Transcript Treatment of Trauma and Eating Disorders – The Emily Program

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Treatment of Trauma and Eating Disorders
The Emily Program, June 2009
Mark Schwartz, Sc.D.
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.com
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Control of Symptom
vs…
Recovery
Eating Disorder Patients’ Experience of Recovery
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
Realistic appraisal of medical dangers

Improvement in care of self (e.g. eating habits, use of leisure time)

New ways to self-soothe, self-regulate

Ability to access social support from family, friends, and fellow
patients

Enhanced problem solving skills

Improved capacity to invest in and work on interpersonal
relationships

Gradual relinquishment of ED identity and eating disorder thoughts
(e.g. “this food will make me fat,” “I’ll feel better after I eat this
package of cookies, etc.)
Eating Disorder Patients’ Experience of Recovery, cont.
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
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
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Ability to take responsibility for self and eschew victim
mentality
Establishment of a sense of “true self,” “real me,” or “knowing
who I am.”
Capacity to formulate goals, tolerate setbacks, yet maintain
positive motivation to get better.
Reclamation of sense of one’s personal power.
Decreased emphasis on perfectionism.
Firmer interpersonal boundaries; enhanced capacitates to set
appropriate boundaries.
Cultivation of sense of purpose, meaning of life.
Temperment
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Triad for Relational Disturbance
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Attachment
 Self
 Affect & Cognition

Intersubjectivity
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
Parents affective expressive becomes the child’s first representation of
their own affects:
▪ Mentalize
▪ Intersubjectivity
▪ Inteface of two minds (Trevarthen, 1979)
▪ Basis of psychotherapy

At 42 minutes of age child imitates parents facial expressions (Meltozoff,
1985)
Secure Base
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
The affective attachment between infant and
care-taker established during the first year of life
evolves into a capacity for object permanence and
evocative constancy during the second year that
provides a “secure base” – enabling the child to
explore and master. These cogitive-affective
schema provide templates that maintain
continuity of interpersonal behavior beyond
infancy.
Two Years – Part 2
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The mothers of the anxiously attached children, by contrast,
seemed unwilling or unable to maintain an appropriate distance.
Some became intrusive and made it impossible for the child to
have his own experience. “They couldn’t tolerate the child having
any frustration, “ Albersheim says. “They would just get in there
and almost solve the problem for him because it was too painful
for them to watch the child struggle. But if children don’t get to
struggle a little bit – and be able to see either that they can
accomplish it or that they need a little help, and to be able to figure
that out on their own – if that’s interfered with, it’s a real loss for
the child.”
Karen, R. (1994). Becoming Attached. New York: Warner Books
Stern’s Work – Part 1
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Molly’s mother was controlling in a different way. She constantly told
Molly how to play with toys (“Shake it up and down – don’t roll it on the
floor”), and, in effect, rode rough-shod over Molly’s natural rhythms of
interest and excitement. Her exertion of power over the baby was such
that Stern and his colleagues often experienced a tightening knot of rage
in their stomachs as they watched the tapes. Molly’s solution was
compliance: “Instead of actively avoiding or opposing these intrusions,”
Stern wrote, “she became one of those enigmatic gazers into space. She
could stare through you, her eyes focused somewhere at infinity and her
facial expressions opaque enough to be just uninterpretable and, at the
same time..by and large, do what she was invited or told to do. Watching
her over the months was like watching her self-regulation of excitement
slip away.”
(Karen, R. (1994). Becoming Attached. New York: Warner Books)
Stern’s Work – Part 2
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Such manipulative misattunements take many forms
and are, Stern argued, the likely origin of later lying,
evasions and secrets. The child, and later the adult,
comes to feel that if people are allowed access to his
true inner experience, they will be able to manipulate
it, distort it, undo it. Only by freezing them out can he
keep his inner experience unspoiled.
(Karen, R. (1994).
Becoming Attached. New York: Warner Books)
Main
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Cecilia displays distress immediately upon finding herself in the unfamiliar laboratory environment, even
though her mother -- a slightly disheveled, overwhelmed-appearing woman -- is present. When the
stranger enters, Cecilia looks suspicious and ill-at-ease, and refuses to engage in interactive play.
Immediately upon separation, she begins to cry, while angrily resisting the stranger’s attempts to comfort
her.
Reunited with her mother, Cecilia cries loudly; when picked up, she does not settle, but continues crying,
wriggling uncomfortably on her mother’s lap. She does not calm even after the mother has held her for a
full minute. As her mother attempts to interest her in the toys, she looks momentarily out into the room,
then turns back to cling again to her mother, crying and apparently still uncomfortable. The mother
repeats, “Calm down, calm down, you’re OK,” but Cecilia refuses to get off her lap and engage in play.
Disorganized Attachment
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Here the reunion is characterized by behaviors that
are not solely aimed at searching for intimacy. It is
as if the child has not succeeded in organizing a
single strategy when his attachment needs are
activated.
Rules of Attachment
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The rules of attachment are quite literally rules to live by – given that they emerge out of
interactions between biologically channeled, survival-based attachment systems. The
behavioral/communicative strategy eventually generates repressed internal/attachment
strategies.
Avoidants could neither be aware of, or express, attachment-related feelings – they inhibit or
minimize internal experiences.
Preoccupieds amplify or maximize awareness and expression of attachment-related feelings
and needs, to ensure continuing care.
Disorganized have their attachment figure unsafe so the person that comforts is dangerous.
Such interactions create deeply entrenched templates for relating that result in distorted
beliefs about self and others causing enactments and do not learn to separate and develop selfagency or a core sense of self, they are overinvolved in watching and caring for their
inconsistent mom, they inhibit the attachment system and distract attention away from unmet
needs.
Active Implementation
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The avoidant infant actively restricts attention to mother – as if to distract from the
anxiety and distress of wanting mother’s comfort.
The preoccupied actively seek and confines self to monitoring mom’s whereabouts,
ignoring the toys and exploring the environment. Gives up the development of self to
survivor.
The disorganized capitulate in external relationships, they also extend internal
relational exchanges between parts of the self, leading to chronic inner conflict,
internal abandonment of parts of self holding traumatic affect and ruthless selfcriticism.
Outpatients actively live by the rules of attachment. Dismissive clients find attention
focused on needs of others, denying their own needs. Preoccupieds are consumed
with doubts about self and others and yearnings. They store up strategies to justify
and maintain pre-existing beliefs.
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The Self
Kohut
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
Self-cohesion requires the presence of others (self-objects,)
the relationship between the person and the other is the
“source” and the transitional object allows for symbolic
representation.

