Download Understanding and Working with Complex Trauma and Dissociation

Understanding and Working with
Complex Trauma and Dissociation
Lynette S. Danylchuk,PhD
[email protected]
Kevin J. Connors, MS, MFT
[email protected]
Presented at:
Mid-Valley Behavioral Care Network
9 April 2013
Abstract
Every clinician has at least one; the difficult, demanding client. This client lives in chaos,
complicating treatment with frequent calls, constant crisis, unremitting self-mutilation, and
repeated threats of suicide. They come to you labeled problematic, oppositional, manipulative,
or worse – Borderline. They present with a history of diagnoses including depression, bi-polar
disorder, generalized anxiety disorder, schizoaffective disorder, eating disorders, as well as
multiple addictions. With such a complex array of emotional and behavioral difficulties, there
are no simple solutions; only a maelstrom of intra-psychic dynamics, overwhelming emotions
and distorted beliefs generating internal storms and external anguish.
This workshop synthesizes state of the art knowledge about complex post-traumatic stress
disorder, attachment theory, and dissociative defenses as well as often overlooked but equally
critical issues of power, control and shame. Empathic attunement to this complex interplay
empowers therapists to formulate effective and nuanced treatment plans. Client reactions are
reframed, shifting from oppositional or manipulative to an appreciation of the nature of their
defenses, the history of their abuse and the direction of their healing.
This seminar will focus on clinical concerns and conflicts, common in the first two stages of
treatment, which derail the therapy process. This is a practical workshop, emphasizing skills,
techniques and perspectives that help the therapist connect with the client and help the client
move beyond therapeutic impasses and acting out behaviors.
The workshop will also address the common reactions of therapists in situations where the
client's behavior leaves the therapist feeling lost, frustrated and confused. The practicum will
include opportunities for participants to discuss their own clinical cases and apply the ideas of
the workshop to them.
The therapist is challenged to identify the trauma in a way that advances the therapy by exploring
what is being expressed through the therapeutic relationship. The therapist is challenged to be
and empathic engaged and sensitive to the dynamics within the client and within the
transference. The therapist is challenged to communicate in ways and on levels where language
often fails. The therapist is challenged to guide the client through new ways of thinking and
perceiving.
Objectives
Participants will be able to:
• Evaluate clients for complex trauma histories and dissociation defenses
• Delineate how complex trauma and dissociation complicate treatment and describe
appropriate & effective treatment strategies
• Describe treatment interventions to increase client safety and stability
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Understanding and Working with Complex Trauma and Dissociation
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INTRODUCTION
Overview
Co-Morbidity of Complex Trauma & Dissociation
Impact of Complex Trauma & Dissociation
On Client’s Lives
In Clinical Practice
Take Home Message:
By having an expanded and comprehensive understanding of trauma based disorders
and dissociative defenses more clients will get better treatment.
Definitions
Complex Trauma
PTSD
Relational Trauma
Developmental Trauma
Dissociation
Dissociation is little understood, and Dissociative Identity Disorder is mistakenly
considered rare.
Clients with complex relational trauma exacerbated by dissociative defenses
remain stuck in inappropriate treatment paradigms. They are labeled as
difficult, oppositional and manipulative. Uninformed clinicians treat
symptoms of depression or anxiety without addressing critical underlying
issues. Therapists may never even ask about the person’s history, treating the
symptoms as if they arose out of nothing.
THEORTICAL FRAME
Phenomenological Presentation – What does it look like?
PTSD Symptoms – Siegel’s Window of Tolerance
Hyper-arousal
Hypo-arousal
Intrusive Flashbacks
Dissociative Symptoms
Conceptualizations of dissociation
Disruption of self-awareness
Disruption of relatedness
Dissociative symptomology
Dissociative amnesia
Depersonalization & Derealization
Somatoform dissociation
Dissociative Identity Disorder
Relational Symptoms
Borderline features
Paranoid features
Narcissistic features
Asocial features
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Diagnosis – How do we find out if someone is dissociative?
Dissociation
Screening Devices DES Dissociative Experience Scale
Formal Diagnostic Tests MID 6.0 Multidimensional Inventory of Dissociation
Clinical Interviews SCID-D
PTSD
Los Angeles Symptom Checklist (Foy)
PTSD Check List (VA)
Trauma Symptom Checklist- 40 (Elliot & Briere)
Differential Diagnosis Considerations
Schizophrenia
Bi-Polar Disorder
Paranoid Disorder
Major Depression
Borderline Personality Disorder
Prevalence – How many people have it?
