Transcript Presentation (PowerPoint)

UNDERSTANDING AND WORKING WITH
COMPLEX TRAUMA & DISSOCIATION
Lynette S. Danylchuk, PhD
Kevin J. Connors, MS, MFT
INTRODUCTION
 The Difficult Client
 Chaotic Lifestyle
 Frequent Crisis Calls
 Suicidal & Para-suicidal
Behaviors
 Manipulative
 Non-Compliant/Oppositional
INTRODUCTION
 The Borderline Client
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Black or White/All or Nothing Thinking
Extreme Ambivalence
Extreme Labiality of Affect
Approach/Avoidance
Self-Harm Behaviors
INTRODUCTION
 The Dissociative Client
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Spaced Out/Foggy
Identity Confusion
Memory Problems
Hears Voices
History of Treatment Failures
THE PROBLEM
 Most Mental Health Practitioners See
Dissociation As Extremely Rare
 Dissociation is seen as DID
 Their Viewpoint Informs the General Public
THE PROBLEM
 Clients with Complex Relational Trauma
Receive Inappropriate Treatment
 Given Negative Labels
 Treated for Surface Symptoms
TAKE HOME MESSAGE
By having an expanded and
comprehensive understanding
of trauma based disorders and
dissociative defenses,
more clients will get better treatment.
WHO ARE THEY?
 Possible Client Populations
 Alcohol/Substance Abuse
 Intimate Partner Violence
 Eating Disorders
COMPLEX TRAUMA
 Impact of Trauma
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Natural Trauma vs. Interpersonal Trauma
Loss of Safety
Loss of Invulnerability
Shattering of Worldview
MEANING AND IMPACT OF COMPLEX
INTERPERSONAL TRAUMA
FREUD ON PSYCHIC TRAUMA
"An experience which within a short
period of time presents the mind
with an increase of stimulus too
powerful to be dealt with or
worked off in the normal way, and
thus must result in permanent
disturbances of the manner in
which energy operates" (1916).
Phenomenological Presentation –
What does it look like?
 PTSD Symptoms – Siegel’s Window of
Tolerance
 Hyper-arousal
 Hypo-arousal
 Intrusive Flashbacks
Window of Tolerance
Window of Tolerance
COMPLEX TRAUMA
 Relational Trauma
 The closer the relationship between perpetrator
& victim the more devastating the damage
 Betrayal
 Loss of Trust
COMPLEX TRAUMA
 Developmental Trauma
 Age of Onset
 Frequency of Abuse
 Lack of Nurturing and
Healing Responses
Dissociative Defenses
 Conceptualizations of Dissociation
 Disruption of self awareness
 Disruption of relatedness
they embody painful experiences, but become autonomous by virtue
of their segregation from the main stream of consciousness . . .
..(they) did not belong to the personal consciousness, were not
connected to the personal perception, and lacked the personality's
sense of self...
~ P. Janet
DISSOCIATION
 Dissociative Symptomology
 Amnesia/ Trance States
 Depersonalization/
Derealization
 Fugue States
 Ego States
 Dissociative Identity Disorder
 DDNOS
Phenomenological Presentation –
What does it look like?
 Relational Symptoms
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Borderline features
Paranoid features
Narcissistic features
Asocial features
DIAGNOSIS
 Frequent Misdiagnosis
 3.6 To 6.8 Years In Mental Health System Prior
To Accurate Diagnosis
 3.2 Diagnoses Prior To Accurate Diagnosis
 High Co-morbidity
DIAGNOSIS
 Dissociation
 Dissociative Experiences Scale-II (Carlson & Putnam)
 Multidimensional Inventory of Dissociation version 6
(Dell)
 Somatoform Dissociation Questionnaire – 20 (Neijuis)
 Somatoform Dissociation Questionnaire - 5 (Neijuis)
 Clinical Interviews
 Dissociative Disorders Interview Schedule (Ross)
 Structured Clinical Interview-Dissociative Disorders (Steinberg)
DIAGNOSIS
 Post Traumatic Stress Disorder
 LA Symptom Checklist (Foy)
 Trauma Symptom Checklist (Briere)
 Adverse Childhood Experiences Scale
(Anda & Feletti)
Diagnosis
 Differential Diagnosis Considerations
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Schizophrenia
Bi-Polar Disorder
Paranoid Disorder
Major Depression
Borderline Personality Disorder
Psychosis
DISSOCIATION &
SUBSTANCE ABUSE
Authors
Benishek &
Wichowki
Population
Studied
N
Substance
Abusers
51
Tamar-Gurol,
Sar, Karadag,
Evren &
Substance
Karagoz
Abusers
104
Tests
Results
DES
25 % >15
DES,
DDIS &
SCID-D
46%>30
DISSOCIATION &
SUBSTANCE ABUSE
 Alcohol or Substance Abuse in Families
Increases Likelihood of Interpersonal
Violence.
