Transcript Slide 1

Innovative Approaches for Treating Post
Traumatic Stress Disorder, Acute Trauma and
Disorganized Attachment
IVAT,
September 2009
Mark Schwartz, Sc.D. and Lori Galperin, MSW, LCSW
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.com
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INTRODUCTION
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HOW IS RECOVERY MEASURED?
Recovery is not just the absence of symptoms…it is the presence of a full life
as evidenced by the ability to be human. A truly recovered life will reflect
spontaneity, freedom, the ability to breathe, to have wants, needs and
desires, knowing that the quest for perfection is an unattainable illusion.
Having the ability to embrace the feminine, having close intimate
relationships, and it is being aware of the tears in your eyes (whether out of
intense or subtle sadness – or out of the joy – or from a flicker of utter
gratefulness) and then to allow your tears to flow freely. It is a life in which
decisions and choices are made more from self and less from a shame and
fear based prison. It is a life where you fully experience pleasure, joy and
passion and believe and know it is good to desire and enjoy sex…
(Theresa Chesnut, 2002)
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UGLY NEEDS, UGLY ME
A defensive parent’s own limitations can also translate into shame for the child…
She perceives her little girl as overly demanding and repeatedly scolds her for being
selfish. The child comes to believe that she is selfish and despises herself for it.
Her natural self-assertion is compromised as she comes to feel that she should not
take, should not ask, should not calculate in her own behalf, for any of these things
may exhibit the hatred quality. What’s more, she finds that if she is restrained and
solicitous, her mother likes and approves of her. Nevertheless, her unmet needs
keep rising to the surface and she acts them out in ways that cause renewed
displeasure in her mother and renewed self-hate in herself. As she gets older, the
girl compensates for her supposed defect with rigid displays of generosity. She
remembers everyone’s birthday, she’s always ready with a compliment, she seems
content to settle for second best. No one must ever know what she truly is; no one
must ever see that clawlike third hand reaching out of pocket with “Selfish!” written
all over it.
Becoming Attached, Robert Karen, Ph.D., Oxford University Press, 1998.
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UGLY NEEDS, UGLY ME, CONT.
Because this inner dynamic proceeds largely outside of awareness, the shame image often persists
into adulthood in a strangely unevolved form. If not understood or worked through, it retains the
terrible charge of parental rejection. The girl becomes a young woman who unconsciously believes
not just that she suffers from a troubling flaw, but that she is revolting and untouchable and that her
selfishness is a deformity that makes her unfit to live among other human beings. People differ in the
degree to which they defend against shame. Some obsessively avoid it by restricting their lives and
narrowing their consciousness. Through an addictive or compulsively busy lifestyle, unwanted selfimages can be kept from impinging upon awareness. Others are more aware of their shame and
tormented by it, sometimes to the point of depression. Perhaps the best evidence that these two
styles of living with shame are associated with avoidant and ambivalent attachment comes from a
study of six-year-olds by Jude Cassidy. Cassidy found that securely attached children have a strong
feeling of self-worth and competence, but when pushed were able to acknowledge imperfections. In
other words, they seemed to be neither tormented by shame nor rigidly defending against it. Avoidant
children, in contrast, persistently portrayed themselves as perfect and refused to admit to any
shortcoming; while the low self-worth of ambivalent children was prominent and undisguised. This
study suggests that from an early age quality of attachment may be connected not only with the
degree of shame formation but with the development of fundamental dysfunctional personality styles.
Becoming Attached, Robert Karen, Ph.D., Oxford University Press, 1998.
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Each mother can only react empathically to the
extent that she has become free of her own
childhood, and she is forced to react without
empathy to the extent that, by denying the
vicissitudes of her early life, she wears invisible
chains.
(Alice Miller)
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CREATION OF THE PUNITIVE FALSE SELF
Parent ignores the emotional attunement with the
emerging self in order to mold them into objects.
 Infant’s needs met with inconsistent and
unreliable attunement, develops a self as
unworthy of attention and incapable of influencing
other who care.
 Parent intrusively over involved creating false self
based upon compliance and externally imposed
standards.