General Population
Waller & Ross suggest 3% of the general population has pathological dissociation
Substance Abuse
Data:
Authors
Population
N
Tests
Results
Benishek &
Wichowki
Tamar-Gurol,
Sar, Karadag,
Evren &
Karagoz
Substance
Abusers
51
DES
25 % > 15
Substance
Abusers
104
DES, DDIS
& SCID-D
46% > 30
Historical antecedents
Alcohol or substance abuse in families increases likelihood of
interpersonal violence, including, intimate partner violence, children
exposed to physical or emotional abuse, neglect and other forms of
childhood maltreatment.
Intimate Partner Violence
Data:
Authors
Population
N
Tests
Results
Connors,
Kemper,
Hamel &
Ensign
Intimate
Partner
Violence –
Victims
95
DES,
CTS, CAT
Trauma
History
31.6 % > 20
18.9% > Taxon
Score of .55
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Intimate Partner Violence
Historical Antecedents:
IPV is itself a form of relational trauma and involves aspects of betrayal
trauma similar to what many child abuse victims experience.
Clients who dissociate may have deontic reasoning deficits and be at
greater risk of re-victimization. (DePrince)
Female victims of child sexual abuse are more likely to experience abuse
at younger ages, and to be abused by family members, than are male
victims of child sexual abuse.
Connors etal (2008) found that participants that reported pathological
levels of dissociation reported that they use isolation & jealously and
general control in their relationships and engaged in higher levels of
physical conflict with their battering partners.
Simonetti, Scott and Murphy (2000) suggested that dissociative coping
mechanisms among batterers play a role in severe intimate partner
violence.
Mantakos (2008) in attempting to develop the Dissociative Partners
Violence Scale sought to establish a correlation between the DPVS
and pathological dissociation. She found a significant correlation
between the 9 items of the DVPS and the DES-T.
Eating Disorders
Data:
Authors
Beato,
Cano,&
Belmonte
Population
Studied
Eating
Disorders
N
118
Tests
DES,
Rosenberg
Self-esteem
Scale, Body
Shape
Questionaire,
Eating
Attiudes
Test-40
Results
30.5 % > 25
Dalle
22.6% had severe
Grave,Tosico, Eating
106
DIS-Q
dissociative
Bartocci
Disorders
symptoms,
Vanderlinden,
12% pathological
Van der Hart, Eating
98
DIS-Q
dissociative
Varga
Disorders
experiences
Historical Antecedents:
Reports of sexual abuse are similar to those in general psychiatric
disorders, and may be a factor in the development of eating disordered
behaviors.
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However, traumatic experiences appear to be more prevalent among
clients diagnosed with bulimia and clients with anorexia nervosa/binge
eating-purging subtype.
Etiology – What causes it?
Response to Physical/ Sexual Trauma
Response to Relational Trauma
Response to Dysfunctional Family Dynamics
Conceptual Models – How do we think about it?
Ego State Model (Watkins)
Component Model
BASK (Braun)
Sequential Model
Structural Model (Van der Hart, et al)
Self as Process
ANP
EP
TREATMENT – DID/DDNOS confirmed – Now What?
ISSTD Treatment Guidelines available at: www.ISST-D.org
Complicating Factors – Heads up – the person you will be treating comes with:
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
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
Externalized Locus of Control – ‘Just tell me what to do…’
Client Symptomology
Lack internal control
Attempt to control others
Assume responsibility for others
Alternately seeks and rejects external control
Perpetrator dynamics (Sgroi, 82 Mey, 82 )
Dysfunctional boundaries
Displacement of responsibility
Isolation
Discounted/distorted feelings
Non-validation of reality
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Shame – ‘I’m a worthless piece of shit who’s not worthy of the air I breathe.’
