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Presentation on theme: "UNDERSTANDING AND WORKING WITH COMPLEX TRAUMA & DISSOCIATION Lynette S. Danylchuk, PhD Kevin J. Connors, MS, MFT."— Presentation transcript:


2 INTRODUCTION  The Difficult Client  Chaotic Lifestyle  Frequent Crisis Calls  Suicidal & Para-suicidal Behaviors  Manipulative  Non-Compliant/Oppositional

3 INTRODUCTION  The Borderline Client  Black or White/All or Nothing Thinking  Extreme Ambivalence  Extreme Labiality of Affect  Approach/Avoidance  Self-Harm Behaviors

4 INTRODUCTION  The Dissociative Client  Spaced Out/Foggy  Identity Confusion  Memory Problems  Hears Voices  History of Treatment Failures

5 THE PROBLEM  Most Mental Health Practitioners See Dissociation As Extremely Rare  Dissociation is seen as DID  Their Viewpoint Informs the General Public

6 THE PROBLEM  Clients with Complex Relational Trauma Receive Inappropriate Treatment  Given Negative Labels  Treated for Surface Symptoms

7 TAKE HOME MESSAGE By having an expanded and comprehensive understanding of trauma based disorders and dissociative defenses, more clients will get better treatment.

8 WHO ARE THEY?  Possible Client Populations  Alcohol/Substance Abuse  Intimate Partner Violence  Eating Disorders

9 COMPLEX TRAUMA  Impact of Trauma  Natural Trauma vs. Interpersonal Trauma  Loss of Safety  Loss of Invulnerability  Shattering of Worldview

10 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).

11 Phenomenological Presentation – What does it look like?  PTSD Symptoms – Siegel’s Window of Tolerance  Hyper-arousal  Hypo-arousal  Intrusive Flashbacks

12 Window of Tolerance


14 COMPLEX TRAUMA  Relational Trauma  The closer the relationship between perpetrator & victim the more devastating the damage  Betrayal  Loss of Trust

15 COMPLEX TRAUMA  Developmental Trauma  Age of Onset  Frequency of Abuse  Lack of Nurturing and Healing Responses

16 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

17 DISSOCIATION  Dissociative Symptomology  Amnesia/ Trance States  Depersonalization/ Derealization  Fugue States  Ego States  Dissociative Identity Disorder  DDNOS

18 Phenomenological Presentation – What does it look like?  Relational Symptoms  Borderline features  Paranoid features  Narcissistic features  Asocial features

19 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

20 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)

21 DIAGNOSIS  Post Traumatic Stress Disorder  LA Symptom Checklist (Foy)  Trauma Symptom Checklist (Briere)  Adverse Childhood Experiences Scale (Anda & Feletti)

22 Diagnosis  Differential Diagnosis Considerations  Schizophrenia  Bi-Polar Disorder  Paranoid Disorder  Major Depression  Borderline Personality Disorder  Psychosis

23 DISSOCIATION & SUBSTANCE ABUSE Authors Population StudiedNTestsResults Benishek & Wichowki Substance Abusers51DES25 % >15 Tamar-Gurol, Sar, Karadag, Evren & Karagoz Substance Abusers104 DES, DDIS & SCID-D46%>30

24 DISSOCIATION & SUBSTANCE ABUSE  Alcohol or Substance Abuse in Families Increases Likelihood of Interpersonal Violence.  Intimate Partner Violence  Child Abuse

25 DISSOCIATION & I P V Authors Population StudiedNTestsResults Connors, Kemper, Hamel & Ensign Intimate Partner Violence – Victims 95 DES, CTS, CAT Trauma History 31.6 % > DES 20 18.9% > DES Taxon Score.55:

26 DISSOCIATION & I P V  Intimate Partner Violence is Relational Trauma  Dissociative Clients at Greater Risk of Re- victimization  Dissociative Clients Engage in More Violence with Battering Partners  IPV-Offenders May Dissociate During Assaults

27 DISSOCIATION & EATING DISORDERS Authors Population StudiedNTestsResults Beato, Cano,& Belmonte Eating Disorders118DES,30.5 % > 25 Dalle Grave, Tosico, & Bartocci Eating Disorders106DIS-Q 22.6% had severe dissociative symptoms Vanderlinden, Van der Hart, & Varga Eating Disorders98DIS-Q 12% pathological dissociative experiences

28 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

29 ETIOLOGY  Neurobiology  Hyper activation of Amygdala  Hypothalamus, Pituitary Adrenal Overstimulation  Increased Right Temporal Lobe Functioning