 Intimate Partner Violence
 Child Abuse
DISSOCIATION &
IPV
Authors
Connors,
Kemper,
Hamel &
Ensign
Population
Studied
Intimate
Partner
Violence –
Victims
N
95
Tests
DES,
CTS, CAT
Trauma
History
Results
31.6 %
> DES 20
18.9%
> DES Taxon
Score .55:
DISSOCIATION &
IPV
 Intimate Partner Violence is Relational
Trauma
 Dissociative Clients at Greater Risk of Revictimization
 Dissociative Clients Engage in More
Violence with Battering Partners
 IPV-Offenders May Dissociate During
Assaults
DISSOCIATION &
EATING DISORDERS
Authors
Beato,
Cano,&
Belmonte
Dalle Grave,
Tosico,
& Bartocci
Vanderlinden,
Van der Hart,
& Varga
Population
Studied
Eating
Disorders
Eating
Disorders
Eating
Disorders
N
118
106
98
Tests
Results
DES,
30.5 % > 25
DIS-Q
22.6% had
severe
dissociative
symptoms
DIS-Q
12%
pathological
dissociative
experiences
DISSOCIATION &
EATING DISORDERS
 Sexual Abuse May Be a Factor in the
Development of Eating Disorders
 Traumatic Experiences More Prevalent
Among Clients with Bulimia & with Anorexia
Nervosa: Binge Eating-Purging Subtype
ETIOLOGY
 Neurobiology
 Hyper activation of Amygdala
 Hypothalamus, Pituitary Adrenal Overstimulation
 Increased Right Temporal
Lobe Functioning
ETIOLOGY
 Neurobiology
 Diminished Hippocampal
Functioning
 Impaired Broca’s Region
ETIOLOGY
 Relational /Developmental Trauma
 Trauma as That Which Overwhelms One’s Ability
to Assimilate & Accommodate
 Interpersonal vs. Natural Trauma
 Betrayal Trauma
 Childhood Abuse
ETIOLOGY
 Disorganized Attachment
 Attachment Theory
 Styles of Attachment
 Effects of Attachment on Adult Relationships
ETIOLOGY
 Dysfunctional
Family Dynamics
 ACA Issues
 Dysfunctional
Social &
Interpersonal
Learning
 Don’t Think,
Don’t Feel,
Don’t Tell
Ego State Model
DISSOCIATION
 Component Model
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Behavior
Affect
Sensation
Knowledge
B
S
A
DISSOCIATION
 Sequential Model
 Ego States/Alters Across Time
 Degrees of Dissociative Barriers
SEQUENTIAL MODEL OF
DISSOCIATION
TRAUMATIC EVENT
TTIME
IME
Annie
Betty
Chuck
Dora
Baby Eek!
