Treating Trauma-Related Dissociation: 2017 edition - Chapter 6

  • 7 Replies
  • 92 Views
*

Hope67

  • Member
  • 1417
    • View Profile
Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« on: January 13, 2019, 06:57:19 PM »
Treating Trauma-Related Dissocation: A Practical, Integrative Approach (2017) by Kathy Steele, Suzette Boon, & Onno Van Der Hart
Chapter 6: Beyond Diagnosis: Further Assessment, Prognosis, and Case Formulation.

Within this chapter, they talk of how "most dissociative patients have many complex symptoms that do not fit neatly into any one diagnostic category" - and they recommend that therapists should have "dual awareness of diagnosis and the overall pervasive developmental impact of cumulative trauma".  They also emphasise that it is "essential to look at what is unique to a given patient".

They talk about the need to assess things over a course of time, and within the therapy.   Therefore assessment by therapists is seen as an 'ongoing process'. 

Domains that they suggest are important include: the" patient's daily functioning, support systems, capacity for relationship with the therapist and others, trauma-related phobias, management of dissociation, and ability to cooperate in therapy, learn new skills, and profit from interventions."

There is a section next entitled "The Patient's Resources and Needs."

Within this, they look at resources such as "Financial resources; social support and sociocultural and religious resources and deficits, and multicultural factors."  They also mention "Cognitive resources and deficits" and within this category they include "traumatic brain injury; capacity to mentalize; schemas; and insight".


On p.125 I found this part particularly interesting where it says "Typically those who have intellectual insight without change are stuck in some type of resistance that is, in principle, amenable to resolution.  But the therapist must then focus on working with the resistance rather than on making further gains in insight."

Another line that resonated with me was where they said "One important note about insight in dissociative patients is that one part may have understanding while another does not.  In other words, insight does not develop evenly across parts.  Dissociative patients can seem to have great insight in (and memory for) one session and have completely lost it in another.  Insight is thus often a slow evolution of realization rather than a series of major 'Aha!' moments."

They then have some case examples of people - one person who has 'delayed insight' and another who has 'behavioural change without insight' -

I am going to give the first example, as it seems to resonate with parts of me, and here it is:

"Case example of delayed insight: Coretta - It was only in the 6th year of therapy that Coretta, a highly dissociative patient with DID and obsessive-compulsive personality disorder, could begin to develop an understanding of her self-punitive behaviour of withholding any pleasurable experiences from herself and could make significant changes to accept more positive experiences in her life.  She had believed for most of those years that she was only being pragmatic and doing without when she needed to, and that her behaviour was normal and responsible.  She would say things that on the surface seemed reasonable, but actually the way she used these beliefs was harmful to her: you have to make do with what you have; you have to do things you don't want to do.   The insight that she was withholding from herself, in order to punish herself for being abused, was long in coming.  But once that insight took hold with true realization, she made significant changes over the course of the next two years, including getting a better paying job and a better place to live, buying herself some new clothes for the first time in years, taking a vacation for the first time as an adult, and finding several healthy relationships."


What is interesting to me, is the conclusion they make that "lack of insight likely leaves patients vulnerable to returning to problematic behaviours during stress."


I also related a lot to this sentence: "The part of the patient that functions in daily life may have a goal to feel better and be more independent and competent; a child part has a wish to be taken care of; most parts have schemas that they are unlovable; and a perpetrator-imitating part screams that no one deserves to get better.  The more that therapists can identify these conflicting thoughts, wishes, goals, and schemas, the better they can help their patients find ways to accept and change them."


*** "Skills to recognize, tolerate, and regulate emotions are essential to develop in the beginning of treatment, as dissociative disorders are partly disorders of regulation."


The next sections are about 'emotional resources' and 'somatic resources' and 'imaginal resources'  and the use of these in therapy. 

The next section is about 'Trauma-related phobias' and how early treatment is "geared toward reducing those phobias, as patients must learn to tolerate inner experience to make progress."  They list several variations of phobias:

"phobia of inner experience (thoughts, emotions, sensations, memories, perceptions, predictions, fantasies, wishes); phobia of traumatic memory; phobia of dissociative parts; phobia of attachment (and intimacy) and attachment loss; and phobia of change."

There is then a section on 'psychological defences' and 'previous treatment history' ; 'attachment patterns'; (I found it particularly interesting that they mentioned that "each dissociative part may have a different attachment style").

The next section (p.132) is entitled 'Assessing the patient's reactions to dissociation' and the Core Concept here is "How the patient reacts to being dissociative, how dissociative parts (and the patient as a whole) deal with conflict, and which conflicts are intense among parts are all essential to assess."

I related to this - on p.133 - when they said "It is much less important that patients accept a diagnosis and certain terminology than it is to find ways to help patients accept their inner experience."

The remaining sections are entitled: 'Assessing precipitants of switching'; 'Relationships and conflicts among dissociative parts'; and then there is a longer section entitled 'Assessing Trauma History'.

p.136 This section is entitled 'Assessing Prognosis'.  Then 'Tracking Treatment Progress' and some case examples at the end of the chapter. 