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FAILED PROTECTORS
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.
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EARLY MALADAPTIVE SCHEMAS
Self-perpetuating
 More resistant to change
 At the core of self-contempt
 Are actively maintained
 Are tied to high levels of affect and arousal
 Lead to distress

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INTERNAL WORKING MODELS
Structural processes to limit access to information
(Main, 1985). “Conscious and unconscious
rules…that direct not only the feelings and
behaviors but also attention, memory and
cognition.
 Rules to live by emerging out of survival based
system.
 Strategies of actively employed – child distracts
himself from wanting mothers comfort – and
rejects her, or denies having needs or preoccupies
self with caring for others.

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PREMISES PHILOSOPHICALLY
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.

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IFS
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PARTS
Sub-personalities or aspects of our personality
that interact internally in patterns that are similar
to the ways that people interact in human systems.
 We all have parts: Think of your playful part, your
organized part, shy part, etc.
 All parts are valuable and have good intentions.
Even though the behaviors might appear to be
destructive, they are intended to protect the
individual.

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PARTS
In response to life experiences, parts can
become extreme and destructive, obscuring the
leadership of the Self.
 People who have undergone severe trauma
typically have more discrete, polarized parts.

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QUALITIES OF SELF
Calmness
Curiosity
Joy
Gratitude
Clarity
Compassion
Confidence
Courage
Connectedness
Humor
Equanimity
Perspective
Peace
Kindness
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COMPASSIONATE WITNESSING
This occurs when the Self of the client is able to witness
the stories of parts from a compassionate position. Ask
the client to identify an activated part (usually
associated with extreme behaviors, thoughts or
feelings). Ask the client where in the body the part is
and how they feel toward it – the answer may indicate
that another part is blended with the Self. Ask the
blended part to please step aside and let the Self work
with the activated part.
This may include asking more than one part to step
aside.
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COMPASSIONATE WITNESSING
When the stories have been told, ask the Self to be
with the part in the way the part had wanted
someone to be with them when the event really
happened. (Many clients do this visually). The part
in question may be stuck in the past, so self may
need also to retrieve the part & bring it to a safe,
comfortable place in the present, after which
Unburdening can proceed.
(It is important to note that this process may take
different forms and the above is a general way to do
this part of the work).
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UNBURDENING
Burdens are thoughts, feelings or energies that
constrain parts and keep them from assuming
their natural healthy roles. After compassionate
witnessing has taken place, ask the part
whether it might like to get rid of the
(burdensome) thoughts and feelings it took on,
related to the scenes just witnessed. Ask
where in the body the burden is located, and
what they would like to give it up to.
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INTERNAL FAMILY SYSTEMS INNOVATIONS
1.
2.
3.
4.
5.
Delegates capacity for healing within the client:
“self-healing”
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,
image-dominated, right brain – previously
unavailable material.
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INTERNAL FAMILY SYSTEMS INNOVATIONS
Unlock the unconscious
7. Integrate disowned parts of self-consolidation.
8. Release of potential residing within
9. Establish a cohesive coherent
autobiographical narrative.
10. Establish an “earned secure” attachment with
self and parts as well as affect regulation.
11. Integrated affect and cognition.
6.
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INTERNAL FAMILY SYSTEMS INNOVATIONS
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.
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ATTACHMENT
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BOWLBY

Attachment systems in infancy prepare to
regulate arousal by effective utilization of
others for self-soothing and self-control.
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CRAVING
The psychologic distress underlying the craving is
the result of an inability to metabolize negative
emotions utilizing the attachment system (Fosha,
2003; Neborsky, 2003). Successful therapy
restores secure attachment which allows for
intimate relationships to utilize for self-soothing.
Injury to the attachment system is the result of
difficulties between the caregiver and child that
results in segregated systems of attachment and
dissociated self-systems. The result is a variant of
narcissism or a false-self personality organization
as a means of avoiding the need for attachment.
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SECURE ATTACHMENT

Because their caretakers have been routinely available
to them, sensitive to their signals, and response with
some degree of reliability (though by no means is
perfect care required), these infants develop a
confidence that supportive care is available to them.

They expect that when a need arises, help will be
available. If they do become threatened or distressed,
the caregiver will help them regain equilibrium.