The need for the experience of self objects is never-ending. A
weak self is therefore the result of faulty self-object
experiences.
False Self
(From Winnicott)
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Parents who are intensively over-involved with their
infant cause the child to develop a false self based
upon compliance. Care-giver doesn’t validate the
child’s developing self, thus leading to alienation
from the core self. Parenting practices that
constitute lack of attunement to the child’s needs,
empathetic failure, lack of validation, threats of harm
or coercion and enforced compliance, all cause the
true self to go underground.
Self Differentiation
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1. Absence of true sense of self
2. Hyper-sensitivity and hyper-reactivity to others,
especially in reaction to rejection or abandonment.
3. Gullibility and suggestibility in relation to
authority.
4. Complaints of isolation and neediness, without
self-support
5. Boundary problems, inability to conceive of self
without reference to others.
Part I: Overview
Dissociation
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

Early dyadic processes lead to a “primary
breakdown’ or lack of integration of a coherent
sense of self; i.e., Unintegrated internal working
models
Disorganized attachment is the initial step in the
developmental trajectory that leaves an individual
vulnerable to developing dissociation in response
to trauma
(Liotta, 2000)
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Attachment
Main, cont.
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When the mother leaves again, Cecilia begins crying loudly
and crawls toward the door. The stranger enters at once,
but Cecilia angrily resists her advances.
The mother is sent in almost immediately and after a
lengthy pause in which she watches as Cecilia continues to
cry, she picks her up and holds her. However, when she
tries to put her down, Cecilia throws herself backward in a
tantrum movement. When mother reaches out to comfort
her, her crying increases and she closes her eyes, throwing
herself about.
Two minutes later, Cecilia remains focused on her mother,
clinging to her knees and fussing in a petulant, dissatisfied
way. She has never engaged with the toys.
Main, cont.
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Her interest was in the narrative coherence. Rather than
focusing on the individual’s story, she looks at the structure of
the story. What the person allows themselves to know, feel
and remember in telling the story. Breaks in the story,
disruptions, inconsistencies, contradictions, lapses,
irrelevancies, and shifts are linguistic efforts to manage that
which is not integrated or regulated in experience or memory.
Fonagy calls this “mentalizing” affective experience to reflect
upon the diversity and compliant of internal mental states.
Specific memories used as evidence supporting general
descriptions of primary relationships are important.
Experience scales (1-9)
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1.
Loving –
-- memories of special and tender concern and soothing when ill.
-- memories of having done something bad, expected to be punished, parents caring
and
forgiven.
-- memories of having done something perceived bad by teachers,etc. and supported
by
parents
-- memories of childhood fears and being comforted
Unloving –
(3) Instrumental attention
(5) Present occasionally
(7) Good enough parenting
Experience scales (1-9)
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2.
Rejection –
-- Turning back of child’s dependence, affection, attention, need and attachment.
-- Speaker avoids discussing relationship with parent or emotional terms.
-- Speaker report rejection of siblings.
-- Speaker recalls favorite towards siblings.
-- Speaker describes being “spoiled rotten” by parent
-- Speaker described self as favorite and other’s rejected.
-- Fear parent would leave.
-- Overtures to parent rejected.
(3) Mildly rejecting of attachment, aloof, “differently showing me love.”
(5) Child seldom given encouragement
(7) Parent mad when child sick misses graduation
(9) Wish child not born
Experience scales (1-9)
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3.
Involving/role reversal
-- Making it clear that the child’s presence is necessary for maintenance of own sense of
well being
(1) Parent looking to child for parenting.
(5) Parent is looking to child as substitute spouse
(7) Parent depends on child’s attention for safety.
-- Taking care of children seems a bit too much.
-- Parent confused on helpless parent not a real adult.
-- Parent complains children are too much.
-- Parent afraid to stand-up to another person.
-- Child advises parent on how to behave as a parent.
-- Parent over-protective.
-- Parent martyr, guilt-inducing “child not loving enough” for parent.
-- Child focused on pleasing parent.
-- Child felt guilty for bad grades, etc. “hurting “ parent.
-- Child says, “I was my mother’s” whole life.
-- Child remembers desire to protect parent
-- Parent treats child as friend or spouse.
Experience scales (1-9)
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4.
Neglecting
-- Parent inattentive preoccupied, uninvolved or inaccessible.
(distinguish neglect from rejection – he never had time for us would be
neglect)
(distinguish neglect from role-reversal – parent ill can be neglect)
-- Parent preoccupied with work, family, household.
-- Parent unable to spend time because kids are too much for them.
-- Child remembers crying at night.
-- Parent always busy thinking of someone else.
-- Parent always with friends, at bar, etc.
Experience scales (1-9)
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5.
Pressured to achieve during childhood
-- Status or position overemphasized.
-- Over-concern with school performance with emphasis of how it looks “regarding
the
family.”
-- High ratings when parental withdrawal of affection if child fails to perform.
-- Child very anxious regarding report card.
-- Parent “pushed” child to care for self and parent unloving.
-- Early excessive excellence stressed.
-- Child pushed to do adult’s work young.
Dismissing of attachment
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1.
Idealization.
2.
Dismissing derogation.
3.
Lack of memory.
4.
Response appears abstract and remote from memories or feeling.
5.
Regard self as strong, independent, normal.
6.
Little articulation of hurt, distress or needing.
7.
Endorsement of negative aspects of parents behavior.
8.
Minimizing or downplaying negative experiences.
9.
Positive wrap-up.
10.
No negative effects.
11.
Made me more independent.
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State of Mind Regarding Attachment
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COHERENCE: (truthful, succinct, relevant, clean)
