DIALOGICAL EXPOSURE revised - nvagt- · PDF fileDialogical exposure in a Gestalt-based...

Dialogical exposure in a Gestalt-based treatment for posttraumatic stress disorder

Willi Butollo 1, Regina Karl1, Julia König1, and Maria Hagl1

1 Department of Psychology, Ludwig Maximilian University of Munich, Germany

DIALOGICAL EXPOSURE IN PTSD TREATMENT 2

Abstract

Traumatic experiences may not only lead to the well-known posttraumatic symptoms,

but can also change a person’s self and self-processes. The importance of the ability to

maintain an intra-psychic dialogue, which is necessary for the resolution of the disruption

which trauma causes in relationships and contact, is often not sufficiently regarded. The

process oriented trauma therapy presented here combines a Gestalt therapeutic frame with

cognitive-behavioral elements and is committed to an interactional and dialogical approach.

This intervention, with “dialogical exposure” as one of the core features, allows for the

identification and resolution of the disruptions of contact so that patients can again experience

continuity in their experience and regain their contact-ability.

Acknowledgment

We warmly thank Sarah Joy Park, Loma Linda University, for her readiness to help

with the manuscript. Her editing has greatly improved the article; any remaining errors are our

own.


The introduction of posttraumatic stress disorder (PTSD) as a diagnosis in 1980

(Diagnostic and statistical manual of mental disorders, Third Edition; DSM-III; American

Psychiatric Association [APA], 1980) led to an enormous increase of scientific interest in the

phenomenology and treatment of trauma-related disorders. Today, PTSD is a well-established

diagnosis, and psychotherapists have several possible interventions at their disposal, with

cognitive-behavioral therapies (CBT) having accumulated the most empirical support

according to recent meta-analyses (e.g., Bradley, Greene, Russ, Dutra, & Westen, 2005;

Bisson et al., 2007). CBT interventions are highly focused on symptom reduction. They

usually include exposure exercises, where the patient is asked to remember the traumatic

event in detail in order to achieve a lessening of related affect and an elaboration of the

trauma memory (Rauch & Foa, 2006). Cognitive methods that challenge and restructure the

dysfunctional beliefs PTSD patients frequently endorse, are also employed (Ehlers, Clark,

Hackman, McManus, & Fennell, 2005; Resick & Schnicke, 1992). CBT’s focus on the

treatment of the core symptoms, however, might pay too little attention to other issues of

posttraumatic adaptation: The way the individual shapes and arranges contact and

relationships can be impaired or destroyed by peri- and posttraumatic processes. We use the

term “contact” in a broader, yet also more specific Gestalt therapeutic sense, where contact is

the touching of boundaries between “me” and all that is “not me”, i.e., the process of

experiencing and organizing these boundaries. Therefore, contact also encompasses the

organization and ongoing formation of one’s own self with its relationship to others, and the

world in general.

Today, humanistic interventions receive only sparse acknowledgment in the scientific

community and their impact seems to be dwindling in clinical practice as well. This is partly

caused by the traditional division between clinical work and empirical research which most

humanistic therapies share. Therapists often fear that a split between “being a researcher” and

“being a therapist” may hinder their ability to be congruent and present in the here and now,


which is a fundamental requirement for successful therapy. Because of this division there

have been few efforts to prove the efficacy of Gestalt therapies. The few existing studies do

show, however, that experiential therapeutic approaches based, among others, on Gestalt

therapeutic principles, can be efficacious in the treatment of PTSD (cf. Elliott, Greenberg, &

Lietaer, 2004). In this context, the research group around Leslie Greenberg has been the most

active (e.g., Greenberg, 2002). Greenberg and colleagues developed emotion focused therapy

(EFT), a form of therapy that relies on Gestalt therapeutic methods such as empty-chair work.

Among the major goals of EFT is the resolution of “unfinished business”, that is, lingering

negative emotions caused by childhood trauma or other interpersonal issues not yet resolved

(Paivio & Greenberg, 1995). The pre-post effect sizes achieved in recent studies evaluating

EFT (Paivio & Nieuwenhuis, 2001; Paivio, Jarry, Chagigiorgis, Hall, & Ralston, 2010) are

comparable to those reported in trials of CBT.