Conceptualizations of shame
Inherent sense of flawed self
Shame is about the self; guilt is about an act (Lewis, 71)
Shame as a significant basis for defense mechanisms (Wurmser, 81)
Shame as an attenuator of affect (Nathanson, 92)
Denial of abuse maintains shame
Perpetrator denial
Familial /societal denial
Self-denial
Therapist denial (C. Dalenberg, 2000)
Fears of counter transference
Fears of legal liability
Fear of the overwhelming pain
Silence and the failure of language
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
Nathanson: Shame vs. Pride
Shame inhibits experiencing the positive affects
Purposeful goal directed, intentional behavior
Success leads to affect: enjoyment-joy
Competence & pleasure antidotes to shame
Paradoxical relationship between shame and powerlessness
Powerlessness leads to shame
Shame is held to avoid powerlessness
Accepting powerlessness to relieve shame
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
Alexithymia
Difficulty identifying feelings
Difficulty expressing feelings
Affect storm
Connection to somatoform dissociation (Clayton , 04)
Pg. 7
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Understanding and Working with Complex Trauma and Dissociation
General Treatment Considerations
Three Stage Trauma Model
1. Safety & Stabilization
2. Remembrance & Mourning
3. Reconnection
Trauma Treatment Triggers Trauma
Treatment frame should be safe but not too safe
There will be complications
Therapists will step in it
Rupture repair process is rich and necessary
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
Therapeutic Relationship
Secure Attachment
Consistent Caring Presence
Sustained Connection
Boundaries
Predictable
Not too rigid, not too loose
Negotiable
Create safe environment within which to meet
Stage One: Safety and Stabilization
Intrusive Flashbacks
Container Imagery
Divide & Put Away (Controlled Dissociation)
Manipulating Memories
Lack of Internal Cooperation
Honor the Resistance/Honor the Fear
Seeing the Whole Person as Conflicted
Alexithymia- ‘I don’t know what to say’
Development of affective language
Modulating an titrating affective experiences
Use of journaling and art exercises
Development of somatic awareness
Distinguish between hyper & hypo arousal
Attention to somatic state changes
Grounding: (See list at end)
Pg. 8
Connors & Danylchuk
Understanding and Working with Complex Trauma and Dissociation
Stage 2: Remembrance & Mourning
General Considerations
They were traumatized, they are not the trauma
They are not the problem
Integration not Exorcism
Growing awareness that what feels bad or scary may be necessary and helpful
Self as Process
Remembrance
Sometimes the Bad Guys are the Best
The Navy Seals of the system,
The parts that took the worst abuse & showed up for the most difficult
experiences,
They saved the innocence and protected the rest
Value the need to identify with the perpetrator
Not Changing History
Dealing with what was, and grieving what was not.
Connecting with the past yields two important fields of information:
What was learned and
What was missing
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,
Healthy habits – self-care, food, employment, finances, and self-expression.
Do Not Need All the Memories
Pivotal points that are paradigmatic memories that speaks for all
Using present to tap into what’s relevant from past
Identify the repetitive patterns of behavior and attendant emotional responses
Highlight how the person learned to adapt
Demonstrates what life in the “warzone” was like.
Critical mass – Consciousness raising
Shift the psyche from inside to outside the trauma vortex.
The need to do every bit of memory work is based on fears
Of not getting it right,
Of the beliefs based about trauma,
Of avoiding making a mistake and being punished
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)
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
Pg. 9
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Trauma Treatment Triggers Trauma
Stage II work elicits Stage I issues
Intense affect inhibits cognitive functioning
Decreasing dissociative defenses increases PTSD symptomology
Safety
Finding other ways to deal with overwhelming emotions
Grounding exercises,
The power of relationship
Learning about the body and mind
How to calm the self,
Become more present
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
Differentiating past from present
Critical Therapeutic Issues
You’re supposed to be able to get over it yourself
We all need each other far more than we are willing to admit.
What was it like to be you, disconnected from the rest of human
kind?
What does it means to be a person and live in the human
condition?
Role of Therapist and Therapeutic Alliance
Cannot be the blank screen
Healing can only occur within the context of a healthy relationship
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
Methods
Assembling Dissociative Components
Non-leading Questions
If you weren’t there, you don’t know.