30 ETIOLOGY  Neurobiology  Diminished Hippocampal Functioning  Impaired Broca’s Region

31 ETIOLOGY  Relational /Developmental Trauma  Trauma as That Which Overwhelms One’s Ability to Assimilate & Accommodate  Interpersonal vs. Natural Trauma  Betrayal Trauma  Childhood Abuse

32 ETIOLOGY  Disorganized Attachment  Attachment Theory  Styles of Attachment  Effects of Attachment on Adult Relationships

33 ETIOLOGY  Dysfunctional Family Dynamics  ACA Issues  Dysfunctional Social & Interpersonal Learning  Don’t Think, Don’t Feel, Don’t Tell

34 Ego State Model

35 DISSOCIATION  Component Model  Behavior  Affect  Sensation  Knowledge BA S K BA

36 DISSOCIATION  Sequential Model  Ego States/Alters Across Time  Degrees of Dissociative Barriers


38 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

39 TREATMENT  Need for On-going Support & Consultation  ISSTD Treatment Guidelines  Component Chapters  Study Groups  Annual Conference  Regional Seminars

40 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

41 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

42 Externalized Locus of Control  Client Symptomology  Lack internal control  Attempt to control others  Assume responsibility for others  Alternately seeks and rejects external control

43 Externalized Locus of Control  Perpetrator Dynamics (Sgroi, 82 Mey, 82 )  Dysfunctional boundaries  Displacement of responsibility  Isolation  Discounted/distorted feelings  Non-validation of reality

44 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)

45 Shame  Denial of Abuse Maintains Shame  Perpetrator denial  Familial /societal denial  Self denial

46 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

47 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

48 Shame  Shame and Powerlessness  Nathanson: Shame vs. Pride ♦ Shame inhibits experiencing the positive affects ♦ Success leads to affect: enjoyment- joy ♦ Competence & pleasure antidotes to shame

49 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

50 Addiction to Chaos (van der Kolk, 87)  Examples of Chaos  Eating disorders  Chemical dependency  Self-injurious behavior  Dysfunctional relationships  Identification with aggressor  Addiction to anger

51 Alexithymia  Difficulty Identifying Feelings  Difficulty Expressing Feelings  Affect Storm  Connection to Somatoform Dissociation (Clayton, 04)

52 INTRODUCTION  Three Stage Trauma Model  Safety and Stability  Remembering and Mourning  Reconnecting

53 INTRODUCTION  Trauma Treatment Triggers Trauma  Treatment frame is safe but not too safe  There will be complications  Therapists will step in it.  Rupture repair process is rich and necessary

54 UNDERLYING THEMES / GUIDING LIGHTS  Transference and Countertransference  Non-linear Nature of Trauma Therapy  Replication of Dysfunctional Trauma Dynamics  Addictive Patterns of Arousal  Power, Powerlessness, Choices and Shame  Shift from Ordeal to Recovery

55 THERAPEUTIC RELATIONSHIP  Secure Attachment  Consistent Caring Presence  Sustained Connection

56 THERAPEUTIC RELATIONSHIP  Boundaries  Predictable  Not too rigid, not too loose  Negotiable  Create safe environment within which to meet

57 STAGE ONE TREATMENT ISSUES  Intrusive Flashbacks  Grounding  Container Imagery  Divide & Put Away (Controlled Dissociation)  Manipulating Memories

58 STAGE ONE TREATMENT ISSUES  Self harm  Explore Intent  Saying What Can’t Be Said  Short-term vs. Long Term Effectiveness

59 STAGE ONE TREATMENT ISSUES  Fear of Disclosure  To Be Seen is to:  Give away power  Be in danger  Create vulnerability

60 STAGE ONE TREATMENT ISSUES  Fear of Disclosure  To Say It Out Loud is to:  Connect to ones’ self and one’s life  Make events real  Make emotions more intense

61 STAGE ONE TREATMENT ISSUES  Lack of Internal Cooperation  Honor the Resistance/Honor the Fear  Seeing the Whole Person as Conflicted

62 STAGE ONE TREATMENT ISSUES  Alexithymia  Teaching Affective Language  Develop Somatic Awareness  Distinguish between hyper & hypo arousal

63 STAGE ONE TREATMENT ISSUES  Affect Modulation and Self Soothing  Relaxation exercise  Breathing  Physical interventions  Hypnotic Interventions  Siphon off  Energy transfer  Internal support system  Emotional rheostat

64 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Transference and Countertransference  Know your own tendencies  What is you and what is not you

65 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Non Linear Nature of Trauma Therapy  Sense of progress or lack of progress  Same feelings over & over

66 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Replication of Dysfunctional Trauma Dynamics  Replay Karpman’s Triangle  Lead to therapist weakening boundaries  Enmeshed in client’s system