Steady flow of ideas, intent thoughts, feelings, clear truthful, consistent,
plausible, reponses, complete, but not long.
COLLABORATIVE:
Speaker appears to value attachment relationships and experiences.
CONSISTENCY:
Descriptions of relationships with parents are supported by specific
memories.
Fonagy: Attachment & Mentalization
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Peter Fonagy and colleagues have described this ability as a
product of the adults’ “reflective function” in which parents
are able to reflect (using words) on the role of states of mind
influencing feelings, perceptions, intentions, beliefs and
behaviors. For this reason, reflective function has been
proposed to be at the heart of secure attachments,
especially when the parent has had a difficult early life.
Metacognitional
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Metacognition means treatment of one’s mental
contents as “objects” on which to reflect, or in
other words “thinking about one’s thinking.”
Distinct skills contribute to its characterization,
such as the ability to reflect on one’s mental states,
elaborating a theory of the other’s mind,
decentralizing, and the sense of mastery and
personal efficacy.
Self-parenting: according to survivors,
qualities of ideal parent
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Unconditionally loving and accepting.
Affirming.
Takes responsibility.
Sets and teaches healthy boundaries.
Is protective.
Values play.
Is forgiving of mistakes.
Encourages growth.
Listens to child in open and receptive way.
These are the qualities of the ideal “self-parent”
TABLE I.I
Facilitating “Earned Secure Attachment”
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1.
Facilitating a coherent, cohesive, collaborative and reflective “fresh” narrative with clarity and perspective.
2.
Examining exaggerated, polarized, internally conflicting loyalties to family system or family system “rules.”
3.
Facilitating metacognition, particulary redefining reactivity, proportion and understanding origins of core beliefs.
4.
Facilitating self-compassion and internal connections to disowned parts of self.
5.
Utilizing an attuned “connected” relationship with therapist as a home base for exploring development.
6.
Learning to solicit and draw on internal and external resources for support, soothing and stress reduction.
7.
Re-examine detailed beliefs about self and others.
8.
Relinquishing defense of dissociation and re-associating affect, sensation, and knowledge such that there can be choice about behavior.
9.
Not inhibit or minimize internal experiences and learn to tolerate distressing emotions and express affection.
10.
Resolution of internal relational exchanges between parts of self.
11.
Internalize self-parenting that is non-punitive, non-punishing and comes to rely on internal voice of wisdom.
12.
Sets and teaches healthy boundaries.
13.
Resolution of significant losses in one’s life.
14.
Deconstruct the attachment patterns and core relational conflicts and revise expectations, and be capable of holding contradictory feeling in
consciousness simultaneously without negation or dissociation.
15.
Integrate traumatic attachments, losses and re-enactments with reduction of shame, recognition or attributions and re-examining trauma-related
behaviors.
16.
Establishing appropriate entitlements related to having needs, expressing needs, and meeting needs.
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Seeding
Development of
Self
Therapists Job with Attachment Trauma
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1.
Transformation of the self through relationship.
2.
Provide a secure base for exploration, development and change.
3.
Provide attunement in helping the client tolerate, modulate and
communicate difficult feelings.
4.
Affect regulating interactions for accessing disavowed or
dissociated experiences strengthening narrative competence.
5.
Deconstruct the attachment patterns of the past to construct
new ones in the present
(see David Wallin, Attachment in Psychotherapy, Guilford Press, 2007)
Deconstructing Attachment
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Implications of Psychotherapy:
1.
Idealization.
2.
Dismissing derogation.
3.
Lack of memory.
4.
Response appears abstract and remote from memories or
feeling.
5.
Regard self as strong, independent, normal.
6.
Little articulation of hurt, distress or needing.
7.
Endorsement of negative aspects of parents behavior.
8.
Minimizing or downplaying negative experiences.
9.
Positive wrap-up.
10.
No negative effects.
11.
Made me more independent.
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Relationship
with Self
Structural Deficits
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
There is good reason to believe that large
segments of the population lack many critical
capacities, such as self-observing abilities,
necessary for mental health, and that even
patients who have them, have them only in part.
These capacities which can be called “structural
capacities” (Greenspan, 1989) have to do with
critical abilities such as self-regulation, relating,
presymbolic-affective communicating,
representing and differentializing experience,
representing internal experiences and self
observation.
From Greenspan, S. (1997). Developmentally Based Psychotherapy, Madison: International Universities Press, Inc.
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
Love is not primarily a relationship to a specific person; it
is an attitude, an orientation of character which
determines the relatedness of a person to the world as a
whole, not toward one “object” of love. If a person loves
only one other person and is indifferent to the rest of his
fellow men, his love is not love but a symbiotic
attachment, or an enlarged egotism…If I truly love one
person I love all persons, I love the world, I love life. If I
can say to somebody else, “I love you,” I must be able to
say, I love in you also myself.”
From The Art of Loving, 1956, Erich Fromm
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Aleksandr I. Solzhenitsyn
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If only there were evil people somewhere
insidiously committing evil deeds, and it were
necessary only to separate them from the rest of
us and destroy them. But, the line dividing good
and evil cuts through the heart of every human
being, and who is willing to destroy a piece of his
own heart?
Gulag Archipelago
SHAME
(Kaufman, 1982)
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Feeling of exposure inherent to the experience
that can accompany extreme amount of utter
worthlessness. Feeling exposed results in the
individual critically scrutinizing the minutest detail,
heightening the awareness of being looked at and
see. The feeling of exposure can produce rage.
MINDFULNESS SKILLS
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
“Notice…”

