the of the creative adjustment to the trauma, the incapability to feel, in the present this is manifested by dissociating, then once arrived at the contact stage, the individual will be unfulfilled as the initial sensation was misinterpreted (Matzko, 1997, p. 38): “in an attempt to satisfy unmet and misidentified needs, compulsive addictive patterns eventually become established (Matzko, 1997, p. 38), therefore withdrawal cannot take place, and the individual goes back to the sensation stage, only to misinterpret it again and go through the same scenario over and over again. Considering that dissociation is developed because the individual cannot “soothe any form of discomfort adequately” (Mate, 2018), we deduct that the initial focus should be on supporting the individual to cope with the discomfort caused by trauma, in small doses granted, in the safety of the therapy room. Without developing this skill, the individual will not be able to arrive at a stage where they can become aware and stay with the effects of the trauma: “restoration and healing must begin at the earliest point of developmental disruption and proceed from there” (Matzko, 1997, p. 39). Helga M Genannt Matzo talks about a Multiphasic Transformation Process Approach when dealing with addicted individuals within a gestalt frame (Matzko, 1997, p. 34). This approach is relationship-based and empowers the individual to take steps towards a desired lifestyle (Matzko, 1997, p. 41). Within a gestalt frame, this approach looks into personal, familial and social environmental factors of the individual’s environment: “this approach exemplifies respect for the integrity of the individual and voluntary adherence to the treatment processes and as such facilitates an emerging awareness of personal participation in creating destructive habits and self-defeating lifestyles” (Matzko, 1997, p. 54). By ‘staying with’ at the sensation stage, the client can go beyond the sensation incurred by the creative adjustment, and discover the real sensation, for which more likely there will be a traumatic emotional trigger at some point in the past, evidenced in the way the individual has dealt with the trauma at the moment it happened: “providing a context for the patient’s problems requires developing the present problem into a rich historical tapestry with particular attention to such family-of-origin issues as early relational disruptions, perceived neglect, insufficient caregiving and trauma” (Matzko, 1997, p. 43). In practical terms, a gestalt therapist “enables the client to amplify what she does and how she does it in the here and now” (Matzko, 1997, p. 42). But this can only happen if the client has developed ways to stay with what arises during the sessions. In this approach, Matzko presents an 11 stage process, or an built-upon circle of experience, adapted for working with clients with addiction issues. This process is the ultimate proof that gestalt should have a ‘go-to’ therapy place when working with addiction.
In Gestalt is, Barry Stevens tells the story of Dennis, one of his patients. In Dennis’s case, Barry exposes how Gestalt combines working with the body and working with the mind in an efficient way. This technique implies staying with what the body is telling us, becoming aware of the sensations and staying with that awareness without deflecting from it (Stevens, 1977, p. 161). Denis wanted a pillow under his head, however Stevens asked him to try without first, and see where that takes him: “let the pain be. If it becomes more intense or less intense, let that happen – or any other changes. Let be what is” (Stevens, 1977, p. 161). If we were to translate this to addiction terms, the pillow is the drug. The individual feels the pain and immediately looks for something to lessen that pain, and in this case, it is drugs. The trauma pain can be exponentially worse than physical pain, and the lack of awareness of what is causing the emotional pain, combined with years of implementing creative adjustments, allows for the individual to continue to numb a pain of he is not aware of – as in what caused it - and implement this short-term ‘treatment’, which in reality is only making it worse, therefore continuing to try to complete a gestalt he is not ever aware of. If the individual can arrive at a stage where they can become aware of the real sensations of the physical and emotional body causing the need for drugs, and if the therapist can create a safe space where the client can sit with those emotions with awareness, the work can begin. Self-regulating at the stage of awareness is perhaps the most important tool the client can learn on the journey of healing the trauma. “Dennis […] later became comfortable without it. This in itself is an accomplishment: to discover how I can get comfortable without manipulating the world (bring a ‘pillow’) to make me comfortable (Stevens, 1977, p. 163). In understanding that traumatic events have a negative effect on our physical body, doesn’t go to say that the addicted client should be treated in a different manner from the non-addicted client. But rather, the therapist, having knowledge of the subject can understand that the addicted and traumatised client will react in different ways. Since trauma and addiction have a negative effect on the body, and they change the bio-chemical reactions of the body, it is extremely beneficial for the therapist to engage as many body work experiments as possible, in order to support the client get in touch with a body which holds the answer to the trauma, which has not only been desensitised by trauma, but also by being numbed by the addictive chemicals used by the client to support the lack of completed gestalts. “See if you can explore it - gently, not pushing it around, like gently friendly with it – and see if you can discover what wants to happen there and let it happen. See if some movement grows out of pain and tension.” (Stevens, 1977, p. 162)
“It seems to me impossible to do a really good job at therapy with someone else without first having gone through it myself” (Stevens, 1977, p. 189). Part of this essay is to talk about how these subjects, trauma and addiction would influence me in the therapy room. But the truth is that I do not know. I can try to imagine and prepare for the ways it might, but without first doing it, putting myself in the position of having to hold space for someone who brings in life stories so similar to mine, I cannot know. I can however guide myself based on the experiences form the process groups. Asses how I felt and reacted when someone opened up about these issues. I have been triggered and instead of staying with their story I went into my own head and stopped being present. And not only that, but I hurt myself in the process. I felt a need to deflect and think about day-to-day mundanities in order to stop my head from going to that painful place. And lastly, I have learned to stay with awareness of what the person was talking about, to kick all and any thoughts which were trying to invade my mind, and to dedicate all my attention to the person talking. But this only came later on, after years of personal therapy and academic studying of these issues - after I have worked in my own personal therapy and learned tools to self-regulate. When I learned that the memories won’t hurt me, and that I can keep them aside and take them to therapy. After I have learned to sometimes show the same kindness to my own process, the way I would show it to someone else. The reality is that working with these issues will affect me. But as long as I have awareness and I can bracket, I know I have support in the form of personal therapy, supervision, peers, friends and family, and why not, curiosity – by staying with that which is going on in my head and body - I can self-educate myself as I go.

So that’s why Sharon, when you talk about the new view of trauma, when we see it as that wound, as long as we see it that way, it’s a wound that can be healed. If we see it as a bunch of things that happened, that’ll never unhappen. […] we don’t have to allow it to define our lives, how we see ourselves, how we see the world, how we relate to other people, how we relate to possibility, how we relate to even spiritual transformation. (Mate, 2021)
“Gestalt therapists do not believe that fundamental change can occur until there is a complete acceptance of the individual’s whole personhood, including embracing aspects that the client may wish to amputate from their being” (Mann, 2010, p. 62)

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