Restoring the Shattered Self The Treatment of Complex

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Restoring the Shattered Self: The Treatment of Complex Trauma AACC National Conference, 2014 Heather

Restoring the Shattered Self: The Treatment of Complex Trauma AACC National Conference, 2014 Heather Davediuk Gingrich, Ph. D. Denver Seminary heather. gingrich@denverseminary. edu www. heathergingrich. com

My Background in this Specialization w Sexual abuse survivors w Dissociative disorders w Other

My Background in this Specialization w Sexual abuse survivors w Dissociative disorders w Other trauma survivors (see Gingrich, 2002) w Research on dissociation and trauma in the Philippines w Recognition of overlap in treatment techniques

www. heathergingrich. com

www. heathergingrich. com

Trauma Field w Posttraumatic Stress w Complex Traumatic Stress Disorder - even single exposure

Trauma Field w Posttraumatic Stress w Complex Traumatic Stress Disorder - even single exposure - natural disasters (Disorders of Extreme Stress) - multiple exposures - incest survivors - rape incident - child abuse and rape - witnessing violence - multi-faceted treatment - combat veterans approaches - primarily cognitive- International Society for behavioral treatments the Study of Trauma and - International Society for Dissociation (ISSTD) Traumatic Stress Studies (ISTSS) Trauma Psychology, Division 56, APA

Posttraumatic Stress Disorder: DSM-V Criteria w w w w Exposure to traumatic event Intrusive

Posttraumatic Stress Disorder: DSM-V Criteria w w w w Exposure to traumatic event Intrusive Symptoms (at least 1) Avoidance Symptoms (at least 1) Negative Alterations in Cognitions and Mood (2 or more) Alterations in arousal and reactivity (2 or more) Symptom duration of more than 1 month Clinically significant distress/impairment in functioning Specifiers – With dissociative symptoms (depersonalization or derealization – With delayed expression American Psychiatric Association, 2013

DSM-5 – Change in Criteria A w Sexual assault listed as a possible traumatic

DSM-5 – Change in Criteria A w Sexual assault listed as a possible traumatic event w Response of fear, helplessness, or horror no longer included http: //pro. psychcentral. com

DSM-5 – Additional Symptom Cluster w Negative thoughts and mood or feelings – a

DSM-5 – Additional Symptom Cluster w Negative thoughts and mood or feelings – a persistent and distorted sense of blame of self or others – estrangement from others or markedly diminished interest in activities – an inability to remember key aspects of the event. http: //pro. psychcentral. com

DSM-5 PTSD Dissociative Subtype w chosen when PTSD is seen with prominent dissociative symptoms

DSM-5 PTSD Dissociative Subtype w chosen when PTSD is seen with prominent dissociative symptoms – depersonalization • experiences of feeling detached from one’s own mind or body – derealization • experiences in which the world seems unreal, dreamlike or distorted. http: //pro. psychcentral. com

DSM-5 -Definition of Dissociation Disruption of and/or discontinuity in the normal integration of consciousness,

DSM-5 -Definition of Dissociation Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience Normal versus Pathological Dissociation

Why Talk About Dissociation? w Used by victims of all kinds of trauma w

Why Talk About Dissociation? w Used by victims of all kinds of trauma w 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) w Dissociative subtype of PTSD in DSM-5 w Explanation for why treatment techniques for dissociative disorders can also be helpful for other trauma survivors. DSM-5 now lists a dissociative subtype

CONTINUUM OF DISSOCIATION DISSOCIATIVE EPISODE NORMAL ACUTE STRESS DISORDER (up to 4 wks. )

CONTINUUM OF DISSOCIATION DISSOCIATIVE EPISODE NORMAL ACUTE STRESS DISORDER (up to 4 wks. ) POST TRAUMATIC STRESS DISORDER (4 weeks +) DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED DISSOCIATIVE DISORDER • • 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 • • DISSOCIATIVE IDENTITY DISORDER DDNOS • with • features of DID Polyfragmented DDNOS Dissociative trance disorder Possession trance disorder DID Polyfragmented DID Adapted from Braun, B. G. (1988)

Developing the Capacity to Dissociate w We are born unintegrated (i. e. , dissociated)

Developing the Capacity to Dissociate w We are born unintegrated (i. e. , dissociated) w Healthy attachment leads to integration of behavioral states w Impact of child abuse w Dissociation as a defense w Mental disorder - dissociative disorder/other disorder with dissociative symptoms Putnam, 1997

