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Restoring the Shattered Restoring the Shattered Self: Self: Phase II
Treatment of Complex Trauma
AACC World Conference, 2015AACC World Conference, 2015
Heather Davediuk Gingrich, Ph.D.Denver Seminary
www.heathergingrich.com
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My Background in this Specialization
Sexual abuse survivors Dissociative disorders Other trauma survivors (see Gingrich, 2002)
Research on dissociation and trauma in the Philippines
Recognition of overlap in treatment techniques
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www.heathergingrich.com
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Trauma Field Posttraumatic
Stress Disorder- even single exposure
- natural disasters- rape incident- witnessing
violence- combat veterans
- primarily cognitive-behavioral treatments- International Society for Traumatic Stress Studies (ISTSS)
Complex Traumatic Stress Disorder
(Disorders of Extreme Stress)- multiple exposures - incest survivors
- child abuse and rape- multi-faceted treatment approaches- International Society for the Study of Trauma and Dissociation (ISSTD)
Trauma Psychology, Division 56, APA
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DSM-5-Definition of Dissociation
Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motorcontrol, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience
Normal versus Pathological Dissociation
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CONTINUUM OF DISSOCIATION
NORMALDISSOCIA-
TIVEEPISODE
ACUTE STRESS
DISORDER(up to 4 wks.)
POSTTRAUMATIC
STRESSDISORDER(4 weeks +)
DISSOCIA-TIVE
DISORDER
DISSOCIA-TIVE
DISORDERNOT
OTHERWISESPECIFIED
DISSOCIA-TIVE
IDENTITYDISORDER
• hypnosis
• ego states
• automatisms
• childhood imaginary play
• fear/terror
• repression
• highway hypnosis
• sleepwalking
• !mystical/
• religious experiences (e.g., meditation, ecstatic experiences)
• flashbacks
• numbness, detachment, absence of emotional response
• reduced awareness of surroundings (dazed)
• derealization
• depersonalization
• amnesia for aspects of the trauma
• Dissociative amnesia
• Dissociative fugue
• Depersonali-zation disorder
• DDNOS with features of DID
• Polyfrag-mented DDNOS
• Dissociative trance disorder
• Possession trance disorder
• DID
• Polyfrag-mented DID
Adapted from Braun, B. G. (1988)
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Why Talk About Dissociation?
Used by victims of all kinds of trauma There is a link between both peritraumatic
dissociation and PTSD, in addition to a well-documented association between trauma and posttraumatic dissociation (see Gingrich, 2005)
Dissociative subtype of PTSD in DSM-5 Explanation for why treatment techniques
for dissociative disorders can also be helpful for other trauma survivorsDSM-5 now lists a dissociative subtype
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Developing the Capacity to Dissociate
We are born unintegrated (i.e., dissociated) Healthy attachment leads to integration of
behavioral states Impact of child abuse Dissociation as a defense Mental disorder
- dissociative disorder/other disorder with dissociative symptoms
Putnam, 1997
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Attachment Style and Dissociation
Attuned, “good enough” parenting
Secure attachment style
Integration of self-states Inattentive/neglectful/abusive parenting
Insecure (Ambivalent/Disorganized)
attachment style
Dissociated self-states(Gingrich, 2013)
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BASK MODEL OF DISSOCIATION
BehaviorAffect (emotions)Sensation (physical)Knowledge
Full, integrated memory includes all four re-associated components.
Braun, 1988
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BASK - KNOWLEDGE
Trauma survivor has full or partial cognitive knowledge of traumatic event
Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation
Generally what people mean when they say “I remember”
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BASK - BEHAVIOR Behavior is dissociated from other aspects
of memory Individual acts in a certain manner without
knowing why Examples:
-avoiding intimate relationships
-vomiting after sexual intercourse
-dislike of particular foods
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BASK - AFFECT
Affect is dissociated from other aspects of memory
Example: feeling of fear for no apparent reason
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BASK – AFFECT(continued)
There are no feelings attached to the cognitive knowledge of the memory
-flat affect-matter-of-fact tone of voicee.g., can talk about being raped as
though discussing the heat of the coming summer
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BASK - SENSATION Physical sensation is dissociated from other
aspects of memory Individual may have cognitive knowledge of the
traumatic event, be aware of related affect, and understand some behavior, but not remember the pain or pleasure associated with the trauma
Examples:
-body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained
-sexual excitement
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BASK ModelBASK Model
Gingrich, H. D., 2013, p. 107
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Three-Phase Treatment Process
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Premature trauma processing can lead to destabilization
– Hospitalization– Inability to function in job– Difficulty parenting– Basic coping capacities can be overwhelmed
Rationale for Phase-Oriented Model
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Phase I – Safety and Stabilization Phase II – Processing of Traumatic
Memories Phase III – Consolidation and Restoration
Three Phases
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Safety within the Therapeutic Relationship
Safety from OthersSafety from Self and Symptoms
Phase I – Safety and Stabilization
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Phase II - Processing of Traumatic Memories
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The Challenges
Assessing readiness for Phase II Adequate pacing
– Allow for maximum functioning– Minimize danger of suicide attempts– Avoid hospitalizations– Prevent premature termination
Appropriate use of grounding techniques Decrease risk of vicarious traumatization
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Assessing Readiness for Phase II
Does counselee have good coping/grounding skills?