“Be curious, not judgmental… Let’s just notice what is happening.”

“Notice what happens in your body when you start to talk about this.”

“Notice the sequence: you were home alone, feeling bored and lonely,
then gradually you start to get agitated and feel trapped, and then you
just had to get out of the house – as if it wasn’t safe there anymore.”

“What might have been the trigger? Let’s go back to the start of the day
and retrace your steps.”

“Did you notice any early warning signs that you were starting to get
overwhelmed?”

“How present in the room are you feeling right now? What would happen
if you changed position? How present do you feel now?
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Eating Disorder
Treatment of ED Premises Philosophically
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
Different developmental trajectories
Symptom has developed as a survival strategy
Symptom is logical, rational and adaptive
Symptom remission is dependent on understanding the
logical development and allowing for a more optimal solution
Re-Framing the Meaning of Symptoms
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




Start with the assumption that every symptom is a valuable piece of data!
Use psychoeducational material to make educated guesses about the meaning of
symptoms, as a symptoms memory or a valiant attempt to cope.
Ask her, “How would this ____ have helped you to survive in an unsafe world?”
“Helped you feel less overwhelmed? Less helpless? More hopeful?”
Look for what the symptom is trying to accomplish: i.e., chronic suicidal feelings
might offer comfort or a “bail-out plan”; cutting might help modulate arousal;
social avoidance could be an attempt to avoid “danger.”
Once it is clear what the symptom is trying to accomplish, then therapist and
patient can look for other ways to accomplish the same goal in a context that
describes the patient as an ingenious and resourceful survivor, rather than as a
damaged victim.
(Fisher, 2001)
Failed Protectors
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Where part got the idea that it had to coerce and shame her
into dieting, working, being nice – usually a parent
monitoring and scorning – part like a single parent – these are
inner censors and tyrants that control us, keep our noses to
the grindstone and do not risk any behavior that brings us the
slightest embarrassment.
Repetition
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Nevertheless, the need to repeat also has a positive
side. Repetition is the language used by a child who has
remained dumb, his only means of expressing himself.
A dumb child needs a particularly empathic partner if
he is to be understood at all. Speech, on the other
hand, is often used less to express genuine feelings and
thoughts that to hide, veil or deny them and, thus, to
express the false self. And so, there often are long
periods in our work with our patients during which we
are dependent on their compulsion to repeat - for this
repetition is then the only manifestation of their true
self.
- Alice Miller
SELF-INJURY
(David Colof, 1991)
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