In a review of six studies on the efficacy of experiential and Gestalt-based treatments

for traumatized patients, Rosner and Henkel (2010) conclude that most researchers use

integrative approaches rather than “pure” Gestalt therapy and that so far methodologically

rigorous studies are scarce. The studies in their review either lacked a control condition, a

randomized design, or diagnostic measurements specific to PTSD.

Dialogical Exposure Therapy (DET)

Coming from a Gestalt therapy background, we believe that established therapies for

PTSD neglect important issues. Therefore we developed dialogical exposure therapy (DET) at

an outpatient clinic for anxiety and trauma related disorders at the Ludwig Maximilian

University of Munich (LMU). This truly integrative therapy embeds established CBT

techniques (such as psychoeducation and in-vivo exposure), and a trauma-focused, yet Gestalt

based exposure method (chair work) in a dialogical framework. This approach addresses the

disruption of self-processes and interpersonal relationships caused by the traumatic


experience. It might be argued that including the term “exposure” implies a theoretical

background of classical conditioning. This is not the case. We consider the term “dialogical

exposure” to highlight a key concept of the therapy: The patient not only remembers the

traumatic experience but enters into a dialogue with aspects of it while being supported within

the therapeutic relationship. The therapy has been manualized (Butollo & Karl, 2012).

Clinically relevant, positive results of this treatment paradigm have been shown in the

work with anxiety disorders (Butollo, Rosner, & Wentzel, 1999). In a pilot study with

traumatically bereaved women in Bosnia, dialogical exposure was shown to be feasible as

group treatment (Hagl, Powell, Rosner, & Butollo, submitted). There were significant

improvements in posttraumatic and general mental health symptoms in this rather severely

traumatized sample with chronic symptoms, and these improvements were maintained during

the one-year follow-up. However, overall the DET condition was not superior to a supportive

group control condition.

Recently, an uncontrolled pilot study of DET with 25 PTSD patients (Butollo, König,

Karl, Henkel, & Rosner, submitted) found significant decreases in PTSD symptoms as well as

in general psychopathology. Effect sizes for PTSD measures were high in the completer

sample and moderate to high in the intent-to-treat sample. Currently, a randomized treatment

study comparing DET with cognitive processing therapy (CPT, Resick & Schnicke, 1992),

which is an established CBT treatment for PTSD, is under way at the LMU outpatient clinic

in Munich.

The self in an interactional understanding of trauma

In this section, we discuss our understanding of fundamental psychological concepts

as they relate to DET. We describe our view of the self as a process rather than a structure.

We see this process as dialogical in its nature and we understand the traumatic incident as

overpowering the self, leading to posttraumatic adaptation which encompasses a

compromised contact-ability as well as the well-known PTSD symptoms. Our theoretical


background comes from two sources: classic Gestalt theory (e.g. Buber, 1923) on the one

hand, and our clinical experience on the other. This means that the ideas we describe here

were shaped by the therapists and clients in Munich. DET therapists typically have at least a

Master-level degree in psychology and training in at least one other treatment form than DET.

Many of them are in training for their psychotherapy license, others are already licensed. We

treat clients with trauma histories ranging from single traumatic events in adulthood to

childhood trauma. As the university based clinic offers therapy within the framework of

compulsory health insurance, clients come from a wide range of socio-economic

backgrounds. However, while many of our clients have roots in other countries, we do not

have extensive experience with clients from other cultures. Therefore, our hypotheses and

observations, as well as our data so far, stem from a Western context.

Self-processes. Experiencing a trauma is an existential experience that affects a

person’s self. We understand the self as a dynamic cognitive-emotional state that constantly

constitutes itself as a result of interactional experience with oneself and the environment; the

inner and outer perception of contact occurring each moment. Therefore “self-processes” is

the more accurate term because it reflects the view of self as a process rather than a structure.

Usually, everyday experiences and new information are integrated effortlessly into the

existing models; a fluent organismic response is possible. Yet, the more extreme traumatic

experience cannot be so easily reconciled with known information and existing experience.

Therefore the self is unable to react to the experience, that is, it has no adequate, self-

supporting response, no “self-action” – it collapses. This frequently results in peritraumatic

feelings of panic, submission, and confusion. The organism quickly searches for coping

mechanisms that will allow it to integrate the experience into the existing self. Because we see

the nature of the self as dialogical, we pay attention to re-establishing these inner and outer

dialogues in trauma therapy.