Attachment Style and Dissociation w Attuned, “good enough” parenting Secure attachment style Integration of

Attachment Style and Dissociation w Attuned, “good enough” parenting Secure attachment style Integration of self-states w Inattentive/neglectful/abusive parenting Insecure (Ambivalent/Disorganized) attachment style Dissociated self-states (Gingrich, 2013)

Dissociative Symptoms w Amnesia: A specific and significant block of time that has passed

Dissociative Symptoms w Amnesia: A specific and significant block of time that has passed but that cannot be accounted for by memory w Depersonalization: Sense of detachment from one’s self, e. g. , a sense of looking at one’s self as if one is an outsider w Derealization: A feeling that one’s surroundings are strange or unreal. w Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict about one’s identity w Identity alteration: Objective behavior indicating the assumption of different identities or ego states, much more distinct than different roles Steinberg (1994).

DSM-V Diagnoses Related to Dissociation w Dissociative disorders – – Dissociative amnesia Depersonalization/derealization disorder

DSM-V Diagnoses Related to Dissociation w Dissociative disorders – – Dissociative amnesia Depersonalization/derealization disorder Dissociative identity disorder (DID) Dissociative disorder not otherwise specified w Selected other disorders with significant dissociative symptoms – – – Post-traumatic stress disorder (PTSD) Somatic symptom and related disorders Schizophrenia Borderline personality disorder (BPD) Others (e. g. , eating and feeding, anxiety)

BASK MODEL OF DISSOCIATION w Behavior w Affect (emotions) w Sensation (physical) w Knowledge

BASK MODEL OF DISSOCIATION w Behavior w Affect (emotions) w Sensation (physical) w Knowledge Full, integrated memory includes all four re-associated components. Braun, 1988

BASK - KNOWLEDGE w Trauma survivor has full or partial cognitive knowledge of traumatic

BASK - KNOWLEDGE w Trauma survivor has full or partial cognitive knowledge of traumatic event w Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation w Generally what people mean when they say “I remember”

BASK - BEHAVIOR w Behavior is dissociated from other aspects of memory w Individual

BASK - BEHAVIOR w Behavior is dissociated from other aspects of memory w Individual acts in a certain manner without knowing why w Examples: -avoiding intimate relationships -vomiting after sexual intercourse -dislike of particular foods

BASK - AFFECT w Affect is dissociated from other aspects of memory w Example:

BASK - AFFECT w Affect is dissociated from other aspects of memory w Example: feeling of fear for no apparent reason

BASK – AFFECT (continued) w There are no feelings attached to the cognitive knowledge

BASK – AFFECT (continued) w There are no feelings attached to the cognitive knowledge of the memory -flat affect -matter-of-fact tone of voice e. g. , can talk about being raped as though discussing the heat of the coming summer

BASK - SENSATION w Physical sensation is dissociated from other aspects of memory w

BASK - SENSATION w Physical sensation is dissociated from other aspects of memory w 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 w Examples: -body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained -sexual excitement

BASK Model Behavior Affect Sensation Knowledge Gingrich, H. D. , 2013, p. 107

BASK Model Behavior Affect Sensation Knowledge Gingrich, H. D. , 2013, p. 107

Three-Phase Treatment Process

Three-Phase Treatment Process

Rationale for Phase-Oriented Model w Premature trauma processing can lead to destabilization – –

Rationale for Phase-Oriented Model w Premature trauma processing can lead to destabilization – – Hospitalization Inability to function in job Difficulty parenting Basic coping capacities can be overwhelmed

Three Phases w Phase I – Safety and Stabilization w Phase II – Processing

Three Phases w Phase I – Safety and Stabilization w Phase II – Processing of Traumatic Memories w Phase III – Consolidation and Restoration

Phase I – Safety and Stabilization w Safety within the Therapeutic Relationship – Developing

Phase I – Safety and Stabilization w Safety within the Therapeutic Relationship – Developing rapport • Facilitative conditions – Becoming a safe person • Remember that every client is unique • Know your limitations • Give advance warning – Remaining a safe person • Keep appropriate therapeutic boundaries • Consult • Protect confidentiality

Phase I – Safety and Stabilization … 2 w Safety from Others • Identifying

Phase I – Safety and Stabilization … 2 w Safety from Others • Identifying healthy vs. unhealthy relationships • Helping clients find physical safety