Self-injury is the container for unmetabolized traumatic stress
and underlying unresolved trans-generational trauma and
loss.
Self injurious/destructive behavior is functional and is always
an attempt to protect the client (system).
Expresses (communicates) underlying dynamics and need and
is “trance logical” (“hurting releases pain”).
Because behavior dissociated from sensation, affect and
knowledge, linkages to specific meaning, function or intent,
will typically be unclear.
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Trauma
Trauma Recovery Domains
(Mary Harvey, Ph.D.)
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1.
2.
3.
4.
Authority Over Memory - Can take event from past, talk about it
with sense of empowerment.
Integration of Memory and Affect - Can feel some appropriate
affect with cognition. New affect (adult-oriented)(1995).
Affect Tolerance and Trauma - Related Affect - Feelings no longer
overwhelmed, get overwhelmed and back into the trauma, ignore
and walk into danger.
Symptom Mastery - Hypervigilant, anxiety, depression,
dissociation, somatic, compulsivity, how much do we need to
measure remission.
Trauma Recovery Domains
(Mary Harvey, Ph.D.)
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5.
6.
7.
8.
Self-Esteem - Capacity for self-care and regard, properly
eat, exercise, sleep, self-soothe.
Self-Cohesion - How one experiences oneself, fragmented,
compartmentalized, self-trust
Safe Attachment - Negotiate and maintain safety in
relationships.
Making Meaning - Making meaning of their experiences.
Amelioration
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Involves:
1.
Acknowledgement (i.e., how it happened… it wasn’t ideal… I was impacted).
2.
Access (to memory, details or aspects stored often state specifically)
3.
Assimilation (of that which was previously compartmentalized, dissociated,
denied or disowned)
4.
(Accompanied by) Affective Expression consonant with the experience, and:
5.
Accurate Attributions
6.
Allowing for Alleviation of shame and inappropriate self-blame
7.
Acceptance, not necessarily “forgiveness”
8.
Amends where needed to parts of self, one’s body or other collaterally damaged
through reenactments, trauma-bonded relations.
9.
Ability to move forward without constraint or compulsion.
Internal Family Systems Innovations
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1.
2.
3.
4.
5.
Delegates capacity for healing within the client: “selfhealing”
Defenses accessed first. Get to know them and celebrate
their genesis.
Get permission to access the parts they protect.
Get fear, shame and punitive internal voices to step back,
allowing a more vulnerable core affect – and more accurate
self-reflection.
Deep structure, access to sensorimotor, visceral, imagedominated, right brain – previously unavailable material.
Internal Family Systems Innovations
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6.
7.
8.
9.
10.
11.
Unlock the unconscious
Integrate disowned parts of self-consolidation.
Release of potential residing within
Establish a cohesive coherent autobiographical narrative.
Establish an “earned secure” attachment with self and parts
as well as affect regulation.
Integrated affect and cognition.
Internal Family Systems Innovations
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12.
Therapist being “in self” allows what Kohut called empathy
– mirroring “without judgment, without sympathy, without
excessive analysis.”
It mirrors the subjective experience of the self providing
self-cohesive.
HOMEWORK ASSIGNMENT
Cognitive Processing Therapy for Rape Victims
(Resick & Schnicke, 1993)
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Assignment #1
Please write at least one page on what it means to you that you were raped. Please consider the
effects the rape has had on your beliefs about yourself, your beliefs about others, and your
beliefs about the world. Also consider the following topics while writing your answer: safety,
trust, power and competence, esteem, and intimacy. Bring this with you to the next session.
Assignment #2
Start over and write the whole incident again at least one more time. If you were unable to
complete the assignment the first time, please write more than last time. Often, the first version
reads like a police report with nothing but facts. Add more sensory details as well as your
thoughts and feelings during the incident. Also, this time, write your current thoughts and
feelings in parentheses (i.e., “I’m feeling very angry”). Remember to read over the new account
at least once before the session. If there was a second incident, please begin writing about that
event.
Assignment #3
Please choose two of your stuck points and answer the questions on the Challenging Questions
Sheet with regards to each of these stuck points. Write your answers on a separate sheet of
paper so that you can keep the list of questions for future reference.
Resistance Group
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
How am I avoiding remembering?
How am I avoiding feeling?
How am I avoiding talking about it?
How am I minimizing it?
How am I avoiding focusing on enjoying parts of life?
How am I avoiding noticing triggers that cause me to hurt self?
How am I avoiding dealing with current life stresses?
How am I still protecting my family?
How am I avoiding being close to others?
What secrets have I not yet discussed?
How am I fighting my therapist and working my program?
Scanning
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And as I count back not from 7 to 6, you’ll be able to begin to move
back safely and comfortably through the years, and from 6 to 5 now,
(just continuing back and allowing your mind to begin to scan, much
like the tuner on a radio dial, just looking for any strong signal
indicating some significant event) and continuing back – from 5 to 4 –
back through more and more years, and allowing your mind to
continue to scan through the years just looking for any strong signal –
and 4 to 3 – and as your mind move s toward some strong signal
indicating some significant event, you’ll be able to focus in and talk