Such confident expectations are precisely what is meant
by attachment security.
L. Alan Stroufe, 2000
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ATTACHMENT AND SELF FANTASY
Attachment becomes a highly structured vehicle
through which increasingly complex information
about the self becomes available.
Developmentally, attachment contributes to
acquired selfhood structures.
Children abstract their uniqueness from the
experience of being involved in a unique
relationship with and then transform that
relationship to identity.
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MIDDLE ADOLESCENCE
“What am I as a person? You’re probably not going to understand. I’m complicated! With my really close friends, I am very
tolerant. I mean I’m pretty understanding and caring. With a group of friends, I’m rowdier. I’m also usually friendly and cheerful
but I can get pretty obnoxious and intolerant if I don’t like how they are acting. I’d like to be cheerful and tolerant all of the time,
that’s the kind of person I want to be, and I’m disappointed in myself when I’m not. At school, I’m serious, even studious every
now and then, but on the other hand, I’m a goof-off too, because if you are too studious, you won’t be popular. So I go back and
forth, which means I don’t do well in terms of my grades. But that causes problems at home, where I’m pretty anxious around
my parents. They expect me to get all A’s and get pretty annoyed with me when report cards come out. I care what they think
about me, and so then I get down on myself, but it’s not fair! I mean I worry about how I should get better grades, but I’d be
mortified in the eyes of my friends if I did too well. So I’m usually pretty stressed out at home, and can even get very sarcastic,
especially when my parents get on my case. But I really don’t understand how I can switch so fast from being cheerful with my
friends, then coming home and feeling anxious, and then getting frustrated and sarcastic with my parents. Which one is the real
me? I have the same question when I am around boys. Sometimes I feel phony. Say I think some guy might be interested in
asking me out. I try to act different, like Madonna. I’ll be a real extrovert, fun-loving and even flirtatious, and I think I am really
good-looking. And then everybody and I mean everybody else is looking at me like they think I am totally weird! They don’t act
like they think that I’m attractive so I end up thinking that I look terrible. I just hate myself when that happens! Because it gets
worse! Then I get self conscious and embarrassed and become radically introverted, and I don’t know who I really am. Am I just
acting like an extrovert, am I just trying to impress them, when I am really an introvert? But I don’t really care what they think,
anyway. I mean, I don’t want to care, that is. I just want to know what my close friends think. I can be my true self with my close
friends. I can’t be my real self with my parents. They don’t understand me. What do they know what its like to be a teenager?
They treat me like I’m still a kid. At least at school, people treat you more like you’re an adult. That gets confusing, though. I
mean, which am I? When you are 15, are you still a kid or an adult? I have a part-time job and the people there treat me like an
adult. I want them to approve of me, so I’m very responsible at work, which makes me feel good about myself there. But then I
go out with my friends and I get pretty crazy and irresponsible. So which am I, responsible or irresponsible? How can the same
person be both? If my parents knew how immature I act sometimes, they would ground me forever, particularly my father. I’m
real distant with him. I’m pretty close to my mother though. But it’s being distant with one parent and close to the other,
especially if we are together, like talking at dinner. Even though I’m close to my mother, I’m still pretty secretive about some
things, particularly the things about myself that confuse me. So I think a lot about who is the real me, and sometimes I try to
figure out when I write in my diary, but I can’t resolve it. There are days when I wish I could just become immune to myself!
The Construction of Self
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MAIN
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.
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MAIN, CONT
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.
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MAIN, CONT
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.
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AVOIDANCE (C)

In the avoidant individual, therefore, reiterated
refusal of his request for help has made him
defensive with regard to his attachment needs.
Often by discounting them and making a show
of self-sufficiency, allows avoidance of new
refusals and reduces the risk that the other
may become irritated or leave forever.
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RESISTANCE-AMBIVALENT (B)

The resistant-ambivalent patient’s attachment
needs, on the other hand, has received
contradictory and unpredictable responses.
Moments of comforting physical and emotional
intimacy have alternated with moments of
despairing aloneness and lack of attunement.
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DISORIENTED-DISORGANIZED (D)

The disoriented-disorganized patient is even
more complex. Searching for and maintaining
intimacy triggers unbearable anxiety and fears
that make it difficult to satisfy his attachment
needs. His pattern has its roots in traumatic
attachment.
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DISMISSING OF ATTACHMENT











Idealization
Dismissing derogation
Lack of memory
Response appears abstract and remote from memories or
feeling
Regard self as strong, independent, normal
Little articulation of hurt, distress or needing
Endorsement of negative aspects of parents behavior
Minimizing or downplaying negative experiences
Positive wrap-up
No negative effects
Made me more independent
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OGAWA RESEARCH