Self as dialogical. DET builds on the assumption that the human psyche continually

configures an interaction partner for its own self and that the interactional experiences

aggregated over the lifetime define the frame and the expectations for this configuration. The

self creates itself in its counterpart; it configures itself constantly, within in the frame of the

known and the expected, in relation to its ever-changing interaction partners. The self emerges

each moment anew and always a little different. Non-human entities such as animals, nature,

the ocean, etc., can also become “interaction partners”.

The impact of trauma. The horror of the traumatic situation can cause a disruption in

the person’s experience. This disruption, which can manifest itself in dissociation, panic, fear

and self-deprecation, becomes a conditioned reaction. It has been a part of the event and the

experience, and every time the trauma is remembered, the disruption is reactivated and

therefore becomes part of the self. The disruption implies a stopping of the ongoing narration

and a “freezing” of the response-ability. The result is an augmented “non-self”, while the

representation of the self, speaking in Gestalt terms, is pushed into the background. That is,

the breaking off of contact is that part of experience where a person “stops and freezes” – he

or she loses the ability to react adequately to inner states as well as to the demands of the

environment (self-action). The more chronic or recurrent a traumatic experience, the more the

conditioned reaction of powerlessness generalizes to other situations. This reaction of

powerlessness is a very aversive and threatening experience. With the appearance of the non-

self (e.g., an intrusion of violence) the freeze reflex (non-response-ability) is conditioned in

relation to the intrusion and to the physical arousal connected with it. This means it can

emerge independently of trauma memories in the future. This is another reason why patients

frequently report that they become more upset about small problems, that they have difficulty

maintaining self-control, that they are easily startled, irritable and nervous. The threat to self-

worth which results from this feeling of “I can’t do anything anymore” can lead the person to

retreat into utter withdrawal. Attempts to “eliminate” the disruptive experience from memory


by avoiding it (and the resulting symptoms mentioned above such as intrusion, panic and so

on) draw the individual into a vicious circle of increasing dysfunction. It is this progressive

destruction of self-processes which horrifies the person and thus sustains the trauma-related

symptoms.

The traumatized self. During and after the traumatic experience no part of the

previously aggregated interactional experience applies. The acute threat presented by the

event results in the absolute dominance of the new experience. Because the experience of self

during the trauma is so extreme – self dissolution, submission, and worthlessness – even well-

developed self-worth processes can be “overruled” by this acute impression. In our clinical

experience, the traumatized self is a chaotic, dissolved self. In the terms of Fritz Perls it tries

to configure itself as an “underdog”, an incapable, passive and overwhelmed creature in

constant need of support and forbearance. In the best case, it is a split self because this implies

that a higher form of self-process, albeit diminished, has been saved. The therapy now

attempts to reduce the dominant posttraumatic self-processes to a realistic proportion and to

actualize the pretraumatic self-processes and integrate them with the new experience.

Posttraumatic adaptation. The so-called posttraumatic adaptation can be found in

the form of the well-known symptoms (intrusion, avoidance, and hyperarousal) of the acute

and posttraumatic stress disorders. The traumatized individual views him- or herself as a

physically and/or psychologically injured person who is subject to injury again in the future,

the world seems hostile and uncontrollable. The self is experienced as damaged and

frequently as worthless (cf., Janoff-Bulman, 1985). It is unable to shape its contacts in a

satisfying way, especially when under stress. This is true for stress stemming from any

source: For a traumatized patient, everyday conflicts which he or she has been able to resolve

easily before can be highly problematic.

The dialogical nature of DET


The relationship – that is, contact and contact-ability – is the focus of the therapy, with

contact referring to the forming of relationships to the outside (social network) and to the

inside (dialogue-ability between the representations of the different possible self-processes;

Butollo, Krüsmann, & Hagl, 1998; Butollo, 2000; Butollo & Hagl, 2003).

DET focuses on the patient’s self-processes in each phase by supporting the patient in

getting in contact with him- or herself and with the world, in responding and in establishing a

flexible and healthy boundary towards the non-self. The whole course of therapy follows an

interactional and dialogical principle. The goal is to identify and resolve the disruptions of

contact so that the patient will be able to experience continuity in his or her self and regain

contact-ability.