Safety from Self and Symptoms w Making sense of symptoms – Symptoms as attempts

Safety from Self and Symptoms w Making sense of symptoms – Symptoms as attempts at coping – Warning signals w Therapeutic use of dissociation – Potentially assess use of dissociation • Somataform Dissociation Questionnaire (SDQ-5 or SDQ-20) (Nijenhuis, 1999) • Dissociative Experiences Scale-II (DES-II) (Putnam, 1997) • Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg, 1993) – Use of parts of self language – Contracting • symptom management • day to day activities • suicide – Ideomotor signaling

Phase II - Processing of Traumatic Memories w Readiness for Phase II Work w

Phase II - Processing of Traumatic Memories w Readiness for Phase II Work w Memory Work – Nature of memory – Accessing dissociated memories • Deciding where to start • When specific memories do not surface – Is memory recovery the goal? – Facilitating the integration of experience • • The importance of details Titrating the process Extent to which reexperiencing is necessary Grounding techniques Checking in Memory containment Structuring the session and counseling relationship

BASK Model Behavior Affect Sensation Knowledge Gingrich, H. D. , 2013, p. 107

BASK Model Behavior Affect Sensation Knowledge Gingrich, H. D. , 2013, p. 107

Phase II - Processing of Traumatic Memories (cont’d) w Facilitating Integration of Self and

Phase II - Processing of Traumatic Memories (cont’d) w Facilitating Integration of Self and Identity w Working through Intense Emotions – General principles – Understanding and dealing with specific emotions • • Mourning: Denial, anger, and depression Guilt, shame, and self-hatred Fear of abandonment Anxiety, terror, and fear w Roadblocks for counselors w Keeping Perspective

Levels of Integration of Self No Integration Partial Integration Full Integration Gingrich, H. D.

Levels of Integration of Self No Integration Partial Integration Full Integration Gingrich, H. D. , 2013, p. 121

Integration of Self and Experience Gingrich, H. D. , 2013, p. 122

Integration of Self and Experience Gingrich, H. D. , 2013, p. 122

Is the Goal Full Integration? w Immediate goal is better functioning w Some highly

Is the Goal Full Integration? w Immediate goal is better functioning w 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 w The process of integration can begin to happen from the beginning of therapy

Dealing with Spiritual Issues (1) w w All phases, but particularly Phases II and

Dealing with Spiritual Issues (1) w w 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 w In time clients can often see that God was there, and is currently involved in their healing process w In highly dissociative clients, some parts of self may have a relationship with Christ, while others may not – E. g. , internal Bible study

Dealing with Spiritual Issues (2) w Distinguish between parts of self and demonic –

Dealing with Spiritual Issues (2) w Distinguish between parts of self and demonic – Ultimately gift of discernment necessary – Potentially VERY destructive to attempt deliverance ministry w 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 w See my article “Not all voices are demonic” (Gingrich, 2005 b)

Phase III – Consolidation and Resolution w w Consolidating changes Development of new coping

Phase III – Consolidation and Resolution w w Consolidating changes Development of new coping strategies Learning to live as an integrated whole Navigating changing relationships – – – Marriage and parenting Friendships Relationship to God and church congregations Community Family of origin w Employment w Confronting the perpetrator w Forgiveness

How the Church Can Help w Educating about CTSD w Providing emotional and spiritual

How the Church Can Help w Educating about CTSD w Providing emotional and spiritual support Formal care Groups Lay counseling Mentoring, spiritual direction and life coaching – Assigned helpers – Informal care – – w Churches and Christian mental health professionals in partnership

References w American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text

References w American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author. w American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5 th ed). Washington, DC: Author. w Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16 -23. w Bull, D. , Ellason, J. , & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26, 188 -196. w Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press. w Gingrich, H. D. (2002). Stalked by Death: Cross-cultural Trauma Work with a Tribal Missionary. Journal of Psychology and Christianity, 21(3), 262 -265.

w Gingrich, H. D. (2005 a). Trauma and dissociation in the Philippines. In G.

w Gingrich, H. D. (2005 a). 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. w Gingrich, H. (2005 b). Not all voices are demonic. Phronesis, (Asian Theological Seminary/Alliance Graduate School, Philippines)12, 81 -104. w Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: Inter. Varsity Press w Mc. Farlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. Mc. Farlane, & L. Weisaeth (Eds. ), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press. w Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum.

w Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New

w Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press. w Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press. w van der Kolk, B. A. , Weisaeth, L. , & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. Mc. Farlane, & L. Weisaeth (Eds. ), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.