Treating Trauma-Related Dissociation: 2017 edition - Chapter 8

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Hope67

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Treating Trauma-Related Dissociation: 2017 edition - Chapter 8
« on: February 09, 2019, 03:39:50 PM »
Book by Kathy Steele, Suzette Boon & Onno Van der Hart "Treating Trauma-Related Dissociation: A Practical Integrative Approach" - Chapter 8 "Principles of Treatment".

They mention that the best approach is "simply good, solid psychotherapy, with the addition of an understanding of and ability to work with trauma and dissociation."  on p.164 they say "The more therapists can help the patient stay in the moment with what is happening internally and in the relationship right now, the more effective therapy will be."  and the title of that paragraph is 'Focus on Process, not Content'.

In particular I related to this paragraph, which says "How the patient is affected by what happened is really the focus of treatment, as well as how the patient may be enacting this in the relationship with the therapist."

The Core Concept is "The content of traumatic memories should not be ignored, but therapists should understand and work with the dynamics of the patient's inner system, and relationships when traumatic memories emerge or are avoided.  What happens within the patient and what happens in relationship when traumatic memories are evoked is an essential focus of treatment."

They focus on pacing and also on changing the focus of therapy as a pacing strategy.  They emphasise enabling the patients to have "regulatory skills and cooperation among parts to manage" - in order to then be able to work with traumatic memories.  "Once regulatory skills are in place, treatment of traumatic memories can commence."

They emphasise a 'window of tolerance' for the patient, and also for the therapist.

p. 170 has a section entitled "Recognize and Utilize the Patient's Somatic Experience" - and its interesting that they said "It is important to note that somatic work does not need to include touch.  The therapist can comment on patients' gestures, posture, and muscle tension, explore sensations and felt experience, and encourage patients to practice new patterns or try experiments of movement and awareness without ever touching them."  There is a section of questions in this section which are useful - and speak of using somatic experience as a positive resource.  They also mention the work of Pat Ogden (2006) and Levine (2008).  They also talk of pairing somatic work with imaginal work.

The next section, on p. 171, is entitled "Use Level of Functioning in Daily Life as a Major Signpost of Progress" - and I particularly found this part relevant to myself - where it says "Because dissociative patients have avoided realizing so many painful experiences, it is likely that they may have more negative feelings as they begin to realize more about their lives" (this really hits home to me - I relate to this a lot).  I find this next sentence hopeful, as it says "However, even when they may feel more genuine emotions that are painful, they may suffer less because they are learning to accept and tolerate inner experience instead of avoid it."

The Core Concept states "The patient's general level of functioning should be maintained or improved by treatment, with any regressions being short-lived.  If the patient has increasing difficulty in dealing with daily life, the intensity and pacing of therapy must be examined as a potential contributor."

The next sections are entitled "Communicate Clearly and Clarify What the Patient Means' and "Set and Keep Boundaries and a Clear Treatment Frame"

p.174 has a section entitled "Understand the Role of Hypnosis, Trance, and Trance-Logic in Dissociative Parts' - and talks about the fact that "Hypnotic trance often occurs regularly in dissociative patients" - and that "All dissociative parts are characterized by a certain degree of trance logic"  Orne (1959) coined this phrase, and it "indicates a special type of concrete thinking that is often paired with strong imaginative components, in which there is a decrease in critical judgement and an increased tolerance of logical incongruity.  It inhibits the ability to reflect and take perspective, and it involves very concrete thinking and psychic equivalence (confusion between internal and external reality).  In trance, dissociative patients more easily think in terms of images than words."

They go on to give examples including "A patient can say with no sense of incongruence that her mother lives in her head, or that a part is sitting on the sofa next to her, or that there is a hallway inside with many doors, some of which are sealed shut.  A "dead" part may talk with the therapist, and a part that is a "tree" can also have a lively conversation with the therapist or comfort a small child part."  They give many more examples.

They emphasise that the therapist "must also help the patient to get out of trance, and live in the present as much as possible." (Kluft, 2013).

p175 there is a section entitled "Treat All Dissociative Parts Equally and as Aspects of One Person" and this starts with the sentence "The literature is unanimous in insisting that therapists view dissociative parts as aspects of a single individual, not as separate entities."  They also say "Therapists are encouraged to treat all parts with the same acceptance and openness, not favouring one over another (Chu, 2011; Kluft, 1993)"

When I first read this section, I underlined this sentence "In complex dissociative disorders, this tendency is magnified, in part by patients who disown aspects of the self that are not acceptable and who do their best to keep those parts out of therapy so that the therapist cannot even access them." (This makes me think about the fact that I have become aware of some parts of myself that feel 'unacceptable' - and which I've not yet written about in my Journal or in the forum.  But I know those parts are there.

The next section is entitled "Never Try to 'Get Rid of' Dissociative Parts"  - they talk of "transforming" and "integrating" them, - not killing them off or exiling them.  "Disowned parts must be accepted and changed".  "Thus, the long-term goal is to help all parts of the patient understand and accept each part, even though certain behaviours are not acceptable.   In this way every part begins to have more in common with the others, sharing similar skills, emotions, and beliefs, to the point that there is no longer the need for parts to be separate.  After all, healthy development of self involves being creative, adaptable, and flexible enough, that we can cope with whatever comes."

Core Concept: "One long-term goal of treatment is to help patients accept with compassion all parts of themselves, and to separate disapproval of behaviours from disapproval of parts of self."

The final sections, on p. 177 are entitled "Constantly Monitor and Manage Transference and Countertransference" and "When the Therapist Becomes Defensive or Makes a Mistake, Repair with the Patient" and finally the section entitled "View Resistance as Protection" - and they state "Our task is to understand the function of resistance as a protection against something the patient is not yet able or ready to experience (Messer, 2002)."

I found this chapter to be helpful and interesting. 

Hope  :)