The term “dialogical” refers to the fundamental attitude assumed during the whole

course of therapy; the dialogical techniques are only crystallizations of this principle. With

respect to therapeutic mindset, “dialogical” means that the therapist is attuned to the contact

between him- or herself and the patient at all times and helps the patient focus on this contact

as well. Our work is based on the assumption that dialogical contact is, in principle, always

possible, if one is able to leave the fixations on certain (negative) past experiences where they

belong – namely, in the past. It is okay if patients shut themselves off. This will manifest itself

in the therapeutic situation and can be openly discussed. If patients feel esteemed and not

criticized, and if they are openly valued and accepted as humans with all their potential and

their weaknesses, they will dare to successively show more and more of themselves. This is

especially hard for PTSD patients, but the attitude throughout the whole therapy is the

conviction that every patient has contact-ability and we work to make this ability accessible

again, without discounting the past or sweeping it under the rug.

Here, DET heavily draws on Buber’s (1923) thinking who stressed that the way one

addresses another person is important for the formation of one’s own self. He differentiated

between Ich und Du versus Ich und Es, translated into I-Thou vs. I-It relationship. The I-Thou


pair of basic words is spoken with the complete being, always in present tense and without

fixation on “aspects” or qualities of the other person. I-It , to the contrary, never is spoken with

the whole being but always from fractions of selves. Also, the I of the I-Thou never questions

its being but just is, never plays roles or follows others’ expectations of how to behave and to

feel.

As therapists we usually will not reach the I-Thou state of mind, since the professional

position does not allow for such a pure configuration of contacts. But Buber’s distinction can

serve as a guideline for the therapist’s stance. To enter into an I-Thou relationship means to

bring your whole self and to address the other person with your total presence. Traumatized

patients are very far away from that in most or even all of their relationships.

Therapeutic Process

DET includes therapeutic work on two levels: The level of the treatment of symptoms

is specific and the methods are based on Gestalt and CBT principles and techniques such as

awareness, self-support, and desensitization. The level of interaction is not specific to a

diagnostic category because it focuses on the subjective processing of the trauma.

The confrontation with the patient’s representation of the perpetrator during the so-

called “dialogical exposure” is the core intervention of DET. Dialogical exposure facilitates

getting in contact and working with different self-processes (such as the pretraumatic,

traumatized and non-traumatized self-processes) on the one hand and with representations of

the aggressor on the other hand. In preparation for dialogical exposure, we work in the self’s

periphery, that is, before attempting trauma work, we support the patient in rebuilding his or

her boundaries. Therapist and patient engage in exercises that involve establishing contact and

re-establishing the ability to maintain relationships as well as exercises to build trust. But the

main vehicle to develop trust is the therapist-patient relationship itself with the development

of their contact processes. This way the traumatized person can learn strategies of self-support


which are an indispensable prerequisite for focusing on the traumatic event. To put it in terms

of physics, the person should be able to maintain equilibrium and therefore needs to establish

a counterweight to balance the weight of the traumatic experience before exposure is

attempted. This means the person has to be able to perceive and express inner emotional states

and to learn techniques of distancing and relaxation.

The social interactional trauma model suggests different phases of posttraumatic

adaptation, and DET accordingly is a phased approach. The different phases overlap and can

have different emphases depending on the type of trauma. Phase I is about perception of the

outside world and differentiation of the perception of safety as well as the acceptance of

feelings of uncertainty. Inner processes are not yet engaged; they are only observed and

soothed. Phase II focuses on inner perception (self-awareness of the feeling/thought

interactions) and stabilization in everyday conflict episodes. Therapists support patients’

contact-ability in non-traumatic areas. This helps patients to improve their self-perception

and, therefore, their negative self-concept. Phase III contains the exposure to the trauma. On

the one hand, this includes object-oriented exposure, which means a discussion of the

experience and, if feasible, a visit to the place where it happened. On the other hand, there is

an imaginal interactional confrontation with the experience, for example with the perpetrator,

the suicide, or the (natural) disaster. The actualized configuration of the self in the traumatic

experience is crucial here, because this makes it possible to work out alternatives to the

collapse of the self. In phase IV the focus is on accepting the experience and the changes

resulting from it, as well as on relapse prevention. Another goal is the generalization of skills

and gains from the therapy setting into everyday life. The four phases will now be described

in more detail.

