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PTSD Daniel Brown, Ph.D. Types of Traumatization • Natural acts – Earthquakes, fires, floods, hurricanes, tornados – Industrial accidents, motor vehicle accidents, plane crashes • Interpersonal violence – – – – – – – 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 – – – – – 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 • • • • 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) – – – – – – – – – 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 • • • • “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 – • • • 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 – – • Motivated by survival instinct Beyond control of victim Belief change – – – • “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 – – – – 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 • • • • • 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 – – – – – – 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 – – – – – 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 – – – – 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 • • • • 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 • • • • Treatment Frame Stabilization Memory & Representational Integration Post-integrative recovery Treatment Frame Issues 1. • Re-traumatization potential – Environmental interventions – Dissonance-evoking interventions • • • • • 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 • • • • 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 – – – – 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 • • • • 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 – – – – 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 • • • • • • Depression Anxiety-spectrum symptoms Pain Sexual dysfunction DIMS (night awakenings) Grief • Use of displacement technique Treatment of Addictive Behaviors • • • • • • • 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 • • • • • 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 • • • • Preventing treatment regression Dangers of restricting life to trauma work Meaningful work Social support network Common Problems During Stabilization • • • • • • • • • 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 • • • • • • • • • • 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 – – – – – – 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: – – – – 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 – – – – – 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)