about where you are and what’s happening. You’ll be able to stay with
that event as long as you want and then move on to the next strong
signal. And now from 3 to 2 (pause) and 2 (short pause) to 1 – And
just allowing your mind to move toward some significant event and as
you focus in, just talk about where you are and what you’re aware of.
Integration
(Horowitz & Krupnick, 1981)
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Before integration occurs, though, the following themes need to be mastered:
1.
2.
3.
4.
5.
6.
7.
8.
Rage at the source of the trauma (i.e., the perpeterators)
Sadness over losses (innocence, childhood)
Discomfort over the realization of personal invulnerability
Discomfort over reactive aggressive impulses
Fear of loss of control over aggressive impulses
Guilt and self-blame (because of failing to control the abuse or
reliving that oneself invited it to occur)
Rage at those exempted from the abuse
Fear of repetition of the event
Skills Building/Stabilization
66
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Begin after safety and health is ensured
Learn skills to protect and nurture
Skills provide the basis for more advanced therapy work
Conflict resolution, boundary setting, emotional regulation, self-care, relaxation,
assertiveness
Examine underlying beliefs that prohibit use of skills
Developing a support system and dealing with difficulties of being in a 12- step
program
Physically recover from withdrawal from chemical use
Stop being preoccupied with chemicals
Learn to solve problems without using alcohol and drugs
Develop hope and motivation
Acute and post-acute withdrawal (PAWS)
Relapse Cycle: euphoric recall, positive expectancy, trigger event, obsession,
compulsion, craving
Education Stage/Early Recovery
67
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Establishing a recovery identity
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Typically continue flooding and strong emotion – usually use escape and avoidance to manage feelings
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Deal with issues related to shame by telling story openly and honestly
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Honor strengths and coping skills
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Mapping: Addressing parts and their interrelationships. Beginning to build alliances with parts Begin
doing “family therapy”
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Rewriting the story: deal with confusion and shame about arousal. Address power and trust issues and
the belief they should have stopped it.
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The major goal is to change the attitudes and beliefs about alcohol and drug use that sets up relapse
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Explore the meaning and purpose of chemical use
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The drinking problem vs. the thinking problem (i.e., the irrational thoughts, unmanageable feelings, and
resulting self-defeating behaviors that accompany the using)
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The addictive self vs. the sober self – putting the sober self in charge
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Reconstructing a life history
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Drug and alcohol history – finding the purpose using served
Crisis Stage/Transition Stage
68
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Maintain safety and health
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Description of patient in crisis stage: Flooding, flashbacks, SI/HI, overdoses, work or family
crisis. May present in relapse mode.
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Assess likelihood of maintaining abstinence, absence of significant withdrawal symptoms, high
functioning in other areas, belief on client’s part to maintain abstinence, social support.
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Treatment tactics: Structure, limits, education, identify triggers and supports, information on
PTSD
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Recognize loss of control over alcohol and drug use.
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Recognize that s/he can’t control because they are addicted.
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Make a commitment to a program of recovery that includes the help of others
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Disease concept
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Denial
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Analyzing presenting problems as they relate to abuse of chemicals
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First 3 steps of AA
Stages of Psychotherapy
69
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External Safety
Connecting – Internal Safety
Witnessing
Retrieval
Unburdening
Invitation (fill the void left by the burden)
Consolidation (What do you want to do now?)
Back to the Protector (How did we do? Do you need
to unload?)
TRAUMA BOND
70
Why it must be addressed:
1.
2.
3.
As long as the trauma bond remains strong, the internal
and external safety necessary for healing/recovery work
does not exist.
Overtly and covertly abusive relationships may continue
with the abusive family of origin.
Re-enactment: The patient may attempt to solve the
primary abusive relationship problems through reenacting these relationships in other significant
relationships. (e.g., abusive spouse)
Trauma Bond
71
1.
Can be understood as enmeshment (Minuchin, 1974):
Overly diffuse boundaries contribute to systems and
systems members’ overload; they then lack resources
to adapt and change under stressful circumstances.
a. Heightened sense of belonging requires a major
yielding of autonomy; discouraging autonomous
exploration and mastery of problems.
“Independence -- even the word scares me.”
72
The protagonist does not know that the
performance is designed to master “events” that
were once too exciting, too frightening, too
mortifying to master in childhood. Unable to
