Presentation on theme: "Heather Davediuk Gingrich, Ph.D."— Presentation transcript:
1Heather Davediuk Gingrich, Ph.D. www.heathergingrich.com Restoring the Shattered Self: The Treatment of Complex Trauma AACC National Conference, 2014April 4, 2013Heather Davediuk Gingrich, Ph.D.Denver SeminaryRestoring the Shattered Self
2My Background in this Specialization Sexual abuse survivorsDissociative disordersOther trauma survivors (see Gingrich, 2002)Research on dissociation and trauma in the PhilippinesRecognition of overlap in treatment techniques
4Trauma Psychology, Division 56, APA Trauma FieldComplex Traumatic Stress Disorder(Disorders of Extreme Stress)- multiple exposures- incest survivors- child abuse and rape- multi-faceted treatment approaches- International Society for the Study of Trauma and Dissociation (ISSTD)Posttraumatic Stress Disorder- even single exposure- natural disasters- rape incident- witnessing violence- combat veterans- primarily cognitive-behavioral treatments- International Society for Traumatic Stress Studies (ISTSS)Trauma Psychology, Division 56, APA
5Posttraumatic Stress Disorder: DSM-V Criteria Exposure to traumatic eventIntrusive Symptoms (at least 1)Avoidance Symptoms (at least 1)Negative Alterations in Cognitions and Mood (2 or more)Alterations in arousal and reactivity (2 or more)Symptom duration of more than 1 monthClinically significant distress/impairment in functioningSpecifiersWith dissociative symptoms (depersonalization or derealizationWith delayed expressionAmerican Psychiatric Association, 2013
6DSM-5 – Change in Criteria A Sexual assault listed as a possible traumatic eventResponse of fear, helplessness, or horror no longer included
7DSM-5 – Additional Symptom Cluster Negative thoughts and mood or feelingsa persistent and distorted sense of blame of self or othersestrangement from others or markedly diminished interest in activitiesan inability to remember key aspects of the event.
8DSM-5 PTSD Dissociative Subtype chosen when PTSD is seen with prominent dissociative symptomsdepersonalizationexperiences of feeling detached from one’s own mind or bodyderealizationexperiences in which the world seems unreal, dreamlike or distorted.
9Heather Davediuk Gingrich, Ph.D. www.heathergingrich.com April 4, 2013DSM-5-Definition of DissociationDisruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motorcontrol, and behavior.Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experienceThe DSM-IV definition of dissociation is (read slide)-CLICK focuses almost exclusively on dissociation as the compartmentalization of mental events, such as thoughts, feelings, memories and attitudes-I refer to this in my manuscript as psychological dissociation- there are some authors that also refer to somatoform dissociation - in DSM-IV this has been subsumed under somatoform disorders (e.g., conversion symptoms)CLICK – It is also important to distinguish between normal and pathological dissociationNormal – automatisms (factory workers – space out), absorption (so involved in a project you lose track of time) and imaginative involvement (can almost imagine yourself as one of the characters in the book or movie)Pathological – dissociative symptoms and disorders will be described later-especially a consideration in cross-cultural research- i.e., what is considered pathological in one culture is not necessarily pathological in another- this consideration was one of the reasons for including Objective 2 in this studyNormal versus Pathological DissociationRestoring the Shattered Self
10Why Talk About Dissociation? Used by victims of all kinds of traumaThere is a link between both peritraumatic dissociation and PTSD, in addition to a well-documented association between trauma and posttraumatic dissociation (see Gingrich, 2005)Dissociative subtype of PTSD in DSM-5Explanation for why treatment techniques for dissociative disorders can also be helpful for other trauma survivorsDSM-5 now lists a dissociative subtype
11CONTINUUM OF DISSOCIATION NORMALDISSOCIA-TIVEEPISODEACUTE STRESS DISORDER(up to 4 wks.)POSTTRAUMATIC STRESSDISORDER(4 weeks +)DISSOCIA-TIVE DISORDERDISSOCIA-TIVE DISORDERNOT OTHERWISESPECIFIEDDISSOCIA-TIVE IDENTITYhypnosisego statesautomatismschildhood imaginary playfear/terrorrepressionhighway hypnosissleepwalking!mystical/religious experiences (e.g., meditation, ecstatic experiences)flashbacksnumbness, detachment, absence of emotional responsereduced awareness of surroundings (dazed)derealizationdepersonalizationamnesia for aspects of the traumaDissociative amnesiaDissociative fugueDepersonali-zation disorderDDNOS with features of DIDPolyfrag-mented DDNOSDissociative trance disorderPossession trance disorderDIDPolyfrag-mented DIDAdapted from Braun, B. G. (1988)
