Download PTSD

PTSD
Daniel Brown, Ph.D.
Types of Traumatization
• Natural acts
– Earthquakes, fires, floods, hurricanes, tornados
– Industrial accidents, motor vehicle accidents, plane
crashes
• Interpersonal violence
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Combat trauma
Political imprisonment, interrogation, torture
Terrorist acts & hostage-taking
Rape & crime victimization
Sexual misconduct & harassment
Domestic, school, & worksite violence
Childhood maltreatment
• Attachment disruption & neglect
• Physical & sexual abuse
Information-Processing Model of
Trauma (Horowitz, 1976)
• Stages of processing a traumatic event
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Outcry
Denial
Intrusion
Alternation between denial & intrusion
Working through; symptom reduction
• Trauma as a crisis in information-processing—
disrupted processing
• Treatment as providing the recovery conditions to
process the traumatic experience
Information-Processing Model:
Symptom Manifestations
• Intrusion phase:
– Hypermnesic flooding
– Affect storms
– Behavioral enactments
• Denial/Numbing phase:
– Amnesia (full, partial, trauma-specific)
– Affective numbing
– Behavioral inhibition
Psycho-biological Model
(Kolb et al., 1982; van der Kolk, 1984)
• Dysregulation of the autonomic nervous system
– Continuous arousal—hypervigilance
– Discontinuous arousal—physiological reactivity to
external trauma triggers & internal intrusive
memories/feelings
– Behavioral signs
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Disturbances in attention & concentration
Sleep disruption
Startle & stimulus sensitivity
Sensation seeking & addiction to trauma
• Dysregulation of the central nervous system
– Predominantely processing trauma in the emotional
brain (amygdala) vs. the narrative areas (hippocampus)
Janet’s Dissociation Model
• Failure to take adaptive action in face of trauma
• Intensification of affect (“vehement emotions”
• “Disaggregation” (dissociation) of consciousness
with split off “nuclei” of consciousness
outside of awareness/control
• Narrowing of field of consciousness
• Re-emergence of split off subconscious fixed
ideas:
– Somnambulistic states
– Hypermnesia & amnesia
– Conversion symptoms, e.g. paralysis
Dis-integrated Experience
Spiegel & Cardena, 1991
“A structured separation of mental processes
… that are ordinarily integrated.”
“Involving at least momentarily unbridgeable
compartmentalization of experiences”
Structural Model for Dissociation
Autobiographical memory
NM
SR
Primary Dissociation (between NM, SR, and TM)
NM
TM
B
A
S
SR
K
Secondary Dissociation (within TM system)
NM
B s a k a
k S
s A
a k b K s
SR
Tertiary Dissociation (within SR system)
NM
Ss Sk Sb
Sb Sa Ss Sk Sb
Somatoform Dissociation Questionnaire
It sometimes happens that:
• My body, or part of it, is insensitive to pain
(analgesia)
• It is as if my body, or part of it, has
disappeared (visual/kinesthetic anesthesia)
I can not speak (or only with great effort) or I
can only whisper (motor inhibition)
I have pain while urinating
Domain of Dissociative Symptoms
(Nijenhuis)
Psychological
Dissociation
Somatoform
Dissociation
Negative
Symptoms
Numbing
Loss of motor
control or sensation
Amnesia
Identity confusion Loss of special
senses
Positive Symptoms
Fixed ideas
Intrusive
memories
Dissociated
Personalities
Physiological
reactivity
Flight,fright,
freeze, submission
Seizures &
contractures
Attribution Model
Core Beliefs Re: Self, World & World of Others
• Shattered assumptions (Janoff-Bulmann)
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Safety
Meaningfulness
Self worth
Trust
Future-orientation
Sense of belonging
Sense of control
Independence
Distribution of power
• Negative schema acquisition (Newman)
• Positive schema acquisition (Frankl)
Developmental Model
Parson, 1984; Brown & Fromm, 1986
• Reversal of gains along developmental lines
– Self pathology
• Self esteem & self agency failure
• Self inhibition and self definitional problems
• Self fragmentation & structural dissociation
– Relational disturbance
• Trauma bonding
• Disturbed power relationships
• Pathological introjects acquired during trauma
– Affect disturbance
• Alexythymia
• Affect regulatory problems—feeling too much or too little
• Extreme numbing (affect experience problems)
Acquired Trauma Bonding: Stockholm
Syndrome in Hostages: Description
• A 131-hour captivity by a prison escapee for 4
hostages in a bank vault in Stockholm, Sweden in
1973
• Victims:
– Came to fear the police more than the robbers
• Phone call from victim to Prime Minister saying, “The robbers
are protecting us from the police”
– Felt no animosity for the robbers
– Were emotional indebted to their captors for their
‘generosity’ of given the victims their lives back
– Supported captor’s defense, visit in jail, or became
engaged to captor
Strentz, 1979
Stockholm Syndrome: Explanation