Florence
Annie
DISSOCIATION
 Structural Dissociation
 Self as Process
 Trauma Results in a
Diminished Sense of Self
 Tiered Levels of Dissociative
Disorganization of Self
♦ Tier I: ANP & EP
♦ Tier II: ANP & EP’s
♦ Tier III: ANP’s & EP’s
TREATMENT
 Need for On-going Support & Consultation
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ISSTD Treatment Guidelines
Component Chapters
Study Groups
Annual Conference
Regional Seminars
www.ISST-D.org
Impact of Abuse on Attachment and
Relationships
 Disorganized Attachment Leads to
Multiple Models of Attachment
 Attachment and Avoidance Become
Enmeshed
 Inability to Transcend “Good Parent/Bad
Parent” Paradigm
 Disconnection From Normal Relationships
Stockholm Syndrome
(Graham & Rawlings, 91)
 Victim Feels Threatened and Fearful
for Survival
 Victim Feels Isolated
 Victim Fells Dependent Upon
Perpetrator
for Safety
 Perpetrator Shows Limited Kindness
 Victim Bonds to Perpetrator
 Victim Adopts Beliefs/Rhetoric &
Perceptions of Perpetrator
Externalized Locus of Control
 Client Symptomology
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Lack internal control
Attempt to control others
Assume responsibility for others
Alternately seeks and rejects external control
Externalized Locus of Control
 Perpetrator Dynamics (Sgroi, 82
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Dysfunctional boundaries
Displacement of responsibility
Isolation
Discounted/distorted feelings
Non-validation of reality
Mey, 82 )
Shame
 Conceptualizations of Shame
 Inherent sense of flawed self
 Shame is about Self; Guilt is
about an act (Lewis, 71)
 Shame as the basis for defense
mechanisms (Wurmser, 81)
 Shame as an attenuator of affect
(Nathanson, 92)
Shame
 Denial of Abuse
Maintains Shame
 Perpetrator denial
 Familial /societal denial
 Self denial
Shame
 Denial of Abuse Maintains Shame
 Therapist denial (C. Dalenberg, 2000)
♦ Fears of counter transference
♦ Fears of legal liability
♦ Fear of the overwhelming pain
♦ Silence and the failure of language
Shame
 Shame and Powerlessness
 E. Erickson: Autonomy vs. Shame
♦ If not able to make change then no autonomy
(powerless)
♦ If powerless to make changes (lacking autonomy),
then shame filled
Shame
 Shame and Powerlessness
 Nathanson: Shame vs. Pride
♦ Shame inhibits experiencing the
positive affects
♦ Success leads to affect: enjoymentjoy
♦ Competence & pleasure antidotes to
shame
Shame
 Shame and Powerlessness
 Paradoxical relationship between
shame and powerlessness
♦ Powerlessness leads to shame
♦ Shame is held to avoid powerlessness
♦ Accepting powerlessness to relieve
shame
Addiction to Chaos
(van der Kolk, 87)
 Examples of Chaos
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Eating disorders
Chemical dependency
Self-injurious behavior
Dysfunctional relationships
Identification with aggressor
Addiction to anger
Alexithymia
 Difficulty Identifying Feelings
 Difficulty Expressing Feelings
 Affect Storm
 Connection to Somatoform
Dissociation
(Clayton , 04)
INTRODUCTION
 Three Stage Trauma Model
 Safety and Stability
 Remembering and Mourning
 Reconnecting
INTRODUCTION
 Trauma Treatment Triggers Trauma
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Treatment frame is safe but not too safe
There will be complications
Therapists will step in it.