Dealing with the client’s need to be believed
Believing their experience while not getting stuck in validating
what you have no way of validating
Not getting caught up in who, what, where, and when
Those basics become a way to avoid loss, abandonment, betrayal
When to talk about ‘why’
The question may be a distraction, moving from emotional to intellectual
It can be a different question, helping to understand others and themselves
Connors & Danylchuk
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Exploring the recalled event
Empowering the person to work with the beliefs about self, others and the
world
Recognizing and responding to the traumatized body & mind
Enumerating and acknowledging the missed chances and lost
opportunities
Developing the client’s ability to question and to view experiences and
events from alternate perspectives
None of these core issues require absolute knowledge of exactly what
happened.
Moving Forward & Backward to Complete Beginning, Middle & End
Allowing non-linear processing
Develop a coherent narrative
Trauma memories tend to be a repeating loop of a portion of the event
Identify the context and finding the frame of reference
Asking either:
What happened next? or
What happened before that?
All along the way, existential issues arise and need to be dealt with
Accept the vulnerability of being human
We need each other in order to survive
Independence is an illusion
We do have the ability to be separate, independent, but not
disconnected from others.
We are interdependent, and that makes us all vulnerable to each
other.
Stage II will often activate Stage I needs
Practice re-stabilization
Sharing Across Alter Personalities
Metaphors for helping
Taking spoonfuls of pain,
Letting feeling be carried out by the breath,
Joining hands,
Giving wisdom, knowledge to others in the system,
Pushing strength into the part that needs it.
When appropriate, ask for spiritual help in the form accessible to the
client, which may mean they create something for themselves that you
would never have thought of.
Metaphors to create a sense of oneness out of many and value all within
Team,
Village,
Orchestra,
Tribe
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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.
Hypnosis
Extremely useful,
Hypnosis with DID clients is often not the usual preparation, induction, etc.
DID people are already in trance,
Help guide their process in healthy directions
EMDR
Can be very useful in specific applications
Be very well trained and careful with DID people
Level 3 training is recommended for anyone with a dissociative client
Somatic Therapies
Very useful
Very powerful
Be careful - Do you want to activate or calm?
Prolonged Exposure
Least useful,
Can be re-traumatizing,
The client may suppress more, looking better while feeling worse
Mourning
Grief
The intensity of grief
Affect comes in waves
Look for relief between the waves
Assurance that the grieving will not go on forever
Learn to accept support and give it to self
Self-soothing
Holding and comforting that should have happened can happen in
visualization with the voice and presence of the therapist to guide it
Key questions
What did you want?
What was done to you?
What didn’t you get because of that?
Therapist’s ability to stay present
Determines how far the client can go
Clients are highly attuned to the reactions and responses of the therapist
Will stop themselves rather than push the therapist too far
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Understanding and Working with Complex Trauma and Dissociation
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Why Me?
Perpetrators and Narcissism
No I and Thou
Other as prop or audience
Karpman’s Triangle:
Roles in a subculture
Therapeutic Exercise
Have client identify roles in family,
How they may have shifted between family members,
Look at own internal system to see how it had to adapt to those
roles,
Explore how internal system reflects those roles to deal with
family
To escape the Triangle and allow for growth and freedom
Mindfulness,
Curiosity,
The ability to observe self and other
What Does It All Mean?
Normalize the reactions and learned behaviors.
Those worked for that original situation
Now the person needs to learn new things.
Developmental process happening within therapy
Who am I?
Letting go of the false self/selves
Allow the authentic self to emerge.
Explore key therapeutic questions
About Self,
About Others
About Relationships
About Life
Finding Strength
Buried treasure: Finding the self amidst the ruins
Identifying the strengths derived from survival
Keen observational skills
Adaptability
Compassion
Wisdom
An increasing ability to see the truth of the world and remain in it
Control
Locus of Control Issues
Attachment to Perpetrator – often a necessary survival tactic
Stockholm Syndrome – seeing how best to connect with perpetrator to live
Control paradigm in dysfunctional families
Explore what can and can’t be controlled
Shifting shame to another areas of life give the illusion of control
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Understanding and Working with Complex Trauma and Dissociation
Pg. 14
Shame
Perpetrators displace blame & shame
Shame as inhibitor: stifles joy, happiness, any kind of vulnerability.
Nathanson’s shame diagram – act out, act in, blame others, blame self.
Keeps the trauma stuck.
Shame avoids Powerlessness
Holding onto shame is an attempt to avoid the feeling of being out of
control and powerless.
Ironically, facing shame pulls the person out of the abyss of powerlessness
Therapist needs to be able to sit with the shame
Explore culpability – where responsibility truly resides
Explore reality of choices
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.