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“An automatic, often unconscious, emotional response to the trauma of becoming a
victim”
Very high level of life-threatening stress or fear-arousal
Creates situation of extreme, frightened dependency & denial of rage in victim
Re-capitulates early infancy dependency
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Captor is both source of life-threatening and life-giving
Positive contact between victim and captor (captor being “nice”)
Results in the development of a strong, positive emotional bond of victim to captor
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Motivated by survival instinct
Beyond control of victim
Belief change
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“The behavior that worked for the dependent infant surfaces again as a means to survival” (p.
152)
Identify with human qualities of captors-- “a process of humanization” (p. 159)
Increased sympathy with/adoption of captors’ belief system
Increased intolerance for ‘outsider’s’ [normal societal] belief system in general and authorities
(police, government) in particular
Development of survival, not escape strategies
Strentz, 1982
Domestic Stockholm Syndrome(DSS):
The Dutton & Painter Trauma Bonding Model
• How strong emotional ties develop in context of intermittent marital
abuse
– Majority of battered women (87%) not physically abused in previous
relationships
– Unmet dependency needs of both partners
– Two common features:
• Power imbalance
• Intermittent reinforcement
– Periodic abuse followed by caretaking (cyclical bad/good treatment)
– “When the physical punishment is administered at intermittent intervals, and when
it is interspersed with permissive and friendly contact, the phenomenon of
“traumatic bonding” seems most powerful” (p. 149)
– Results in a strong emotional attachment or trauma bond
• “Strong emotional ties between two persons where one person intermittently
harasses, beats, threatens, abuses or intimidates the other” (p. 147)
• Cognitive changes– introjection of self-blame & lowered self-esteem
• Makes it difficult to leave the abusive relationship—elastic band metaphor
Dutton & Painter, 1981
Trauma Bonding and the Difficulty of
Leaving an Abusive Relationship
• This attachment bond is likens “to an elastic band
which stretches away from the abuser with time
and subsequently ‘snaps’ the woman back. As the
immediate trauma subsides, the strength of the
traumatically-formed bond reveals itself through
an incremental focus on the desirable aspects of
the relationship, and a subsequent sudden and
dramatic shift in the woman’s ‘belief gestalt’ about
the relationship…[so that she] alters her memory
for the past abuse, and her perceived likelihood of
future abuse.”
Dutton & Painter, 1993, p. 109
Empirical Test of Trauma Bonding Model of
Domestic Violence
• Intensive interviews of 75 women who recently
left a physically vs. emotionally abusive
relationship
• Results
– Evidence of both power imbalance & intermittent
maltreatment by abusive partner
– PTSD symptoms & low self-esteem both immediately
& 6-months after leaving abusive relationship
– Abusive relationship, not family-of-origin variables
accounted for most of variance of trauma symptoms
– Prolonged effects
• “Attachment persisted for these women despite their remaining
outside the prior relationship”
Dutton & Painter, 1993
Cognitive Modifications of the Trauma
Bonding Model for Domestic Violence
• Criticisms:
– Intermittent abuse/caring is one key element but not the
“unique cause” of trauma bonding
• Power imbalances exist in many relationships that
are not abusive
– Power imbalance is “not a consequence but an
antecedent of the abuse”
• Induction of a mental model in victim
– Network of schemas & beliefs
• Traumatic bond protects victim’s psychological
integrity
Montero, 2000
Stages in Development of the Cognitive Bond
• Trigger phase
– Initial physical abuse breaks previous security in relationship
– Disorientation and acute stress reaction
• Reorientation
– Cognitive dissonance between abuse evidence and her going along
with relationship
– Cognitive restructuring to reduce dissonance
– Self-blame cognitions
• Coping
– Managing the abuse potential
• Adaptation
– Assumes abuser’s beliefs and projects guilt outside couple milieu
• Full emergence of Domestic Stockholm Syndrome
Montero, 2000
Modifications of the Trauma Bonding Model
for Domestic Violence
• Similarities to hostages
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Victimizers usually male
Domination strategies
Victim as symbolic target (blame women as group)
Victim uses active strategies to stay alive
• Attuned to what pleases & displeases victimizer
• Submission
– Counter-productive denial of danger & failure to see available
options
– Survival as success
• Differences from hostages
– Voluntary nature of initial relationship
– Unlikely that outsides negotiate for release
Graham, Rawlings & Rimini, 19??