Is counselee functioning adequately? What is the support network like? Are you (the counselor) prepared to:
– Hear horrific stories?– Deal with intense emotions?
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False Memory Syndrome Foundation (1992)
Research Findings– Brain research – Memory blocks do happen– Memory is not infallible
Implications– Do not ask leading questions– Always hold out healthy skepticism about the
details while validating the counselee’s experience
Nature of Memory
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Accessing Dissociated Memories
Deciding where to startWhen specific memories do not
surface Is memory recovery the goal?
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BASK ModelBASK Model
Gingrich, H. D., 2013, p. 107
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Facilitating the Integration of Experience
The importance of details Titrating the process Extent to which re-experiencing is necessary Grounding techniques Checking in Memory containment Structuring the session and counseling
relationship
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Working through Intense Emotions– General principles
• Importance of safety
• Being a container for counselee’s emotions
• Identifying and expressing feelings– E.g., Gestalt techniques
– Connecting physical sensation with an emotion
• Pulling people out of the intensity
• Use ability to dissociate
Facilitating Integration of Self and Identity
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Understanding and Dealing with Specific Emotions
Mourning: Denial, anger, and depression Guilt, shame, and self-hatred Fear of abandonment Anxiety, terror, and fear
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Levels of Integration of SelfLevels of Integration of Self
No Integration Partial Integration Full Integration
Gingrich, H. D., 2013, p. 121
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Integration of Self and ExperienceIntegration of Self and Experience
Gingrich, H. D., 2013, p. 122
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Is the Goal Full Integration?
Immediate goal is better functioning Some highly dissociative clients never
fully integrate– May be afraid to (i.e., fear of death of parts of
self)– Too much work and time
The process of integration can begin to happen from the beginning of therapy
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Roadblocks for Counselors
Difficulty managing the emotional intensity– Counselee’s picking that up– Symptoms of vicarious traumatization’\
Will this never end?
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Dealing with Spiritual Issues (1)
All phases, but particularly Phases II and III Gradual, often difficult process Allow client to set pace Often are questions re: why God did not protect
from the trauma In time clients can often see that God was there,
and is currently involved in their healing process In highly dissociative clients, some parts of self
may have a relationship with Christ, while others may not– E.g., internal Bible study
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Dealing with Spiritual Issues (2)
Distinguish between parts of self and demonic– Ultimately gift of discernment necessary– Potentially VERY destructive to attempt deliverance
ministry If any kind of deliverance/exorcism ritual is
decided upon make sure that the following factors are incorporated (Bull, Ellason, & Ross, 1998):– Permission of the individual– Noncoercion– Active participation by the individual– Understanding of DID dynamics by those in charge– Implementation of the procedure within the context of
psychotherapy See my article “Not all voices are demonic”
(Gingrich, 2005b)
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Keeping Perspective
God is in ultimately in control of the process
It may have taken decades for the harm to have been done, so the healing cannot be expected to take place quickly
Even five-ten years is short in the context of a life-time
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How the Church Can Help Educating about CTSD Providing emotional and spiritual support
– Formal care– Groups– Lay counseling– Mentoring, spiritual direction and life
coaching– Assigned helpers– Informal care
Churches and Christian mental health professionals in partnership
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References American Psychiatric Association (2000). Diagnostic and
statistical manual of mental disorders (text revision). Washington, DC: Author.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed). Washington, DC: Author.
Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16-23.
Bull, D., Ellason, J., & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26, 188-196.
Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press.
Gingrich, H. D. (2002). Stalked by Death: Cross-cultural Trauma Work with a Tribal Missionary. Journal of Psychology and Christianity, 21(3), 262-265.
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Gingrich, H. D. (2005a). Trauma and dissociation in the Philippines. In G. F. Rhoades, Jr. and V. Sar (2005), Trauma and dissociation in a cross-cultural perspective: Not just a North American phenomenon. New York, NY: Haworth Press.
Gingrich, H. (2005b). Not all voices are demonic. Phronesis, (Asian Theological Seminary/Alliance Graduate School, Philippines)12, 81-104.
Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: InterVarsity Press
McFarlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press.
Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum.
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Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press.
Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press.
van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.