67 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Addictive Patterns of Arousal  Chaos as defense  Loss of drama = Loss of life  Enmeshment vs intimacy

68 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Power, Powerlessness, Choices and Shame  Identify options  Reaction vs choice  Shame  Defense  Holding shame holds onto the meaning and the value of the loss and abuse

69 UNDERLYING THEMES/ GUIDING LIGHTS (a reprise)  Shift from Ordeal to Recovery  Recognizing the trauma is past  Agency over trauma vs. being controlled by trauma  Integrate vs. exorcise


71 ABOUT THE CLIENT  They were traumatized  They are not the trauma  They are not the problem Unable to accomplish "normal" tasks not from resistance/opposition or manipulation but from lack of capacity (Gold, 04)

72 REMEMBRANCE: General Considerations  Integration not Exorcism  Sometimes the Bad Guys are the Best  Value the Need to Identify with the Perpetrator

73 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

74 REMEMBRANCE: General Considerations  Do Not Need All the Memories  Use the Present to Tap into the Past  Identify Repetitive Patterns of Behavior  Consciousness Raising

75 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)

76 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

77 REMEMBRANCE: General Considerations  Safety  Critical Therapeutic Issues  Trauma Treatment Triggers Trauma  Therapists Will Make Mistakes

78 REMEMBRANCE: Safety  Dealing with Overwhelming Emotions  Grounding exercises,  The power of relationship  Learning about the body and mind  How to calm the self,  Become more present

79 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

80 REMEMBRANCE: Safety  Differentiating Past from Present  Cell Phones  Newspapers/Magazines  “Where’s the Doorknob?”

81 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

82 REMEMBRANCE: Methods  Assembling Dissociative Components  Non-leading Questions  When to talk about ‘why’  Exploring the recalled event K S B A

83 REMEMBRANCE: Methods  Moving Forward & Backward to Complete Beginning, Middle & End  Allowing non-linear processing  Develop a coherent narrative

84 REMEMBRANCE: Methods  Moving Forward & Backward to Complete Beginning, Middle & End  Trauma memories tend to be a repeating loop of a portion of the event  Identify the context and finding the frame of reference

85 REMEMBRANCE: Methods  Moving Forward & Backward to Complete Beginning, Middle & End  All along the way, existential issues arise and need to be dealt with  Stage II will often activate Stage I needs

86 REMEMBRANCE: Methods  Sharing Across Alter Personalities  Metaphors for helping  Metaphors to create a sense of oneness out of many and value all within

87 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.

88 REMEMBRANCE: Specialized Techniques  Hypnosis  EMDR  Somatic Therapies  Prolonged Exposure

89 MOURNING: GRIEF  The intensity of grief  Self-soothing  Key questions  Therapist’s ability to stay present

90 MOURNING: Why Me?  Perpetrators and Narcissism  Karpman’s Triangle RESCUER PERSECUTOR VICTIM

91 MOURNING: What Does It All Mean?  Normalize the reactions and learned behaviors.  Developmental process happening within therapy  Finding Strength

92 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 G rant me the S erenity to Accept what I cannot change, the C ourage to c hange the things I can, and the W isdom to know the difference.

93 MOURNING: Shame  Shame as inhibitor: stifles joy, happiness, any kind of vulnerability.  Nathanson’s shame diagram – act out, act in, blame others, blame self.

94 MOURNING: Shame  Keeps the trauma stuck.  Shame avoids Powerlessness

95 MOURNING: Shame  Therapist needs to be able to sit with the shame  Explore culpability – where responsibility truly resides  Explore reality of choices

96 MOURNING: Shame  Challenging Core Trauma Beliefs  Identify survival response  I’m bad, I deserved it  Powerlessness  Role within the family

97 Stage 3: Integration  Not the end of therapy, but the stage that most resembles therapy with non- dissociative 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.

98 The Impact of Chronic Interpersonal Trauma  Strips the Ability to be in Community  No attachment = No connection  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.

99 The Impact of Chronic Interpersonal Trauma  Abandonment, Shame, and Powerlessness are the key Elements  Abandonment: Not wanted, not included  Shame: Not worthy  Powerlessness: Not able to build a bridge back

100 The Impact of Chronic Interpersonal Trauma  Therapy Builds the Bridge  The Therapeutic Alliance Creates Community

101 “Paradoxically, trauma both occurs in the context of a relationship and can only be healed in the context of a relationship”

102 ISSTD Treatment Guidelines are available at our website www. ISST-D. org

103 CONTACT US Lynette S Danylchuk, PhD Kevin J Connors, MS, MFT



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