126 children with disorganized attachment followed
until age 19. Prediction of Dissociative Disorder from
maternal unavailability and disorganized attachment in
the first 24 months of life was more predictive than
trauma. Trauma history did not add to the prediction, of
dissociation after disorganized attachment.
Specifically maternal Dissociative symptoms, disrupted
maternal affective communication, maternal lack of
involvement at 12 months, significantly contributed 5
other measures non >19
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DISORGANIZED ATTACHMENT

Drawing close to the other is thus accompanied
by the expectation of re-experiencing the
anxiety of unpredictable availability, the fear
that allowing oneself to ask for and obtain care
may mean giving up one’s identity and
independence.
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ADULT ATTACHMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
Describe your relationship with your parents as a young
child (i.e., derogation, relevance violation, loving).
5 adjectives to describe your relationship with
mother/father as young child (i.e., idealization,
dysfunctional).
Your first remembered separation from parent
Ever frightened or worried as a child
Did you tell your parents
Any close relative or loved one die
How did you respond
Do you think loss has had an affect on your personality
What is your relationship like with parents now
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ATTACHMENT
82% of infants who were maltreated were
classified disorganized (Carlson, 1989).
 Strange situation at 12 months predicted AAI
results reverse, 75% accuracy (Main, 1985).
 AAI predicts strange situation results before
children are born (Lizendorn, 1995).
 Strange situation consistency is changed by
trauma, in the negative direction.
 Psychotherapy can transfer insecure into secure
attachment in adults (Hesse, 1999)

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THERAPISTS JOB WITH ATTACHMENT TRAUMA
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)
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META PSYCHOLOGY:
DECONSTRUCT HOW AND WHY –
AND WHAT IS THERAPEUTIC ABOUT THERAPY?
WHAT IS CHANGED?
HOW TO CHANGE IT?
WHY DID IT NOT WORK?
a.
Self – accessing the Self (of client & therapist)
b. Affect – Regulation/Soothing/Awareness
c. Relationship – Bonding, Attachment
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METACOGNITIONAL
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.
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REFLECTIVE FUNCTION (FONAGY)