Phase I: Safety

Important issues:

• Therapeutic relationship and safety within session


• Development of an explanatory model and a model of change

• Activation of existing resources/self-support skills

• Activation of supportive relationships (social resources)

• Activation of safety

• Coping with symptoms

During the first phase the focus is outward. In this phase, the concepts of the

environment are reappraised, revised and strengthened. The goal is re-establishing contact

with reality, and with the reality that uncertainty has to be tolerated. It is also important to

encourage and support the ability to perceive intra-psychic processes.

Therapists work to help patients re-establish the ability to distinguish between

perception (present action with present content) and imagination (present action with content

that is in the past or the future, e.g., memories, fears, and expectations). In this phase it is

necessary to develop strategies that establish safety in the current reality, including in each

contact episode between patient and therapist during sessions. Therapists encourage

reassuring and positive contact during sessions and validate the patients’ inner experiences.

Safety here refers to interpersonal safety before all else, that is, being able to trust in people as

well as in the environment to send signals that indicate a threat or safety. However, these

signals may have lost their credibility because of the traumatic experiences. Therefore,

therapeutic work on generating safety should include the perception, differentiation, appraisal

and evaluation of safety signals. Therapists encourage patients to observe emotions of feeling

safe and feeling unsafe and to relate these experiences to their actual life situations. It is

important to acknowledge the need for safety and at the same time to encourage tolerance of

feelings of uncertainty. The therapeutic relationship is a perfect opportunity to explore those

processes of ongoing contact with respect to trust issues. Therapists stress awareness and

acceptance of how those interactions and experiences develop, rather than striving to reach a

goal in the sense of “creating” patients’ trust.


The next aspect relates to intra-psychic safety: The posttraumatic self has lost the

continuity of experience; that means it cannot or can only with difficulty be brought in contact

with known and familiar (pre-traumatic) experiential content. This means that self-appraisals

concerning one’s own abilities, skills, traits, and emotions cannot be activated. Therapists

help re-establish contact to pretraumatic self-processes by discussing present experience in

relation to earlier self-concepts and experiences. The following example shows how a patient

reconnects with a helpful presence from her past.

Therapist: Which member of your family could and would want to support you?

Who was sympathetic and affectionate? Whom could you trust?

Patient: That would be my grandma. I could feel comfortable with her.

T.: Imagine your grandmother sitting on the empty chair. How do you feel?

P.: … strange, that’s not realistic.

T.: Take a moment to really feel this… maybe you’re sad, or you’re happy to see

her… maybe there’s something you would like to tell her?

P.: Yes. I’m sad that you’re not here anymore, I really need you right now; you

would understand me.

T.: Imagine her here right now. How does that feel?

P.: Good, lighter somehow…

T.: … maybe you would like to ask your grandma to comfort you, to hug you, hold

you… maybe you would like to tell her that you belong to her and would like to build an

internal connection with her and that no one is allowed to disrupt this tie. (Butollo & Karl,

2012, p. 103 f.).

In this example, the patient was able to reconnect with the earlier experience of being

comforted by her grandmother. In this phase, the therapist is active and makes suggestions in

order to increase the patient’s possibilities. Patients are able to tell what they need very well


and will reject suggestions that do not fit. This also strengthens a patients’ perception of his or

her needs.

The phase of safety makes intense use of therapist-patient relationship issues in the

sense that the therapist assures the patient that he or she is safe in this relationship. Together,

they explore patient processes within in-session contact episodes. Therapists are active and

create highly structured sessions during this first phase of work.

Phase II: Stability

Important issues:

• Awareness and expression of emotion and control of inner processes

• Inner perception and representation of relationships

• Perception of personal boundaries

In the phase of stability the focus is not so much on an outside orientation, but

attention turns toward intra-psychic processes. Right from the start patients are encouraged to

express their inner dialogues about the traumatic experience. The traumatic experience might

have happened only once, but the client replays the interaction over and over in his or her own

mind, making the incident go on and on in repetition. The intra-psychic balance of self/other,

which may have been stable before the traumatic incident, has become unbalanced during the

incident and keeps getting worse from posttraumatic repetition. The self-messages during and

after the trauma imprint “worthless” and “powerless” into the traumatized person’s mind. The

aggressor might have hurt a person once, but within the person’s self-processes his or her self-

esteem is killed a thousand times.

