Surviving Sexual Abuse: Counseling Adults Abused as Children
Restoring the Shattered Self: The Treatment of Complex Trauma AACC National Conference, 2014 Heather Davediuk Gingrich, Ph.D. Denver Seminary [email protected] www.heathergingrich.com 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 www.heathergingrich.com Trauma Field Posttraumatic Stress Disorder Complex Traumatic Stress Disorder - even single exposure (Disorders of Extreme Stress) - multiple exposures - natural disasters - 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
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 Sexual assault listed as a possible traumatic event Response of fear, helplessness, or horror no longer included http://pro.psychcentral.com
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. http://pro.psychcentral.com DSM-5 PTSD Dissociative Subtype chosen when PTSD is seen with prominent
dissociative symptoms depersonalization experiences of feeling detached from ones 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, 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? 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 CONTINUUM OF DISSOCIATION DISSOCIATIVE EPISODE NORMAL hypnosis ego states automatism
s childhood imaginary play fear/terror repression highway hypnosis
sleepwalking !mystical/ religious experiences (e.g., meditation, ecstatic experiences) ACUTE STRESS DISORDER (up to 4 wks.)
POST TRAUMATIC STRESS DISORDER (4 weeks +) flashbacks numbness, detachment, absence of emotional response
reduced awareness of surroundings (dazed) derealization depersonalization amnesia for aspects of the trauma DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED DISSOCIATIVE DISORDER
DDNOS with features of DID Polyfragmented DDNOS Dissociative trance disorder Possession trance disorder DISSOCIATIVE
IDENTITY DISORDER DID Polyfragmented DID Adapted from Braun, B. G. (1988) 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 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) 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 ones self, e.g., a sense of looking at ones self as if one is an outsider Derealization: A feeling that ones surroundings are strange or unreal. Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict about ones identity
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 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)
BASK MODEL OF DISSOCIATION Behavior Affect (emotions) Sensation (physical) Knowledge Full, integrated memory includes all four re-associated components. Braun, 1988 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 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 BASK - AFFECT Affect is dissociated from other aspects of memory
Example: feeling of fear for no apparent reason BASK AFFECT (continued) 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 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 BASK Model Gingrich, H. D., 2013, p. 107 Three-Phase Treatment
Process 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 Three Phases Phase I Safety and Stabilization Phase II Processing of Traumatic Memories Phase III Consolidation and Restoration
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 Phase I Safety and Stabilization 2
Safety from Others Identifying healthy vs. unhealthy relationships Helping clients find physical safety 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 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 BASK Model Gingrich, H. D., 2013, p. 107 Phase II - Processing of Traumatic Memories (contd) 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 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 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 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 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) 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 Confronting the perpetrator Forgiveness 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 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 clinicians 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. 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 counselors 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. 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.
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ACGME EVALUATION REQUIREMENTS. What you will receive via e-mail: Talk w/slides. Evaluation form templates. 1. Resident Semiannual Evaluation. 2.Summative Evaluation. 3.Annual Faculty Evaluation. 4.USF Morsani College of Medicine Annual Program Review . Links. Common Program Requirements (CPR)
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