Relates to our capacity for insight and empathy.
Parents with high reflective function have secure
children.
Buffers early trauma and diminishes
intergenerational transmission.
Allows us to feel our feelings and reflect upon the
meaning.
Allows parents to
a.
b.
c.
Understand child’s distress
Can then, cope with alleviate the distress
Understand that the parents state of mind becomes the
child’s.
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FACILITATING “EARNED SECURE ATTACHMENT”
1.
Facilitating a coherent cohesive and reflective narrative
2.
Neutralizing idealization and loyalties to family system
3.
Facilitating metacognition
4.
Facilitating self-compassion
5.
Utilizing an attuned relationship with therapist as a home base for exploration of developmental change
6.
Asking others for self-soothing under stress
7.
Re-examine detailed beliefs about self and others
8.
Relinquishing defense of dissociation and re-associating affect, sensation, and knowledge
9.
Not inhibit or minimize internal experiences and learn to tolerate, express attachment and related emotions
10.
Resolution of internal relational exchanges between parts of self
11.
Internalize self-parenting, is forgiving of mistakes, listens to disowned parts of self
12.
Sets and teaches healthy boundaries
13.
Resolution of significant losses in one’s life
14.
Deconstruct the attachment patterns of the past and construct new ones
15.
Integrate traumatic attachments, losses and re-enactments.
16.
Establishing appropriate entitlements related to having needs, expressing needs, and meeting needs
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TRAUMA WORK
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AFFECT AS A “TRAILHEAD”
Every deep desire, every powerful emotion, gives a
trail into the unconscious. Usually there is only oneway traffic: outbound, toward the world of
sensation and action. But we can follow the trail to
its source by going against the current. With this
desire to go against desire, to buck the demands of
biological conditioning, the journey of selfrealization begins in earnest.
Meditation in Action
Eknath Easwaran
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DISSOCIATION AND SELF-DEVELOPMENT
Sexual and physical abuse at the hands of family
members cause the child to split off experiences,
relegating them to an inaccessible part of self.
Dissociation of one’s experiences sets the stage for loss
of one’s true self. The true self becomes corroded with
inner badness and is concealed at all costs. Persistent
attempts to be good, thus leading to a socially
acceptable self, are experienced as non-authentic. The
adolescent is compelled with the demand to create
multiple selves in different contexts.
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REPETITION
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
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REENACTMENT 1
There was a time at age 10 (right before I almost got beat to death and put into a foster home) that I was babysitting while my parents
were out of town. I felt so lonely and scared. I had an empty funny feeling inside I had to fill – I didn’t know what it was. I found myself in
the room where my younger brother was asleep. He evidently was sleeping nude because I really don’t remember taking his unders down.
I touched him down there so we could “fill each other”. I felt sick as I started doing this but kept on a couple of seconds more. He was
asleep and looked so innocent that I really felt disgusted and I stopped. I got really sick and ran crying because I was so ashamed. I
wonder if he remembers it. I’m sure he does.
I did the same thing one time with my younger sister. My older sister had taught me how to masturbate when I was 5 so men wouldn’t
touch me. I was changing my younger sister’s panties and when I pulled them up I guess I was “triggered” into wanting to “break” her in.
(So she wouldn’t hurt? Or to get her used to it? Or maybe I even wondered what my older sister had gotten out of touching me?) I
touched her and realized I didn’t like what I was doing. I felt sick in my stomach – guilty – ashamed and sorry for what I had attempted to
do – or had started to do. I never even thought these things again – ever – with any children.
One day (at age 21?)…my mother lived across the street from me. She would ask my husband if I could go drinking with her so I could
drive home and it was okay with him.
I was over at her house. I always had a “need” to be close to mommy and hoped there would be that one day she would hold and comfort
me – and tell me she was so sorry for what happened to me. That day she said, “Let’s go lay down.” I said, “OK!” (I remember thinking – I
was going to take a nap with my mommy!
We were lying down. I had my clothes on. She was lying there with her eyes shut. I glanced down and saw she wasn’t covered. She was
either undressed or dressed very seductively. Her leg moved out a little (while she was sleeping?).
All of a sudden I felt anger, a rage and an overwhelming feeling I can’t describe. I wanted to molest my mother. I wanted to do to her what
had been done to me by my father and stepfather. She had allowed it to happen – she knew about it all along. I wanted to rape her. I
reached over and put my hand on her crotch and started to put my finger in her. She squirmed with a moan of desire and I snapped into
reality. I was overwhelmed with feelings of a sickness in my stomach. I felt both shame and guilt – I don’t know. I ran out. I got sick and
went home. It has never been mentioned again.
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REENACTMENT 2
As a child I would lock myself in the bathroom and play with dolls the way I had been touched. One would be
in bed, the other would fondle him or her. I couldn’t understand why I did this or where it came from. I was
ashamed of this awareness, but couldn’t help acting it out, I thought the shame belonged inside me, that the
awareness was created solely from me.
During teenage, I turned to boys to duplicate some of those feelings – of being cared for or loved. I knew I
was fooling myself, I felt the emptiness I was left with after my liaisons with boys, but was all I had. I was
desperate to feel loved. My need for affection was so great, I couldn’t say not to many people and I rarely
did.
Do you want to know why I had my tubes tied at age 18? Because whenever I thought of myself around my
child, a mental image would always appear. The image was clear, and I believed in its certainty. I saw myself
not being able to control the thing that lived in me from you. I saw myself fondling sexually my own infant.