12Developing the Capacity to Dissociate We are born unintegrated (i.e., dissociated)Healthy attachment leads to integration of behavioral statesImpact of child abuseDissociation as a defenseMental disorder- dissociative disorder/other disorder with dissociative symptomsPutnam, 1997
13Attachment Style and Dissociation Attuned, “good enough” parentingSecure attachment styleIntegration of self-statesInattentive/neglectful/abusive parentingInsecure (Ambivalent/Disorganized)attachment styleDissociated self-states(Gingrich, 2013)
14Dissociative Symptoms Amnesia: A specific and significant block of time that has passed but that cannot be accounted for by memoryDepersonalization: Sense of detachment from one’s self, e.g., a sense of looking at one’s self as if one is an outsiderDerealization: A feeling that one’s surroundings are strange or unreal.Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict about one’s identityIdentity alteration: Objective behavior indicating the assumption of different identities or ego states, much more distinct than different rolesSteinberg (1994).
15DSM-V Diagnoses Related to Dissociation Dissociative disordersDissociative amnesiaDepersonalization/derealization disorderDissociative identity disorder (DID)Dissociative disorder not otherwise specifiedSelected other disorders with significant dissociative symptomsPost-traumatic stress disorder (PTSD)Somatic symptom and related disordersSchizophreniaBorderline personality disorder (BPD)Others (e.g., eating and feeding, anxiety)
16BASK MODEL OF DISSOCIATION BehaviorAffect (emotions)Sensation (physical)KnowledgeFull, integrated memory includes all four re-associated components.Braun, 1988
17BASK - KNOWLEDGETrauma survivor has full or partial cognitive knowledge of traumatic eventCognitive knowledge of the trauma is dissociated from behavior, affect and sensationGenerally what people mean when they say “I remember”
18BASK - BEHAVIOR Behavior is dissociated from other aspects of memory Individual acts in a certain manner without knowing whyExamples:-avoiding intimate relationships-vomiting after sexual intercourse-dislike of particular foods
19BASK - AFFECT Affect is dissociated from other aspects of memory Example: feeling of fear for no apparent reason
20BASK – AFFECT (continued) There are no feelings attached to the cognitive knowledge of the memory-flat affect-matter-of-fact tone of voicee.g., can talk about being raped as though discussing the heat of the coming summer
21BASK - SENSATIONPhysical sensation is dissociated from other aspects of memoryIndividual may have cognitive knowledge of the traumatic event, be aware of related affect, and understand some behavior, but not remember the pain or pleasure associated with the traumaExamples:-body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained-sexual excitement
22BASK Model Behavior Affect Sensation Knowledge Behavior Affect Gingrich, H. D., 2013, p. 107
24Rationale for Phase-Oriented Model Premature trauma processing can lead to destabilizationHospitalizationInability to function in jobDifficulty parentingBasic coping capacities can be overwhelmed
25Three Phases Phase I – Safety and Stabilization Phase II – Processing of Traumatic MemoriesPhase III – Consolidation and Restoration
26Phase I – Safety and Stabilization Safety within the Therapeutic RelationshipDeveloping rapportFacilitative conditionsBecoming a safe personRemember that every client is uniqueKnow your limitationsGive advance warningRemaining a safe personKeep appropriate therapeutic boundariesConsultProtect confidentiality
27Phase I – Safety and Stabilization …2 Safety from OthersIdentifying healthy vs. unhealthy relationshipsHelping clients find physical safety
28Safety from Self and Symptoms Making sense of symptomsSymptoms as attempts at copingWarning signalsTherapeutic use of dissociationPotentially assess use of dissociationSomataform Dissociation Questionnaire (SDQ-5 or SDQ-20) (Nijenhuis, 1999)Dissociative Experiences Scale-II (DES-II) (Putnam, 1997)Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg, 1993)Use of parts of self languageContractingsymptom managementday to day activitiessuicideIdeomotor signaling