Modifications of the Trauma Bonding Model
for Domestic Violence: Dissociation
• 49-item assessment scale of possible cognitive
distortions and coping strategies in young women
abused when dating
• Results:
– Core Stockholm Syndrome
• Victim is in a dissociated state characterized by:
– Attachment to positive aspects of relationship
– Compartmentalization of violent part of relationship
– Psychological damage
• Depression & low self-esteem
• Loss of sense of self
– Love-dependence
• Feeling cannot survive without partner
Graham et al., 1995
Reactivation of Attachment Representations
in Domestic Violence: Both Partners
• Assessment of level of object relations development in
abusive partner relationships
• 81 men & women reporting physical abuse vs. 13 women
reporting no partner violence
• Significantly lower level (more primitive) object
representations in both men & women in abusive vs. nonabusive relationships
– More “highly malevolent”
– Less differentiated, integrated, or complex
• “Men and women in abusive relationships exhibit more
primitive levels of representations of themselves and others
than do men and women in non-abusive relationships” (p.
112)
Cogan & Porcerelli, 1996
Traumatic Incestuous Bonding Cycle
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A Build-up
B Overt sexual abuse
C Emotional relief
D Downside—guilt or shame
E Build up again
deYoung & Lowry, 1992
Contextual Model of Trauma
• Pre-emigration stress
– Trauma
– Loss of home, livelihood, social position, family,
community, homeland
– Customs & beliefs
• Emigration & relocation stress
• Post-emigration stress
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Safety & sanctuary issues
Living situation
Cultural customs & beliefs
Language & education
Relationships
Acculturation issues
Effects of Traumatization:
5 Domains, 3 Areas
Affect dysregulation
Self pathology
Relational disturbance
Intrusive Re-experiencing
Numbing
Physiological reactivity
Shattered core beliefs
Consciousness
Acquisition of negative beliefs
Memory
Acquisition of positive
Identity
beliefs
Motor disturbances
Sensory disturbances
Functional medical illnesses
PTSD
Dissociation
Somatoform
Attributional
Developmental
Simple vs. Complex Trauma
• Simple trauma
– Typically single-incident trauma
– Fits the information-processing model
• Provide recovery environment to process the traumatic
experience
• Little emphasis on treatment frame or stabilization
– Interaction of trauma and personality addressed
• Complex trauma
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Processing trauma per se often insufficient for recovery
Treatment frame issues important
Elaboration of stabilization skills
Addressing developmental issues necessary
Relational-based treatment critical to recovery
Assessment of PTSD 1.
• Multi-method assessment
• Structured Interviews—CAPS; SCID-D
• Psychometric testing
– PTSD
• Impact of Events
• Traumatic Stress Inventory (TSI)
– Dissociation
• Dissociative Experiences Scale
• Somatoform Dissociation Questionnaire
– Coping
• Ways of Coping
• Peritraumatic Dissociative Experiences Questionnaire
Assessment of PTSD 2.