The summary at the end of the chapter says "Assessment, prognosis, and case formulation are integral in informing treatment planning and progress.  Therapists should make ongoing assessments and change treatment plans accordingly.  They should also regularly - quarterly, every six months, or annually - discuss treatment progress and goals with patients to determine whether therapy is effective and what might need to be adjusted or improved."


(My conclusions on reading this chapter are that a therapist who is informed about complex trauma and dissociation follow a thorough procedure when assessing, and it was interesting to see the factors they look for, and the complexity of working with the needs of the different dissociative parts.  I related to some aspects of the case examples given, although my level of insight was limited, as I think it 'touched' certain parts - but I wasn't completely sure why - if that makes sense).

Hope  :)

*

Hope67

  • Member
  • 1417
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #1 on: January 13, 2019, 07:08:11 PM »
Not sure how I managed to put italics through the whole of that chapter, but I'm not sure how to change it, so I'll leave it as it is...
Hope  :)

*

woodsgnome

  • Member
  • 1332
  • I did not wish to live what was not life
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #2 on: January 14, 2019, 03:33:25 AM »
Thanks for putting these summaries together, Hope. Maybe I'll find some patience with myself better after reading this, given as how dissociation has filtered into several parts of my therapy sessions. My t has, per the suggestion in the book, extreme patience as she senses how often I fall into this self-defeating pattern.

She especially seems adept at slowly bringing me back  to noticing my tendency to resist any hints suggesting okayness, softly noting how easily I revert to hesitation about acknowledging the many good parts of my being. It's as if I consider that very dangerous territory for reasons associated with various traumas.

I also tend to want to get down on myself for not being more resilient more quickly to these patterns; she tries to bring me back to consider I'm not as awful as I treat myself. It works, but I can as quickly dissociate and revert to resistance. So -- frustrating and as suggested, I tend to jump from short insights about this back to resistance, also apparently typical per the authors.

I think we (and certain therapists) can lose sight of just how complex these outcomes really are. Many thanks for bringing this book to the fore.

*

Wattlebird

  • Member
  • 548
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #3 on: January 14, 2019, 10:54:42 AM »
Hi hope I like what it says,
Treating Trauma-Related Dissocation: A Practical, Integrative Approach (2017) by Kathy Steele, Suzette Boon, & Onno Van Der Hart
Chapter 6

*** "Skills to recognize, tolerate, and regulate emotions are essential to develop in the beginning of treatment, as dissociative disorders are partly disorders of regulation."

This really resonated, and "that insight is often a slow realisation rather than a series of aha moments" and all parts don't always have that insight yet, I've muddled the words but I think it still gets across the same meaning.
After reading this I purchased the book today, (I think I'm working on greater insight and not the continued resistance haha no I'm working on the resistance as well. )
Thanks hope

*

sj

  • Member
  • 58
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #4 on: January 14, 2019, 11:59:57 AM »
hi Hope
this sounds really interesting and useful - thanks for posting it  :thumbup: ... I've checked if it's in my state's library system but it's not, so I've added it to my ever-growing book wishlist  :whistling:
 


*** "Skills to recognize, tolerate, and regulate emotions are essential to develop in the beginning of treatment, as dissociative disorders are partly disorders of regulation."


This really resonated, and "that insight is often a slow realisation rather than a series of aha moments" and all parts don't always have that insight yet, I've muddled the words but I think it still gets across the same meaning.

hi Wattlebird
I've not worked with this stuff in any focused way, yet, but the bit you highlighted and your comment on it resonated with and intrigued me. Ta

*

Three Roses

  • Member
  • 2012
  • CPTSD is an injury, not an illness.
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #5 on: January 14, 2019, 05:24:49 PM »
Hi sj, some library systems will purchase books if they're requested enough. May I suggest contacting your local library to see if there are options? Best wishes to you  :wave:

*

sj

  • Member
  • 58
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #6 on: January 15, 2019, 06:46:23 AM »
Hi sj, some library systems will purchase books if they're requested enough. May I suggest contacting your local library to see if there are options? Best wishes to you  :wave:

Good suggestion TR  :thumbup:

*

Hope67

  • Member
  • 1417
    • View Profile
Re: Treating Trauma-Related Dissociation: 2017 edition - Chapter 6
« Reply #7 on: January 16, 2019, 07:12:42 PM »
Hi everyone,
It is so nice to read that you each have found these summaries helpful - I am feeling a bit tired at the moment, otherwise I would have replied to you each individually - so please forgive me for not doing so, but I've read all your comments here.
Sj - what I would say to you is that there are several versions of this book, by the same authors - I think one is called 'Coping with' and the one that I have is called 'Treating...' - so you might want to decide which one to get.  I think I might have gone for the wrong one - BUT - I have found it helpful - so I am glad to have it - and I know that Wattlebird has the other one - 'Coping with...' and that she has also purchased the 'Treating...' one - I suspect I may end up purchasing the 'Coping with...' one too - unless I can get my library to order it - that might be an option, if they're agreeable.
I'll hope to summarise the next chapter on the weekend, when I have a bit more time.  I am keen to do it, but trying to pace myself at the same time.
Hope  :)