Restoring the Shattered Self:

Transcription

1 Restoring the Shattered Self: * Symptom Stabilization for Complex Trauma Survivors Heather Davediuk Gingrich, Ph.D. Denver Seminary heather.gingrich@denverseminary.edu

2 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 Heather Davediuk Gingrich,

3 Heather Davediuk Gingrich,

4 Posttraumatic Stress Disorder - even single exposure - natural disasters - rape incident - witnessing violence - combat veterans - primarily cognitivebehavioral treatments - International Society for Traumatic Stress Studies (ISTSS) Trauma Field 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 Heather Davediuk Gingrich,

5 Posttraumatic Stress Disorder: DSM-5 Criteria 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,

6 DSM-5 Change in Criteria A Sexual assault listed as a possible traumatic event Response of fear, helplessness, or horror no longer included Heather Davediuk Gingrich,

7 DSM-5 Additional Symptom Cluster 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. Heather Davediuk Gingrich,

8 DSM-5 PTSD Dissociative Subtype 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. Heather Davediuk Gingrich,

9 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 Heather Davediuk Gingrich,

10 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 survivors; DSM-5 now lists a dissociative subtype Heather Davediuk Gingrich,

11 Normal versus Pathological Dissociation 11

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

13 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 Heather Davediuk Gingrich,

14 Attachment Style and Dissociation Attuned, good enough parenting Secure attachment style Integration of self-states Inattentive/neglectful/abusive parenting Insecure (Ambivalent/Disorganized) attachment styles Dissociated self-states (Gingrich, 2013) 14

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

16 Heather Davediuk Gingrich, DSM-V Diagnoses Related to Dissociation Dissociative disorders Dissociative amnesia Depersonalization/derealization disorder Dissociative identity disorder (DID) Dissociative disorder not otherwise specified 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, bipolar)

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

18 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 Heather Davediuk Gingrich,

19 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 Heather Davediuk Gingrich,

20 BASK - AFFECT Affect is dissociated from other aspects of memory Example: feeling of fear for no apparent reason Heather Davediuk Gingrich,

21 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 Heather Davediuk Gingrich,

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

23 Three-Phase Treatment Process 23

24 Rationale for Phase-Oriented Model Premature trauma processing can lead to destabilization Hospitalization Inability to function in job Difficulty parenting Basic coping capacities can be overwhelmed Heather Davediuk Gingrich,

25 Three Phases Phase I Safety and Stabilization Phase II Processing of Traumatic Memories Phase III Consolidation and Restoration Heather Davediuk Gingrich,

26 Phase I Safety and Stabilization 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 Heather Davediuk Gingrich,

27 Phase I Safety and Stabilization (cont d) Safety from Others Identifying healthy vs. unhealthy relationships Helping clients find physical safety Heather Davediuk Gingrich,

28 Safety from Self and Symptoms Making sense of symptoms Symptoms as attempts at coping Warning signals 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 Heather Davediuk Gingrich,

29 Heather Davediuk Gingrich, Phase II - Processing of Traumatic Memories Readiness for Phase II Work 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

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

31 Phase II - Processing of Traumatic Memories (cont d) Facilitating Integration of Self and Identity 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 Roadblocks for counselors Keeping Perspective Heather Davediuk Gingrich,

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

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

34 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 Heather Davediuk Gingrich,

35 Dealing with Spiritual Issues 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 Heather Davediuk Gingrich,

36 Dealing with Spiritual Issues (cont d) 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 Non-coercion 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) Heather Davediuk Gingrich,

37 Phase III Consolidation and Resolution 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 Employment Decision as to whether or not to confront the perpetrator Forgiveness Heather Davediuk Gingrich,

38 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

39 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, (5 th ed). Washington, DC: Author. Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), Bull, D., Ellason, J., & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26, 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),

40 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, 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. 40

41 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, NY: Guilford Press. 41

42 AACC Research Opportunity Mindi Brown Lunday is a Counseling Psychology Doctoral student through Argosy University Online completing her dissertation research on the spiritual impact of trauma. Throughout her clinical experience and educational research, it became evident that those who are able to integrate spiritual concepts into their healing have a better prognosis following trauma, yet many therapists do not feel comfortable addressing spiritual matters inside the therapy room. In order to address these concerns, she is conducting a qualitative case study exploring the Christian principles current therapists are using when working with trauma clients. The goal is to identify and better understand what trauma survivors need in order to heal the spiritual impact of trauma and to identify specific interventions that are currently working in order to assist therapists who have not been trained, or are hesitant, to incorporate spiritual matters in therapy. If you would like to be a part of this research study or would like more information, please contact Mindi at mindilunday@gmail.com or by phone,