Many traumatized individuals have lost the trust in their own abilities; they feel

incapable of acting and as a result develop negative self-concepts and self-processes. The loss

of knowledge of their own capabilities can cause patients to lose their ability to cope with

their daily life, which is a humiliating experience in itself. The internal processes resulting

from this experience can lead to an overwhelming sense of threat and cause them to revert to


avoidance strategies. The therapeutic work consists of encouraging the patient to not avoid

aversive inner states, but allow them to become part of his or her self again and thus to

strengthen self-acceptance while feeling down at the same time. Therapists accompany

patients into the abyss of their traumatized selves, support their self-awareness in that moment

and value their self-processes. While feeling weak and hurt, patients receive validation as

human beings going through extremely difficult moments. They become able to verbalize and

therefore, change, their inner dialogues, which usually revolve around themes like guilt,

shame, and self-loathing. In the following example, the feeling of being left alone is

discussed.

Therapist: How does it feel to be alone and nobody notices you?

Patient: It is hard to bear; I don’t want to feel it. It tears me apart.

T.: What tears you apart?

P.: I can’t go there.

T.: Are you maybe avoiding a feeling? What could that emotion be: pain, sadness,

loneliness; how does it feel to be left alone?

P.: - very bad, I don’t want to feel this.

T.: I can understand that you would rather avoid this feeling. I suggest that you

imagine, here in this moment, that you are all by yourself. How does that feel?

P.: - very bad, it is sad.

T.: Stay with it, you are completely alone…

The therapist tries to keep the patient in the imagined aversive situation. He expresses

understanding for the wish to avoid that inner scenario, but encourages her not to wander

from the subject or give explanations. He invites her to return to the situation time and again

in order to consciously get to know the feeling. Gradually, the patient can learn to tolerate the

feeling, that is, get in touch, in contact, with it. The therapist also encourages her to express

the feeling and to see whom this expression might be addressed to (Butollo & Karl, 2012, p.


101f). Working like this might appear more directive than it is commonly supported in

humanistic therapies. However, in working with traumatized clients we believe it is important

to search for a middle ground between being purely awareness-oriented and encouraging

clients to experience usually avoided feelings and memories.

Psychological trauma always implies a violation of boundaries of the person

concerned. These boundaries are only damaged in the best case; in the worst case they are

destroyed. This experience of massive violation of boundaries necessitates a great sensitivity

in dealing with boundary issues. Working with boundaries means to maintain a feeling of

integrity during a real or imaginary episode of threat. This means to perceive, name, and

assert one’s needs and wishes. When boundaries can be maintained and the patient has

sufficient techniques of self-support, he or she is able to take a stand against the inner

perpetrator representation and put it in its place in the imagined dialogue that is enacted in the

following confrontation phase.

Phase III: Confrontation

Important issues:

• Object-oriented exposure step 1

o Patient tells the whole trauma history (narrative)

o Discussing the event and the perpetrator

• Object-oriented exposure step 2

o Discussing the event and the perpetrator with the therapist in the imagined

presence of the perpetrator

o Formulating a “response” to the trauma/the perpetrator

• Dialogical exposure

o Entering into a dialogue with the imagined perpetrator/trauma

• Working with aspects of the trauma that were hurtful

• Working with the impact of the experience on life


• Working with broken life goals

The phase of confrontation focuses on those aspects of the trauma which are

responsible for the deformation of the self. By re-establishing the inner contact and by

correcting over-generalized ideas of the implications of the traumatic experience, the self can

find an answer to the traumatic message inflicted on it (response-ability). It is not enough to

think so, but the patient’s self has to be activated as an opponent of the perpetrator again. By

doing so, the patient leaves behind the “boundary-less” confluence with the representation of

the perpetrator. Self-reconfiguration happens within newly strengthened self-boundaries, from

where the patient “aggresses” against the imagined perpetrator in various ways, be they

aggressive or non-aggressive. For the therapeutic process this means that contact with the

traumatic memories needs to be re-established: On the one hand fantasies about the

circumstances of the traumatic experience which have been developed post-trauma have to be

examined. On the other hand the blockages and restrictions a person experiences because of

the trauma have to be observed and processed.