• Beliefs & Schemas
– Young Schema Questionnaire
• 232 questions, 18 domains
– Traumatic Attachment Belief Scale
• 5 basic needs
• Relational Disturbance
– Relationship Questionnaire
– Adult Attachment Inventory
• Psycho-physiological testing
• Personality factors
– Memory suggestibility
– Fantasy-proneness
• Malingering
– Structured Interviews of Reported Symptoms
– Malingering Probability Scale
Assessment of PTSD 3.
• Depression
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Beck Depression Inventory
Automatic Thought Questionnaire
Dysfunctional Attitude Scale
Index of Self Esteem
• Anxiety
– Beck Anxiety Scale
– Penn Worry Scale
– State-Trait Anxiety Scale
• SCL-90
• Axis II
– SCID-II
– MCMI-3
Simple PTSD:
Acute vs. Chronic PTSD
• 8-9% of traumatized individuals develop chronic
PTSD (25% for war trauma)
• Predictors of chronic PTSD:
– Severity of exposure (duration, severity, cumulative,
destructiveness, conflict)
– Age of traumatization
– Betrayal trauma
– Extremes of arousal (disrupted processing)
• Disruptive effects of extreme fear arousal
• Dissociative coping style & disrupted processing
– Coping style
– Cultural context
Disrupted Trauma Processing
Severity of PTSD
More
Extreme
Fear Arousal
Dissociation
Less
Low
High
Fear Arousal
Part 2.
Treatment of Single-Incident Trauma
Treatment of Single-Incident Trauma
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Dynamic psychotherapy (meaning-making)
Hypnotherapy
Cognitive-behavioral therapy
EMDR
• Common ingredients
Psychodynamic Treatment of Trauma
(Horowitz, 1976)
• Trauma defined as incomplete informationprocessing
• Traumatic stress activates conflict according to
character style
• Goals of dynamic treatment:
– Complete information-processing of trauma
– Meaning-making
– Identify character/defensive style & resolve conflicts
that interfere with trauma processing
Hypnotherapy for PTSD
(Brown & Fromm, 1986)
• Stabilization skills
• Trauma processing with hypnosis:
– State of heightened attentional focus
– Richness of imagery
– Greater access to under current of affective
states
– Greater access to inner resources for coping &
mastery in context of permissive relational
context
Exposure-Based Treatment of Rape
(Foa et al, 1995)
“I’m going to ask you to recall the details of the assault. It is
best for you to close your eyes so you won’t be distracted.
I will ask you to recall these painful memories as vividly as
possible. We call this reliving. I don’t want you to tell a
story about the assault in the past tense. Rather, I would
like you to describe the assault in the present tense, as if it
were happening right now. I’d like you to close your eyes
and tell me what happened during the assault in as much
detail as you remember. This includes details about the
surroundings, your activities, the perpetrator’s activities,
how you felt including your physiological responses like
your heart beating fast, and what your thoughts were
during the assault. If you start to feel uncomfortable and
want to run away or avoid it by leaving the image, I will
help you to stay with it.”
Exposure-Based Treatment of Rape
(Foa et al, 1995)
“I’m going to ask you to recall the details of the assault. It is
best for you to close your eyes so you won’t be distracted.
I will ask you to recall these painful memories as vividly as
possible. We call this reliving. I don’t want you to tell a
story about the assault in the past tense. Rather, I would
like you to describe the assault in the present tense, as if it
were happening right now. I’d like you to close your eyes
and tell me what happened during the assault in as much
detail as you remember. This includes details about the
surroundings, your activities, the perpetrator’s activities,
how you felt including your physiological responses like
your heart beating fast, and what your thoughts were
during the assault. If you start to feel uncomfortable and
want to run away or avoid it by leaving the image, I will
help you to stay with it.”