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REENACTMENT 3
It was because I couldn’t lay still when she was putting that thing in my pee-pee. I sat in my bed eating chips
and wondering who was going to help me, eating peanut butter to take the taste of her pussy out of my
mouth, eating more peanut butter because I can’t get the taste of Petey’s blood out of my mouth. Counting
all the holes in the ceiling, wondering who I was going to talk to, eating handfuls of raw oatmeal, wondering
who was going to sit with me in the window, wandering if I’d really, really had enough goodness in me to lay
really still. I remember eating peanuts one by one counting them as I went 380 peanuts all together. I ate
them. It was ending the loneliness and guilt for having Petey slaughtered in front of my eyes. Watching his
throat being sliced and 380 peanuts later I decided it was my fault, and I wanted my mouth to be drenched in
his blood, in my mouth I wanted to be back in the blood, I was bad. I felt like I was a fat bitch and I felt guilty
for having the need to eat the candy, I didn’t deserve to have the food I had, I was very bad, 12 x 12 = 144,
12 x 6 = 72, 12 x 3 = 36 – half of half. I wanted to cry, because I didn’t have any tears I was afraid to cry, I
hated the idea of who was going to protect me after my father left my bed at night. Who was going to be
there to pet when they brought back to the house in the wee hours of the morning. Who was going to lick my
face and make me giggle. No one, I was alone, totally alone 12 x 4 = 48, 6 x 6 = 36 – no one. I want to cry
but I’m afraid – I’ll eat that’s what I’ll do, I’ll eat this and it will make me feel good to have this in my belly.
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
Trauma related to structural dissociation then,
is a deficiency in the cohesiveness and
flexibility of the personality structure. The lack
of cohesion and integration of the personality
manifests itself most clearly in the alteration
between the vivid re-experiencing of the
traumatic event and avoidance of reminders of
the traumatic experience
(van der Hart et al. 2006)
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
If ego states are split off, projected, rejected,
indulged or otherwise unassimilated, they
become black holes that absorb fear and
create the defensive posture of the isolated self
– unable to make satisfying contact with one’s
self or others. When split-off ego states are
made conscious, accepted and tolerated or
integrated, the self can be at one, and
compassion can be released.
Epstein, 1995
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EATING DISORDER IS…
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Inability to express internal distress to others…
Way to shout help…
Way to get love and attention…
Fear of growing up and assuming adulthood…
Not having an identity, an anchor…
Not having the structural capacities to make it as an
adult…
Fear or overwhelming terror to be…
A manifestation of unresolved trauma…
A manifestation of parent’s unfinished business…
A way of separating from mother…
A way of identifying with mother and father…
A way of staying connected to mother to protect her
from her own emptiness…
A substitute for love…
A good girl’s method of rebellion…
A manifestation of cravings due to inner emptiness…
A relief from depression…
A way of coping with loneliness – a substitute
relationship…
A solution to internal double binds – I must but I
can’t…
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An escape from requiring perfection…
A manifestation of the need to care for a parent and
simultaneously to escape…
A susceptibility to influence and needing to please
people, while people reject you and are never pleased…
An Obsessive Compulsive Disorder…
The manifestation of an insoluble double-bind…
Having something that is one’s own that no one else can
touch…
A need for father’s presence…
A desire to maintain a child’s body…
A sacrifice of authentic needs and desires in order to
seek illusion of ideal…
A way to cope with or cover up other horrific, intrusive
thoughts or memories…
An attempt to waste away…
An attempt at acquiring perfection…
A holding pattern
A question: will anyone notice?
“Safety” (that can kill)
A distancer
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“SELF-EMPATHY” - The internalizing (evoking) of
the attentive, validating, caring relationship to
oneself. This involves helping the client
articulate her experience and bring it into her
own internal relational context.
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INTER-PSYCHIC INTIMACY
(between the couple)
vs.
INTRA-PSYCHIC INTIMACY
(within the individual)
56
TRAUMA RECOVERY DOMAINS
(MARY HARVEY, Ph.D.)
1.
2.
3.
4.
Authority Over Memory – can take event from the past,
talk about it with sense of empowerment.
Integration of Memory and Affect – can feel some
appropriate affect with cognition. New affect (adultoriented) (1995).
Affect Tolerance and Trauma – Related Affect – feeling
no longer overwhelmed, get overwhelmed and back
into the trauma, ignore the walk into danger.
Symptom Mastery – Hypervigilant, anxiety, depression,
dissociation, somatic, compulsivity, how much do we
need to measure remission.
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TRAUMA RECOVERY DOMAINS
(MARY HARVEY, Ph.D.)
5.
6.
7.
8.
Self-esteem – capacity for self-care and
regard, properly eat, exercise, sleep and selfsoothe.
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.
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STEPS IN TRAUMA RESOLUTION
1.
2.
3.
4.
5.
6.
Develop safety and trust.
Establish grounding and containment
Establish control over out-of-control behavior
Teach cognitive errors, affect modulation and life
skills.
Establish relationship between injured and
executive selves.
Allow injured self to “tell,” reassociating affect,
sensation and knowledge.
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STEPS IN TRAUMA RESOLUTION
6.
7.
8.
9.
10.
11.
Permit the injured and adult selves to reprocess
information with therapist assistance.
Encourage release of affect embedded in
memory.
Encourage catharsis.
Encourage confrontation.
Encourage presentation.
Facilitate greater integration.
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STUCKPOINTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
How am I avoiding remembering?
How am I avoiding feelings?
How am I avoiding talking about it?
How am I minimizing?
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 those who hurt me?
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?
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