The exposure is conducted in three levels. First, the patient and the therapist discuss

the event (the perpetrator, the situation) with the perpetrator being the third person about

whom the other two (patient and therapist) speak. This means the perpetrator is not present,

not even in imagination, while the patient describes what happened to him or her and how the

perpetrator behaved – it is a “narrative exposure” in past tense, perhaps “aboutism” in Fritz

Perls’ terms. This discussion, for which therapist and patient are in close dialogical contact,

results in an activation of emotions connected with the event. As a rule, imagining or bringing

back the whole situation is too much for the patient at this point, so first some changes are

made to the image before the aggressor, who is the object of the confrontation, is allowed to

enter the picture (e.g. “imagine a wall or a window with thick glass protecting you”).

In a second step, the patient talks to the therapist in the “presence” of the imagined

aggressor about the aggressor and what he or she did to the patient (“object oriented


exposure” or higher level “aboutism”). During this part the therapist and the patient

collaborate in generating themes or sentences the patient wants to say to the aggressor.

Therapist and patient speak about the “third party”, in a way “the enemy”, discussing the

trauma or specific aspects of it in the third person. This does not really match Buber’s concept

of I-It relationship, but it comes close. In Buber’s concept of an I-It relationship a person (“I”)

encounters another person (“It”), but only perceives specific aspects, qualities, threats that are

identified in this person, instead of really and fully entering contact; that is, the person does

not really, with his/her full being, encounter the Thou, as in an I-Thou relationship.

In a third step the patient sits opposite to the imagined aggressor addressing him or her

directly, telling what there is to tell and expressing current emotions. It can be helpful for the

patient to evoke representations of significant others (e.g. family members) who stand witness

to the patient’s experiences and lend comfort and support. Dialogical exposure is an

adaptation of the empty chair technique to the dialogical work with the trauma.

So during the first step only therapist and patient are in contact. In the second step,

there is an interactional triangle with patient and therapist in dialogical contact, and patient

and perpetrator in an I–It type of object oriented exposure contact. When the patient enters the

dialogical, that is, direct encounter with the (imagined) perpetrator, the therapist moves into

the supporting background.

We call this technique dialogical exposure, not only because the patient enters a direct

dialogue with the imagined aggressor or the event but because of the above stated dialogical

principle of genuine contact; in step one and two between patient and therapist, and in step

three between patient and perpetrator. Therapists emphatically address patients as valuable

human beings, allowing them to experience their own value as well. This may be

accompanied by periods of hesitation and doubt on the side of the patient, but essentially

therapists make their patients the offer of accepting them as they are. Eventually, patients may

adopt this – directly and indirectly expressed – message and accept themselves in the same


way. Dialogical interaction creates self-processes which strengthen patients’ self-esteem and

self-acceptance.

Dialogical exposure is the core of the therapy. It demands patients and therapists to

work actively. This modification of the empty-chair technique is particularly appropriate for

externalizing the representations of the “state of a relationship” and for making them

amenable to processing and change. For example the patient can ask an (imagined)

counterpart for help and support or can express unresolved feelings and blocked affect

towards the aggressor. Another possibility is the exploration of different self-processes which

can then be perceived in a differentiated manner and can be brought in contact with each

other. In this way lingering problems and the emotions connected with them can be expressed

and resolved in the course of an imagined dialogue. The following example from Butollo &

Karl (2012, p. 162f.) is a short part of a dialogical exposure session with a patient who had

been sexually abused during his childhood.

Patient (to the therapist): I would like to ask him what he was thinking, to

abuse me and other students like that.

Therapist: Don’t ask him questions (except rhetorical ones), but tell him

what is going on with you. By asking questions you will make yourself dependent on

the perpetrator and his collaboration.

P. (to the therapist): I’m still afraid to create a boundary between us. It’s hard

because I feel like a traitor for betraying him and our “special” relationship. Rationally,

I know that that’s nonsense, but I feel guilty for testifying against him to the police,

after he had been arrested because of the suspicions of another child’s father.

T.: Try to express yourself to the perpetrator by telling him what you feel

towards him right now; try not to make yourself dependent on him and his possible

responses. Hold your boundaries tight as if they were a wall between you two and tell

him, across this wall, what you want to tell him, whether he likes it or not.


P. (towards the perpetrator, that is, the empty chair): I am stunned by the

unspeakable crime that you committed.

T.: Say that again and pay attention to what you are feeling.

P.: What you did to me is an unspeakable outrage and I get angry when I

think about how you betrayed me.