Effectiveness of Rape Trauma Treatment
• 9 biweekly (90 minute) sessions resulted in:
• Increased organization of rape memory
• Increase narrative length & detail of
memory
• Increased emotions and thoughts about rape
• Reduction in trauma-related symptoms
• Reduction in depression correlated with
meaning-making
Summary of Exposure-Based Rape
Treatment
“The employment of exposure techniques
with trauma victims consists of engaging
the patient in the trauma memories with the
intent of habituating intense fear responses
to trauma reminders…the treatments should
be directed toward both organizing the
memory and correcting the maladaptive
schemas” (Foa, 1993, pp. 294-296)
Outcome Studies on PTSD Treatment
• Brom, Kleber & Defares (1989)
– Behavioral desensitization, Hynotherapy, &
– Psychodynamic therapy
– All 3 treatments efficacious (60%) vs. controls (26%)
over 15 sessions
– Behavioral & hypnotherapy better for intrusions,
dynamic better for avoidance
• Some methods better suited to a particular case
• Figley (1999)
– Comparable efficacy for 4 different types of innovative
trauma treatments because each contains similar active
treatment components
Differential Response to Trauma
Treatment (Jaycox, Foa & Morral, 1998)
• 9 Bi-weekly sessions (90 minutes) of PET
exposure for rape trauma
• Treatment effect
– Engagement + habituation =
57%
– Engagement + non-habituation =
15%
– Low engagement + non-habituation = 11%
Active Treatment Ingredients
• Stabilization skills
• Habituation of phobic and/or anxiety response to
traumatic memory
• Emotional engagement
• Modification of trauma-specific cognitive
distortions
• Integration of dissociated states
• Personification & realization
• Return to normal self, affective, & relational
development
Part 3.
Treatment of Complex Trauma
Treatment of Complex Trauma
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Treatment Frame
Stabilization
Memory & Representational Integration
Post-integrative recovery
Treatment Frame Issues 1.
• Re-traumatization potential
– Environmental interventions
– Dissonance-evoking interventions
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Keep conflict within system; avoid induction
Use language of ‘parts’ in conflict
Establish adaptive function of each part
Framing the conflict to heighten dissonance
Resolution strategies
– Activating the ‘part’ that knows the solution
– Conference table technique
• Working with skewed solutions
– Stating the parameters of an acceptable solution
• Re-balancing the system
Treatment Frame Issues 2.
Behavioral Contracting
• Self/other harmfulness
• Therapy-interfering behaviors
– Trust in the treatment relationship
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Lying
Factitious behavior
Refusing to discuss certain topics
Not giving consent to talk with other treaters
– External threats to treatment
• Leaving town
• Decreasing frequency of sessions
• Financial interferences
Treatment Frame Issues 3.
Behavioral Contracting
• Behavioral threats to treatment
– Not showing up
– Coming late
– Not leaving the session
• Contractual breaches
– Not taking medications or doing homework
– Not following treatment recommendations
• Behavioral problems in treatment hour
– Toxic, abusive behavior
– Sexualizing the treatment
Treatment Frame Issues 4.
Behavioral Contracting
• Behavioral problems between sessions
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Drugs & sexual acting out
Extra-therapeutic demands
Regression in level of functioning
Boundary violations of therapist’s privacy
• Not working in the treatment hour
– Constant crises
– Trivial themes
– Journaling instead of working
Bimodal Distribution of
Hypnotizability Scores
N= 533
NUMBER OF CASES
60
50
40
High Range
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
HYPNOTIC RESPONSIVENESS
The Domain of Hypnosis
Hypnotic
Relationship
Hypnotic Role-Taking
Hypnotic Transference
Alliance
Communicative
influence
Altered State of
Consciousness
Attention Skill
Arousal Shift
Time Distortion
Dissociation
Trance Logic
GRO Fading
Involuntarism
Access to Imagery,
Memory, Affect
Expectancies
Motivation
Attitude
Response Expectancies
Efficacy
Hypnotizability & Trauma
• Response to the SHSS:C
– Normals
– PTSD
– DID
5.5 [of 12] Hilgard, 1966
8.5
Frankel, 1976
10.5
Bliss, 1984
Stabilization Skills
• Physiological reactivity
– Continuous arousal
– Discontinuous arousal
• Core skills
– Self observational capacity
– Affect regulation skills
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Trauma-specific skills
Coping enhancement
Trauma-specific beliefs
Everyday functioning
Classification of Anxiety Disorders
• Continuous arousal
=
GAD
Hyperarousal
Excessive thought-realistic worry
Excessive thought-unrealistic
+ Avoidance =
OCD
• Discontinuous arousal
– External
– Internal
Phobia
Panic
+ Avoidance =
• Both
Agoraphobia
PTSD
Anxiety Dimensions of PTSD
• Continuous arousal
hypervigilance
• Like GAD
• Discontinuous arousal
– Triggered by external reminders of trauma
• Like phobia
– Triggered by internal memories & emotions
• Like panic
• Progressive phobic avoidance
– Phobia of memory, dissociative identities, normalcy
Treatment of Physiological Arousal
• Continuous hyperarousal
– Drug treatment
– Modulated hypnotic relaxation
• Elevator technique
• Affect dial
– Dyadic regulation
• Discontinuous/episodic arousal
– External trauma triggers
• Self monitoring & cue induced relaxation
• Displacement technique
• Desensitization
– Internal intrusions (memories & affects)
• Cue induced safe places
• Exposure treatment (fear-of-fear hierarchy)
Core Skills
• Self observational capacity
– Self-monitoring
– Mindfulness
• Affect regulatory skills
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Self soothing
Coping enhancement
Affect dial
Exposure-based treatment
Trauma-Specific Skills 1.