29Phase II - Processing of Traumatic Memories Readiness for Phase II WorkMemory WorkNature of memoryAccessing dissociated memoriesDeciding where to startWhen specific memories do not surfaceIs memory recovery the goal?Facilitating the integration of experienceThe importance of detailsTitrating the processExtent to which reexperiencing is necessaryGrounding techniquesChecking inMemory containmentStructuring the session and counseling relationship
30BASK Model Behavior Affect Sensation Knowledge Behavior Affect Gingrich, H. D., 2013, p. 107
31Phase II - Processing of Traumatic Memories (cont’d) Facilitating Integration of Self and IdentityWorking through Intense EmotionsGeneral principlesUnderstanding and dealing with specific emotionsMourning: Denial, anger, and depressionGuilt, shame, and self-hatredFear of abandonmentAnxiety, terror, and fearRoadblocks for counselorsKeeping Perspective
32Levels of Integration of Self No IntegrationPartial IntegrationFull IntegrationGingrich, H. D., 2013, p. 121
33Integration of Self and Experience Gingrich, H. D., 2013, p. 122
34Is the Goal Full Integration? Immediate goal is better functioningSome highly dissociative clients never fully integrateMay be afraid to (i.e., fear of death of parts of self)Too much work and timeThe process of integration can begin to happen from the beginning of therapy
35Dealing with Spiritual Issues (1) Heather Davediuk Gingrich, Ph.D.April 4, 2013Dealing with Spiritual Issues (1)All phases, but particularly Phases II and IIIGradual, often difficult processAllow client to set paceOften are questions re: why God did not protect from the traumaIn time clients can often see that God was there, and is currently involved in their healing processIn highly dissociative clients, some parts of self may have a relationship with Christ, while others may notE.g., internal Bible studyRestoring the Shattered Self
36Dealing with Spiritual Issues (2) Distinguish between parts of self and demonicUltimately gift of discernment necessaryPotentially VERY destructive to attempt deliverance ministryIf any kind of deliverance/exorcism ritual is decided upon make sure that the following factors are incorporated (Bull, Ellason, & Ross, 1998):Permission of the individualNoncoercionActive participation by the individualUnderstanding of DID dynamics by those in chargeImplementation of the procedure within the context of psychotherapySee my article “Not all voices are demonic” (Gingrich, 2005b)
37Phase III – Consolidation and Resolution Consolidating changesDevelopment of new coping strategiesLearning to live as an integrated wholeNavigating changing relationshipsMarriage and parentingFriendshipsRelationship to God and church congregationsCommunityFamily of originEmploymentConfronting the perpetratorForgiveness
38How the Church Can Help Educating about CTSD Providing emotional and spiritual supportFormal careGroupsLay counselingMentoring, spiritual direction and life coachingAssigned helpersInformal careChurches and Christian mental health professionals in partnership
39ReferencesAmerican Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author.American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed). Washington, DC: Author.Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2),Bull, D., Ellason, J., & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26,Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press.Gingrich, H. D. (2002). Stalked by Death: Cross-cultural Trauma Work with a Tribal Missionary. Journal of Psychology and Christianity, 21(3),
40Gingrich, H. D. (2005a). Trauma and dissociation in the Philippines Gingrich, H. D. (2005a). Trauma and dissociation in the Philippines. In G. F. Rhoades, Jr. and V. Sar (2005), Trauma and dissociation in a cross-cultural perspective: Not just a North American phenomenon. New York, NY: Haworth Press.Gingrich, H. (2005b). Not all voices are demonic. Phronesis, (Asian Theological Seminary/Alliance Graduate School, Philippines)12,Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: InterVarsity PressMcFarlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press.Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum.
41Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press.Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press.van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.