CONCLUDING REMARKS
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 order to avoid the reality of
our own personal human needs and frailties.
Abandonment, Shame, and Powerlessness are the key elements
Abandonment:
Not wanted, not included
Shame:
Not worthy
Powerlessness: Not able to build a bridge back
Therapy Builds the Bridge - The Therapeutic Alliance Creates Community
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Understanding and Working with Complex Trauma and Dissociation
Pg. 15
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Mandler, J. M., (2004). The foundations of mind: origins of conceptual
thought. Oxford: Oxford Press.
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syndromes. New York: Norton.
Nijenhuis, E.R.S. (1999). Somatoform dissociation: phenomena, measurement, and
theoretical issues. Netherlands: Van Gorcum.
Ogden, P. & Minton K. (2000) Sensorimotor psychotherapy: One method for processing traumatic memory. Traumatolgy 6(3)
O’Hanlon, B., Bertolino, B. (1998). Even from a broken web: brief,
respectful solution-oriented therapy for sexual abuse and trauma. New York:
John Wiley & Sons.
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Ericksonian approach. New York: Norton.
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Phillips, M., Frederick, C. (1995). Healing the divided self: clinical and
Ericksonian hypnotherapy for post-traumatic and dissociative conditions. New York: Norton.
Connors & Danylchuk
Understanding and Working with Complex Trauma and Dissociation
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Pliszka, S. R. ((2003). Neuroscience for the mental health clinician. New
York: Guilford.
Rhoades, G.F., Sar, V. (2006). Trauma and dissociation in a cross-cultural
perspective: not just a North American phenomena. New York: Hawthorne
Maltreatment & Trauma Press.
Rothschild, B. (2000). The body remembers: the psychophysiology of trauma and
trauma treatment. New York: Norton.
One of the first somatic books.
Rothschild., B. (2010). 8 keys to safe trauma recovery: take-charge strategies
to empower your healing. New York: Norton.
Good for clients.
Rosen, S. (1982). My voice will go with you: the teaching tales of Milton H.
Erickson. New York: Norton.
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workbook for healing. New York: Guilford.
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Schiraldi, G. R., (2000). The post-traumatic stress sourcebook: a guide to
healing, recovery and growth. Los Angeles: Lowell House.
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Schore, A. N. (2003). Affect dysregulation and disorders of the self. New
York: Norton.
Schupp, L. (2006). Assessing and Treating Trauma and PTSD.
Shapiro, R. (2010). The trauma treatment handbook: protocols across the
spectrum. New York: Norton.
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interact to shape who we are. New York: Guilford.
Siegel, D. J. (2010). Mindsight: the new science of personal transformation.
New York: Bantam.
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and brain. New York: Norton.
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clinicians, researchers, & educators. Maryland: Sidran.
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positive changes in the aftermath of crisis. New Jersey: Lawrence Erlbaum
Assoc.
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emotions: theory and research. New York: Guilford.
Connors & Danylchuk
Understanding and Working with Complex Trauma and Dissociation
Van der Hart, O., Nijenhuis, E., Steele, K. (2006). The haunted self:
structural dissociation and the treatment of chronic traumatization . New
York: W. W. Norton & Company.
This book has very helpful tables in the midst of the writing, with do’s and
don’ts that help therapists set the therapy frame and guide the client
through the process.
van der Hart, O., Steele, K., Boon, S., Brown, P., (1993) The Treatment of Traumatic Memories: Synthesis,
Realization, and Integration. Dissociation, 6, (2/3), 162-180
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Wieland, S., (2010). Dissociation in traumatized children and adolescents:
theory and clinical interventions. New York: Routledge.
Brand new – great for working with children and adolescents, which means it
would be helpful for dissociative clients who have those parts active in
present time.
Ziegler, D. (2002). Traumatic Experience and the Brain.
Internet Links:
http://www.isst-d.org/
http://www.isst-d.org/training/Training-index.htm
http://www.trauma-pages.com/
http://www.sidran.org/
http://www.istss.org/Home.htm
http://www.isst-d.org/jtd/GUIDELINES_REVISED2011.pdf
https://www.cmellc.com/landing/pdf/A10001101.pdf
http://www.firstpersonplural.org.uk/dvd
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