• Scene generation
– “a scene will come to you that is somehow about…”
• Affect amplification
– Direct
• “more clearly and intensely”
– Time distortion
• Although only a short amount of clock time will pass it will
seem to you that a much longer time has elapsed, long enough
to completely feel…”
• Expanding duration and context of state-of-mind
• Cue utlization
Trauma-Specific Skills 2.
• Safety re: fear
– “completely safe and secure
– Problems:
• Disconnection “safe and connected”
• Intrusive shifting “even safer place”
• Soothing re: dysphoric states
– “deep sense of comfort or soothing”
– Use of sandwiched interventions
• Grounding re: dissociative states
– “sense of being grounded or solid within yourself”
– Problems: boundary diffusion
• Closeness/distance regulation
– Bubble imagery
Trauma-Related Symptoms
• Self-monitoring re: triggering events
• Displacement technique
– Scene generation re: displaced other who
effectively copes with problem
– Graded suggestions for insight
– Rehearsal in fantasy
– Post-hypnotic reinforcement re: jns
• Emphasis on using inner resources for
mastery
Treatment of Ancillary Symptoms
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Depression
Anxiety-spectrum symptoms
Pain
Sexual dysfunction
DIMS (night awakenings)
Grief
• Use of displacement technique
Treatment of Addictive Behaviors
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Motivation and stage of change
Stabilization—role of relaxation treatment
Self monitoring of urges & behaviors
Self regulation skills
Affect regulation skills
Cognitive interventions
Exploratory hypnotherapy with dissociative
re-enactments
• Relapse prevention skills
Working with Trauma-Specific Beliefs
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Exposure-based methods
Exploratory methods
Dissonance-evoking methods
Future-time orientation
Attachment-related methods
– Ideal parent figure technique
Self & Relational Development
• Self development
– Self esteem “especially good about self”
– Self agency
• “especially effective”
• “eliciting exactly the kind of response…”
– Self definition
• “real” “most you” “qualities uniquely you”
• Secure attachment
Enhancing Everyday Functioning
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Preventing treatment regression
Dangers of restricting life to trauma work
Meaningful work
Social support network
Common Problems During Stabilization
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Triggering in everyday life
Shifting to unsafe mode
Rapid switching
Dissociative re-enactments
Depression following disclosure
Behavioral distance regulation
Noxious trance
Blocking and acting out alters
Phobic avoidance
Signs of Stabilization
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Patient feels more settled
Decrease fear/reactivity to what comes up
Comfortable with hypnosis
Spontaneous use of trauma-specific skills
Security of attachment, at least in therapy
Enhanced self-esteem
Decreased core PTSD symptoms
Enhanced coping with ancillary symptoms
Modification of trauma-specific beliefs
Curiosity to uncover in context of mastery &
stabilization
Memory Integration
• Structural integration
• Processing explicit, narrative memory
– Memory recovery & dissociative amnesia
• Processing implicit, enacted memory
– Transference work
Structural Model for Dissociation
NM
SR
Primary Dissociation (between NM, SR, and TM)
NM
TM
B
A
S
SR
K
Secondary Dissociation (within TM system)
NM
B s a k a
k S
s A
a k b K s
SR
Tertiary Dissociation (within SR system)
NM
Ss Sk Sb
Sb Sa Ss Sk Sb
Treatment Implications of Structural
Dissociation
• Structuralization of the traumatic memory,
not content-related memory recover
• Putting the Humpty Dumpty of the
dis-integrated memory system and the self
representational system back together
Processing Explicit Narrative Memory
for Trauma
• Indications:
– Full or partial dissociative amnesia
