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UNDERSTANDING AND WORKING WITH COMPLEX TRAUMA & DISSOCIATION

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1 UNDERSTANDING AND WORKING WITH COMPLEX TRAUMA & DISSOCIATION
Lynette S. Danylchuk, PhD Kevin J. Connors, MS, MFT

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

13 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 Studied N Tests Results Benishek & Wichowki Substance Abusers 51 DES 25 % >15 Tamar-Gurol, Sar, Karadag, Evren & Karagoz 104 DES, DDIS & SCID-D 46%>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 Studied N Tests Results
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 Studied N Tests Results Beato, Cano,& Belmonte Eating Disorders 118 DES, 30.5 % > 25 Dalle Grave, Tosico, & Bartocci 106 DIS-Q 22.6% had severe dissociative symptoms Vanderlinden, Van der Hart, & Varga Eating Disorders 98 12% pathological 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 B A S K Component Model Behavior Affect Sensation
Knowledge B A S K

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

37 SEQUENTIAL MODEL OF DISSOCIATION
TRAUMATIC EVENT T I M E TIME Annie Betty Chuck Dora Baby Eek! Florence

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

70 STAGE 2: REMEMBRANCE AND MOURNING

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

83 Moving Forward & Backward to Complete Beginning, Middle & End
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 Sharing Across Alter Personalities
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 Grant me the Serenity to Accept what I cannot change, the Courage to change the things I can, and the Wisdom 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 l.danylchuk@usa.net
Kevin J Connors, MS, MFT

104


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