T.: Say the sentence again and try to put some of your anger in this phrase,

so that the message really gets across.

P. (screaming): I’m so angry because of what you did to me when I was a

defenseless child!

T.: How does it feel to say it like that?

P.: I’m a little scared by this murderous anger.

T.: I think your murderous anger is appropriate considering how you were

abused.

It is important that patients are not pushed to confront traumatic memories and

situations but that they are given sufficient time to experience their fears and impulses of

avoidance. That way, they can gradually learn to accept themselves with all those feelings,

which might cause them also to experience themselves as weak or incompetent or powerless.

Eventually, by accepting their limits, they can risk confronting traumatic memories.

Dialogical exposure or confrontation can take several sessions, that is, it can be a long process

which cannot always be finished within the timeframe allocated for the therapy. Dialogical

exposure has to be continued until the situation is resolved in a way that is acceptable to the

patient. This is the case when the patient can believably state it is so. The patient should now

be able to tell the trauma narrative in a coherent way, which means, verbal and nonverbal

expressions match, there are no omissions, and the expression of emotion is appropriate. In

some cases the patient becomes able to experimentally change his or her perspective and

achieves a softer attitude. This can help integrate the traumatic event into the context of his or


her life. Trauma-related damage of ego-boundaries can be healed when patients are able to

take a stand during the imagined contact with the perpetrator, and thus re-establish their ego

boundaries.

Phase IV: Integration

Important issues:

• Integration of the negative experience with all aspects of the self-processes (positive

and negative emotions)

• Establishing contact with the patient’s own aggression

• Development of perspectives for the future

• Grief and maturation

• Acceptance of boundaries (acceptance of the change)

This last phase is about grieving for the lost ideal self and becoming open to a more

realistic view of self and the future. The goal is to “reunite”, or better, to re-establish contact

between a person’s split self-processes, the healthy ones as well as the traumatized ones. This

means that the traumatic experience, which before had been processed only in a fragmented

way, is encoded as belonging to the whole person, as part of the person’s history. On the one

hand, this means that the traumatized self-processes will be allowed to resonate with every

activation of the self. The trauma is part of the biography and will contribute to future

experience. On the other hand, it means that the person’s life is no longer dominated by the

trauma. The traumatic experience has become a part of an again functioning self; the person is

no longer a victim, but a survivor.

Example:

A pedestrian crosses the tracks right before the arrival of a train, the train conductor

can prevent a collision at the last moment by operating the emergency brake. The conductor,

who has already experienced more than one suicide by train, gets out and slaps the pedestrian


in the face. In therapy, he can come to terms with the fears caused by the near miss, but he has

lingering feelings of guilt because he was violent against the pedestrian.

The patient must not judge or reject himself as “someone who slaps people”, but it is

the goal that he realizes that he has this potential in him and accepts this side of himself. He

should develop the wish to learn not to be violent whenever he is extremely angry. But he

should also accept that it is adequate to feel aggressive when another person almost causes

him to have an accident by being careless and that this feeling is okay. In a role play both

parts – the peaceful, adjusted one and the aggressive one – can be brought into contact with

each other.

The goal is that the patient will feel more free, relaxed and open. In contrast to a

perpetrator, aggressive impulses are felt and accepted, but not acted upon. (Butollo & Karl,

2012, p. 187).

After a successful course of treatment the “posttraumatic personality” will be more

relaxed and sustain a better contact with its own emotions and needs. Boundaries and

limitations can be recognized and accepted. The person may be more sober and disillusioned,

less prone to rhapsodize or idealize, but he or she will not be overly pessimistic or defensive

in his or her dealings with the world. The posttraumatic personality knows its possibilities and

its limitations.

Conclusion

While therapies from the humanistic tradition have not been extensively studied, there

are encouraging results from treatments for traumatized patients which include Gestalt

techniques. In this article, we have described the theory behind and the therapeutic process of

dialogical exposure therapy (DET). This therapy aims to reduce intra- and interpersonal

problems as well as improve general and posttraumatic symptoms. By doing so, this approach

widens the impact of therapy beyond simply reducing core trauma symptoms in the sense of a


PTSD diagnosis. It therefore should also reduce relapse rates. If so, this could be the

advantage of the dialogical, interactional work with traumatized patients.


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