remember the events, his life is given up to reliving
them in a disguised form.
Stoller
The Most Common Mistakes Made by Therapists in Working with
Self-destructiveness
73
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Not understanding the degree of relief associated with self-harm.
Not understanding the survivor’s need to avoid relying on others.
Not understanding that care of the body is not a priority: when your body only
matters as a vehicle for discharging tension, its care becomes meaningless.
Not understanding that post-traumatic shame and secrecy make it feel “normal” to
hide the extent of the self-harm even from the therapist.
Not understanding that the patient has no internalized Protector introject, only posttraumatic introjects: as internalized Abuser, a helpless child victim, and nonproductive bystander.
Becoming engaged in a struggle with the patient around issues of safety in which the
therapist becomes the spokesperson in favor of safety and the patient the
spokesperson in favor of self-harm, thereby neglecting the task of helping the patient
struggle with her own internal conflict.
(Fisher 1999)
ANGER AND RAGE
(Michael Lewis, 1991)
74
Anger feels justified, whereas in rage one feels powerless.
Injury is recognized in anger, but injury is denied in rage.
Anger is conscious, whereas rage, based on shame substitution, is
pushed from awareness.
While anger may be easily resolved, rage, initiated by shame, sets
up a feeling trap, whereas shame leads to rage which, in turn,
leads to shame.
Anger is not displaced, rage is.
ANGER AND RAGE
(Michael Lewis, 1991)
75
Anger feels justified, whereas in rage one feels powerless.
Injury is recognized in anger, but injury is denied in rage.
Anger is conscious, whereas rage, based on shame substitution, is
pushed from awareness.
While anger may be easily resolved, rage, initiated by shame, sets
up a feeling trap, whereas shame leads to rage which, in turn,
leads to shame.
Anger is not displaced, rage is.
Learning to Contract
76
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Therapeutic contracting is complicated in trauma work because of issues of
power and control, dependence and mastery: as therapists, we want to avoid
becoming the patient’s external locus of control, and we want to help the
patient use contracts to self-regulate arousal and impulsivity.
Therefore, commitment to the work of recovery or to choices that enhance
stability and safety are more helpful than contracts “to” the therapist: i.e.,
committing to not isolate, go to appointments, use specific coping skills.
Time-limited commitments are more helpful: “I can keep myself safe until
tomorrow morning… Until I go to work… For the next five minutes.”
Coping commitments are more helpful: “I commit to using my Survival Kit…
To not being alone… To follow my safety plan.”
A commitment must always be honored OR a new commitment negotiated:
ignoring broken commitments is “re-enactment” behavior on the part of both
patient and therapist.
(Fisher, 1999)
RE-FRAMING THE MEANING OF SYMPTOMS, cont.
77
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Suicidal impulses: “You found a way to live by always having a way out,
always having a bail-out plan to give you some control over your fate”
Cutting or self-injury: “Hurting the body when you feel overwhelmed is an
ingenious way to stop the pain because it triggers your body to produce
adrenaline”
Hypervigilence: “You learned to stand guard over yourself when there was
no one there to protect you”
Sexual acting-out: “You found a way to have power over me”
Mistrust and paranoia: “You learned the hard way that it is safer to
assume the worst in people rather than the best”
Self-loathing: “You found a way to have some explanation, some control
by blaming yourself - that way, you could still change things”
Addictive behavior: “You found that alcohol took away the fear of being
around people, and then when you were too relaxed, cocaine made you
feel more powerful”
Fisher, 2001
28
Compulsive Self-Injury
(Dusty Miller, 1996)
78
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TRS women and men do to their bodies something
that represents what was done to them in
childhood…
For women and men who can be understood as
suffering from Trauma Re-Enactment Syndrome,
patterns of self-harming behavior tell a story of how
the child learned to be in relationships and learned
to be with (her) self.
CENTRAL CHARACTERISTICS OF TRAUMA RE-ENACTMENT SYNDROME
(Dusty Miller, 1994)
79
1.
2.
3.
4.
The sense of being at war with one’s own body.
Excessive secrecy as a central organizing principle of
life.
Inability to self-protect, often evident in a specific
kind of fragmentation of the self, and
Relationships in which the struggle for control
overshadow all else.
DISSOCIATIVE PROCESS WITH FAMILY
ABUSE LEADS TO TRIADIC SELF
(Miller, 1996)
80
1.
2.
3.
“Bad” part of her father as a separate part of herself
(i.e., in control, powerful, strong = safe)
Absence of protecting bystander splits off as the
weak, helpless
Victim – “wounded child”
Self-harm = abuser commands harmful activity,
victim responds and bystander says “I can’t protect
you”
Hypersexuality
81
Low threshold for sexual responsiveness, often with obsessivecompulsive rituals of sexual expression that displace the
unfolding of connection or caring for the partner. The rituals
may also revolve around masturbation rather than partnered
sex, or paraphilic sex, accompanied by a great deal of shame
with a primary emphasis on relief or anxiety or tension
Love Map
82
Personalized, developmental representation or template in
the mind and in the brain that depicts the idealized lover and
the idealized program of sexuoerotic activity with the lover,
as projected in imagery and ideation or actually engaged in
with that lover.
Cybersex
83
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As of January 1999, there were 19,542,710 total unique
visitors/month on the top five pay porn Websites, and there
were 98,527,275 total unique visitors/month on the top five
free porn Websites.