Rupture repair process is
rich and necessary
UNDERLYING THEMES / GUIDING
LIGHTS
 Transference and Countertransference
 Non-linear Nature of Trauma Therapy
 Replication of Dysfunctional Trauma
Dynamics
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Addictive Patterns of Arousal
Power, Powerlessness,
Choices and Shame
Shift from Ordeal to Recovery
THERAPEUTIC RELATIONSHIP
 Secure Attachment
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Consistent Caring Presence
Sustained Connection
THERAPEUTIC RELATIONSHIP
 Boundaries
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Predictable
Not too rigid, not too loose
Negotiable
Create safe environment within which to meet
STAGE ONE TREATMENT ISSUES
 Intrusive Flashbacks
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Grounding
Container Imagery
Divide & Put Away
(Controlled Dissociation)
Manipulating Memories
STAGE ONE TREATMENT ISSUES
 Self harm
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Explore Intent
Saying What Can’t Be Said
Short-term vs. Long Term Effectiveness
STAGE ONE TREATMENT ISSUES
 Fear of Disclosure
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To Be Seen is to:
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Give away power
Be in danger
Create vulnerability
STAGE ONE TREATMENT ISSUES
 Fear of Disclosure
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To Say It Out Loud is to:
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Connect to ones’ self and one’s life
Make events real
Make emotions more intense
STAGE ONE TREATMENT ISSUES
 Lack of Internal Cooperation
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Honor the Resistance/Honor the Fear
Seeing the Whole Person as Conflicted
STAGE ONE TREATMENT ISSUES
 Alexithymia
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Teaching Affective Language
Develop Somatic Awareness
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Distinguish between hyper & hypo arousal
STAGE ONE TREATMENT ISSUES
 Affect Modulation and Self Soothing
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Relaxation exercise
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Breathing
Physical interventions
Hypnotic Interventions
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Siphon off
Energy transfer
Internal support system
Emotional rheostat
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Transference and Countertransference
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Know your own tendencies
What is you and what is not you
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Non Linear Nature of Trauma Therapy
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Sense of progress or lack of progress
Same feelings over & over
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Replication of Dysfunctional
Trauma Dynamics
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Replay Karpman’s Triangle
Lead to therapist weakening boundaries
Enmeshed in client’s system
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Addictive Patterns of Arousal
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Chaos as defense
Loss of drama = Loss of life
Enmeshment vs intimacy
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Power, Powerlessness,
Choices and Shame
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Identify options
Reaction vs choice
Shame
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Defense
Holding shame holds onto the meaning and
the value of the loss and abuse
UNDERLYING THEMES/
GUIDING LIGHTS (a reprise)
 Shift from Ordeal to Recovery
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Recognizing the trauma is past
Agency over trauma vs. being controlled by
trauma
Integrate vs. exorcise
STAGE 2:
REMEMBRANCE
AND MOURNING
ABOUT THE CLIENT
 They were traumatized
 They are not the trauma
 They are not the problem
REMEMBRANCE:
General Considerations
 Integration not Exorcism
 Sometimes the Bad Guys are the Best
 Value the Need to Identify with the
Perpetrator
REMEMBRANCE:
General Considerations
 Not Changing History
 Dealing with what was,
 Grieving what was not.
 What was learned may (or may not) be useful in
different ways in the present.
 What was missed needs to be learned – earned
attachment, relational skills
REMEMBRANCE:
General Considerations
 Do Not Need All the Memories
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Use the Present to Tap into the Past
Identify Repetitive Patterns of Behavior
Consciousness Raising
REMEMBRANCE:
General Considerations
 Need to Understand the Meaning of the
Trauma Event
 Unbridled expression of emotion (without attached
meaning) is unhealthy and
re-traumatizing
 Recounting without affect remains disconnected &
dissociated
 Assembling all the components of the trauma
includes the meaning assigned at the time of the
trauma. (Think BASK)
REMEMBRANCE:
General Considerations
 Pacing
 Resist the urge to turn therapy into
another ordeal
 The slower you go, the faster you get
there
 Trauma is not a paced experience
 Trauma is subjectively felt as if there
is no beginning, middle, and end
 Learning to pace one’s self heals of
the effects of trauma
REMEMBRANCE:
General Considerations
 Safety
 Critical Therapeutic
Issues
 Trauma Treatment
Triggers Trauma
 Therapists Will
Make Mistakes
REMEMBRANCE:
Safety
 Dealing with Overwhelming Emotions
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Grounding exercises,
The power of relationship
Learning about the body and mind
How to calm the self,
Become more present
REMEMBRANCE:
Safety
 Affect regulation
 Name the fear/affect
 Identify where in your body you are experiencing
the fear/affect,
 Identify where in your body you are NOT
experiencing the fear/affect,
 Shift your focus between the two
REMEMBRANCE:
Safety
 Differentiating Past from Present
 Cell Phones
 Newspapers/Magazines
 “Where’s the Doorknob?”
Therapists Will Make Mistakes
 Be mindful of when & how
 Be able to say, “I’m sorry.”
