Treating Trauma-Related Dissociation: 2017 edition - Chapter 4

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Treating Trauma-Related Dissociation: 2017 edition - Chapter 4
« on: December 07, 2018, 09:56:42 AM »
Treating Trauma-Related Dissociation: 2017 edition by Kathy Steele, Suzette Boon & Onno Van Der Hart.
Chapter 4: Beyond Attachment: A Collaborative Therapeutic Relationship.

This chapter emphasises that "a collaborative model" is paramount and that it will enable "adult growth, change, and development".

p.68 talk about the "challenges in using a Parent-Infant Attachment Model in trauma therapy" - and points out that there is potential that "some parts of the patient are often terrified that therapy will end and that the therapist will abandon them" - and therefore they may not engage  - hence they are talking about how the therapist should be able to recognise and work with the deep conflicts - and resolve these over the course of treatment.

They conclude that "therapists need a model that takes into account the contradictions, conflicts, and confusions of multiple dissociative parts within one person."

Personally, I found this paragraph on p.69 very helpful:
"A major goal in therapy is to help dissociative patients first accept child parts, develop understanding and compassion for them, and eventually realize they are aspects of themselves.  They can learn to take care of child parts and foster the child parts to "grow up" and learn to deal with dependency needs from an adult perspective.  Most importantly - our patients must also grieve what has been lost in childhood - what cannot be undone or loved away no matter how much someone does, or cares, or is available in the present."

Further parts of the chapter focus on "Collaboration versus caregiving in therapy" and say that both therapist and patients can confuse these things.  They give some examples in the chapter and conclude "We - patient and therapist - work as a team to ehlp the patient realize inner conflicts and painful realities, including the fact that the therapist is not a caregiver."

A paragraph on p.74 felt very relevant to me - and it was this one "Chronic trauma survivors struggle with managing adequate regulation of closeness and distance, often swinging wildly between the extremes according to the defenses and needs of various parts of themselves that are dominant in the moment."

They go on to talk about the complexity for the therapist of working with someone who has dissociative parts - and that it can be like a roller-coaster for the therapist.  This makes me feel better in myself, knowing that it's more complicated - and will take time to get to grips with.  But not impossible!  I have hope.

p.75 has a table entitled "The Over- and Underinvolved Therapist" and then lists the possible factors that could result from either of those things, and the potential for burn-out.  In the paragraph leading up to that table they said "The therapists' job is to stand relatively still no matter which part of the patient is prominent, without pursuing or distancing much, without becoming too enmeshed or too detached, while being engaged and present to the greatest degree possible."

(My personal reflection on that paragraph is that I find it helpful in trying to say 'engaged' with my different parts - as opposed to blending with them - i.e. I have noticed that I can be curious about them, and I can 'sit with them' sometimes - I can feel their presence and I'm beginning to notice characteristics or 'feelings' about them etc.  Occasionally I feel blended with them, and that's when I feel as if I'm incredibly anxious and maybe that is comparable to an EF (emotional flashback) - I'm not sure if I make sense of these things in the way I should - but I'm trying to express what it feels like in this reflection).

Another particularly helpful paragraph to me is on p.76 and is as follows:
"Therapists can support patients in recognizing ways in which patients themselves create ruptures with others, and how to handle their own relational mistakes, which often involve the inappropriate reactions of different dissociative parts.  Patients learn to accept their inner experiences (Including dissociative parts) without judgement, fear, or shame - a task modelled by the therapist."

There is a section entitled "Collaboration and Implicit Communications: The Felt Sense of You and Me" - they mention that verbal language and also body language are important.  The point they make is that "Language and implicit communications must be relatively congruent with each other for us to accurately share and mentalize" - they go on to talk about 'felt sense' and that "Dissociative parts often communicate implicitly when they are "behind the scenes" - that is, when they are not in complete executive control."  They give this example:
"Therapists often feel these unspoken undercurrents, these persistent threads of feelings and urges.  For example, therapists may feel confusion or fogginess, a strong pull to distance or caretake, lassitude or hopelessness, sexual tension, anger, dread, sadness, or a sense of not really knowing the patient even after many months.  These each tell the therapist something about the patient and about what the patient cannot or dares not yet know or speak."