In November 1999, Nielsen Net Ratings figures showed
12.5M surfers visited porn sites in September from their
homes, a 140% rise in traffic in just six months.

Nearly 17% of Internet users have problems with using sex on
the Net.
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Severe problems with sex on the Net exists for 1% of Internet
users, and 40% of these extreme cases are women.
Cybersex, cont.
84
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Most e-porn traffic, about 70%, occurs weekdays between 9 a.m.
and 5 p.m.
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There are 100,000 Websites dedicated to selling sex in some way;
this does not include chat rooms, e-mail or other forms of sexual
contact on the Web.

About 200 sex-related Websites are added each day.

Sex on the Internet constitutes the third largest economic sector on
the Web (software and computers rank first and second),
generating $1 billion annually.

The greatest technological innovations on the Web were developed
by the sex industry (video streaming is one example).
COMPONENTS OF TREATMENT:
SEXUAL COMPULSIVITY
85
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Stopping the behavior
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Minimization and denial: Opening the door – cognitive distortions, anger towards women
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Relapse prevention
- high risk situations
- apparent irrelevant decisions
- effective coping responses
- understanding your moods
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Arousal reconditioning
- social and relational skills
- impulse control
- shame/rage
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Values classification
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Anger management, problem solving, assertiveness
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Enhancing empathy
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Victimization and family issues
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Awareness of feelings
- healthy sexuality
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Making amends
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Healthy relationships and intimacy
Hypo Sexuality
86
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Sexual response is consistently inhibited

Low initiatory behavior

States “I don’t enjoy sex very much and would prefer to have sex less than
once a month”

In relationships, often one partner is hypersexual and the other feels
pressured and thereby hyposexuality and this dynamic becomes
amplified, creating labels “too much – too little” – which becomes
disposition.
Contradictory Aspects of Sexual Arousal
87
It is therefore, quite uncommon for one individual to be both
hypersexual and hyposexual within the same or different
periods of their lives. Their extremes of responsiveness seem
contradictory, but are actually a predictable adaptation to a
set of complex overwhelming behavioral structures, evolved
in a response to original rejection, abandonment, neglect,
assault and resultant re-creations and misappraisals.