 Repair of therapeutic ruptures is as
important as any other piece of good
therapy
 A golden opportunity to strengthen the
therapeutic alliance
REMEMBRANCE:
Methods
 Assembling Dissociative Components
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Non-leading Questions
When to talk about ‘why’
Exploring the recalled event
REMEMBRANCE:
Methods
 Moving Forward &
Backward to
Complete
Beginning, Middle &
End
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Allowing non-linear
processing
Develop a coherent
narrative
REMEMBRANCE:
Methods
 Moving Forward & Backward to Complete
Beginning, Middle & End
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Trauma memories tend to be a repeating loop
of a portion of the event
Identify the context and finding the frame of
reference
REMEMBRANCE:
Methods
 Moving Forward &
Backward to Complete
Beginning, Middle &
End
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All along the way,
existential issues arise
and need to be dealt
with
Stage II will often
activate Stage I needs
REMEMBRANCE:
Methods
 Sharing Across Alter Personalities
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Metaphors for helping
Metaphors to create a sense of oneness out of
many and value all within
REMEMBRANCE:
Specialized Techniques
Caveat:
 Tools, not panaceas. Use with wisdom and caution.
 Many new specialized techniques can work well with
severely traumatized people, but they must be used
with the awareness and cooperation of the client’s
system.
 Severely traumatized people are avoiding their pain,
etc. for a good reason.
 The desire to be fixed, quickly, without pain can
cause therapists and clients to use a technique too
much or too soon.
REMEMBRANCE:
Specialized Techniques
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Hypnosis
EMDR
Somatic Therapies
Prolonged Exposure
MOURNING:
GRIEF
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The intensity of grief
Self-soothing
Key questions
Therapist’s ability to stay present
MOURNING:
Why Me?
 Perpetrators and
Narcissism
 Karpman’s
Triangle
RESCUER
PERSECUTOR
VICTIM
MOURNING:
What Does It All Mean?
 Normalize the reactions and learned
behaviors.
 Developmental process happening within
therapy
 Finding Strength
MOURNING:
Control
 Locus of Control Issues
 Explore what can and can’t be controlled
 Shifting shame to another areas of life give
the illusion of control
MOURNING:
Shame
 Shame as inhibitor:
stifles joy,
happiness, any kind
of vulnerability.
 Nathanson’s shame
diagram – act out,
act in, blame
others, blame self.
MOURNING:
Shame
 Keeps the trauma stuck.
 Shame avoids Powerlessness
MOURNING:
Shame
 Therapist needs to be able to sit with the
shame
 Explore culpability – where responsibility
truly resides
 Explore reality of choices
MOURNING:
Shame
 Challenging Core Trauma Beliefs
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Identify survival response
I’m bad, I deserved it
Powerlessness
Role within the family
Stage 3: Integration
 Not the end of therapy, but the stage that
most resembles therapy with nondissociative people.
 Loneliness, mourning the loss of ‘others’
inside.
 ‘who am I?’ questions, learning to relate as
a whole person, from the inside out, finding
meaning and purpose, working on
relationships.
The Impact of
Chronic Interpersonal Trauma
 Strips the Ability to be in
Community
 No attachment = No connection
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In the natural world, this would
mean certain death
To the trauma survivor this is felt
as complete annihilation
People exclude others who are
seen as excluded in other to avoid
the reality of our own personal
human needs.
The Impact of
Chronic Interpersonal Trauma
 Abandonment, Shame, and Powerlessness
are the key Elements
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Abandonment: Not wanted, not included
Shame: Not worthy
Powerlessness: Not able to build a bridge back
The Impact of
Chronic Interpersonal Trauma
 Therapy Builds the Bridge
 The Therapeutic Alliance Creates
Community
“Paradoxically,
trauma both occurs
in the context of a relationship
and can only be healed
in the context of a relationship”
ISSTD Treatment
Guidelines
are available at
our website
www. ISST-D. org
CONTACT US
Lynette S Danylchuk, PhD
[email protected]
Kevin J Connors, MS, MFT
[email protected]