(Personal reflection: I really find that last paragraph and example really interesting, as I do notice undercurrents and themes - sometimes in my writing when I've re-read things that I've written here in this forum - or one part of me will be shocked at what another part has communicated - etc.  I recognise parts of me that 'rub things out' - but I feel like they still know what has been rubbed out - if that makes sense).

p.78 There are a couple of paragraphs here that I found like 'pearls' - and they are:
"When social engagement is coupled with the ability to understand another's intentions and motivations, we are able to regularly repair and reconnect, which is what helps (re)regulate us.  Through repair we can strengthen our trust that a good enough relationship can withstand the usual foibles and failures of a good enough person.  We can also accept that not all relationships last for the length of our lives, and we do not have to negate the good parts of a relationship when it ends or changes.  WE come to realize that loss is forever a part of life and love, and that we can still take the risk to be vulnerable and open, and tolerate loss when it comes."

(Personal reflections - I found that quite triggering, as I fear abandonment and loss - I find it very emotive - but at the same time, I wanted to share that paragraph as I feel it is really important).

This paragraph - also from p.78 - was very helpful:
"We each have a tendency to prefer either relational regulation or self-regulation.  Some people naturally tend to reach out to others first when distressed - to call a friend or talk to a partner.  Others find it natural to want to self-regulate first - to take a walk, to reflect and sort out their feeings before talking to someone else.  Either approach is fine, as long as we are also able and willing to use a nonpreferred type of regulation when it is needed and appropriate."

(Personal reflection: I found that gave me 'food for thought' - and I wish I had been able to do more relational regulation when I was a child - I think I relied entirely on self-regulation.  As an adult, I still rely on self-regulation more - but I am now reaching out and using relational regulation - and it's a refreshing and helpful way - so far anyway.

They wrote a Core Concpt as "Relational support does not depend solely on face-to-face contact but rather on whether one person has a felt sense of the other's support and whether that felt sense is experienced even in the absence of the other."

(Personal reflection: I think that this forum has become a means of 'relational support' to me - because I have a strong 'felt sense' of support from the people I've communicated with here - and it really helps to cope in 'real life' situations -  :grouphug:  I think this has grown to enable me to feel stronger to reach out for 'relational support' amongst some of my friends, and even to people I've not know very long.  It's a bit of a scary prospect at the same time, but overall it's been positive.)

p.80 to 83 include a "Case Example of helping a patient develop a felt experience of the therapists' role" and they go into detail in the form of what was said in the therapy session - I'll just comment on one part of this - where the patient (Nathalie) said to the therapist "You want David and Sam here? ("David" and "Sam" are the parts of Nathalie that protect her from disappointment and hurt by insisting she avoid relational closeness and trust.)"

Personal reflection: I have those parts too - I don't have names for them, but I really relate to the description and function of those parts. 

The remaining parts of the chapter focus on more case examples - and it says that "a major goal is to help patients participate in life and relationships.  If they remain in a safe cocoon with the therapist, some patients may be unwilling to ever risk the rough-and-tumble of the real world."

p.86 has a "Case example of learning to self-regulate" and I relate to this part which says  that there was a part of the patient (Roger)  whose function was "to prevent Roger from having painful experiences and to defend against shame by attacking self"

(Personal Reflection: I recognise that I have a part which does this - and has this same function).

The Summary they provide on p.89 to conclude the chapter says
"A parent-infant model of attachment can greatly inform the therapeutic relationship - yet there are difficulties with using the model without additional modifications.  Our innate need to collaborate and share can also contribute to the structure of the therapeutic relationship.  Collaboration is as much about implicit communication and sharing as it is about explicit words, and good collaboration results in a sense of competence and well-being.  Countertransference discolsures can be a powerful way to promote collaboration in therapy."

(Reflection: I think this is a useful chapter and I gained quite a bit from reading it - although it took me a couple of re-reads to really process it - and take it in, and gradually I think I understood it better.  Many examples from it resonated with me - and I felt it was personally relevant.

Hope  :)



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Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 4
« Reply #1 on: December 30, 2018, 02:24:18 PM »

p.68 talk about the "challenges in using a Parent-Infant Attachment Model in trauma therapy" - and points out that there is potential that "some parts of the patient are often terrified that therapy will end and that the therapist will abandon them" - and therefore they may not engage 

Yes my t has used this model and when she explained it to me I freaked out a bit.
When I read this about how the therapist can best work with dissociation in clients, I am amazed at how spot on my t is with this, she never caregives (which used to frustrate me a lot) is accepting of all my parts. It's very encouraging.
I also prefer to self regulate, but am learning to relationally regulate a bit, I agree that this forum has helped me learn to do this better (a lot better) and my t of course.
Good work hope



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Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 4
« Reply #2 on: December 31, 2018, 03:56:43 PM »
Hi Wattlebird,
It sounds like your T is great - especially that she never caregives and is accepting of all your parts.  That does sound very encouraging. 
I like your mention of self-regulating and relationally regulating - that's something I have learned through this book, and through discussing things here.  So helpful. 
Hope  :)