– Predominately behavioral, not narrative memory for
trauma e.g. early age of trauma
• Goals:
– Maximize organization, completeness, & accuracy of
narrative memory
– Minimize memory error rate
– Personification & realization
– Meaning-making & narrative construction
Methods for Memory Retrieval
• Hierarchy of methods:
– Free recall
– Context reinstatement
– Dyadic regulation & transference work
• Risks of increasing the memory error rate:
– Personality traits:
• High memory suggestibility
• Psychopathology & severe cognitive distortion
– Borderline, factitious, & psychotic disorders
– Treatment methods:
• Therapist systematically supplying content about abuse-related
themes
Stages of Memory Integration
• Early phase
– Symbolized retrieval
– Normal vs. trauma dreamwork
• Free recall and symbolization
– Successive scenes reveal more, conceal less
• Embedded memory episodes within symbolization
• Fragmented recovery
– Open-ended free recall
Stages of Memory Integration 2.
• Middle phase
– Retrieval with BASK dissociation
– Organization within episodes
– Problem of disconnection
Stages of Memory Integration 3.
• Late phase
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Retrieval without BASK dissociation
Organization across episodes
Developing a comprehensive picture of the abuse
Personification & realization
Progressive interiorization
Changes in type of memory content
• Coping and aftermath memories
Implicit Memory Processing
• Transference re-enactment as implicit memory for
abuse (Davies & Frawley)
• Unnecessary to recover narrative abuse memories
because the abuse memory is already expressed
within the transference re-enactments:
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Neglected child/ uninvolved parent
Enraged victim/sadistic abuser
Seduced child/seducing parent
Entitled child/omnipotent rescuer
Representational Integration
• Types
• Victim self
• Abuser self
• Failed protector self
• Nature of dissociated representational parts
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Endure as compartmentalized self states
Dissociated from conscious self representation
Rigidly defended against
Quasi-autonomous existence (implicit influence)
Can be activated
• Signs of activation
Representational Integration:
Therapeutic Strategies
• Working with impulses
– Revenge fantasies
• Working with self states
– Ego state therapy
– Fusion and integration rituals
– Secure attachment imagery
• Problem of disavowal of abuser states or
sadistic aggression
Signs of Representational Integration
• Ownerships
• Integrative dreams
• Acceptance of realistic harm caused to
others
• Increased mastery over aggression in
fantasy
• Decreased dissociation
• Increased behavioral assertiveness
Treating Psycho-Physiological Reactivity
• Basic pattern
– Elevated ANS activation across indices
– Over- and under- reactivity
– Failed habituation
• Treatment
– Desensitization
– Cue induced calming
– Calming with stimulus challenge
Treatment of DDNOS/DID
• Handling discontinuous awareness
– Expanding field of consciousness
– Personification & realization (self)
• Stabilizing dissociative shifts in state
(voluntary control)
• Problem of learned phobias
• Disavowal of mental contents
• Structural integration
Working with Sadistic Abuse
• Sadistic use as domination and power via
infliction of physical and emotional
suffering
• Necessity of transference work
– Exploratory work contra-indicated
– “To be known is to be controlled”
Structural Integration Treatment
Strategies
• Memory processing over time– The puzzle
analogy (Braun)
– Identification, accessing, & communication
• Therapist-to-part- The relational model
• Part-to-part- The dissonance model of ego state
therapy (Watkins, Brown)
• Part-to-part- The suggested co-presence model
(van der Hart & Steele)
• Whole-to-part- Internal Family Systems model
(R. Schwartz)
• Whole-to-part- Attachment Model
(Brown)