Treating Trauma-Related Dissociation: 2017 edition - Chapter 9

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Treating Trauma-Related Dissociation: 2017 edition - Chapter 9
« on: February 16, 2019, 06:41:27 PM »
Treating Trauma-Related Dissociation: 2017 edition by Kathy Steele, Suzette Boon & Onno Van der Hart.  Chapter 9: Phase-Oriented Treatment: An Overview.

On p.179 they say "Therapy begins with stabilization, then treatment of traumatic memory, and finally integration of dissociative parts and more standard therapy issues."
They comment that "Phased treatment is not actually linear; rather, it is recursive, returning as needed to earlier issues according to the needs of the patient.  They emphasise the need of the therapist to be reflexive and meet the patient's needs, whilst staying within a window of tolerance.

p.180 it says "Therapists will normally face resistance, rage, intense shame, suicidality and other self-destructive behaviours, powerlessness, and vulnerability."

The next section is entitled "Phase 1: Safety, Stabilization, Symptom Reduction, and Skills Building."
I found this part particularly helpful "Patients must practice skills to regulate arousal before addressing memories directly in order to maximise the chance of success."

p.181 There is a section entitled "Managing and Working with Traumatic Memories in Phase 1" and I found this part helpful, where it says "Exposure treatments for PTSD are not completely effective for the long-term and pervasive effects of complex developmental trauma.  Since a major consequence of chronic trauma is a deficient integrative capacity, patients often do not yet have the foundation to tolerate exposure to traumatic memory early in therapy (Boon et. al. 2011); Gold, 2000; Kluft, 2013; Steele 2005; Van der Hart 2006).

Especially interesting to me was this sentence "Many problems of dissociative patients are developmental - that is, they lack capacities that are learned over the course of normal development.  No amount of work on traumatic memories will provide these capacities."

I was particularly fascinated by this sentence, at the bottom of p.181 where it says "Many patients either present either with a complete aversion to traumatic memories or an aggressive push to talking about them that overrides the fears and concerns of some dissociative parts of themselves.  In Phase 1, the therapist must be mindful of this inner conflict and ensure that it is fully addressed so that therapy is neither too stagnant nor too fast-paced (Van der Hart & Steele, 1999)."

p.185 has a section entitled "Containment of Flashbacks"  and defines them as "reactivated somatosensory relivings that involve some or all of the components of a traumatic memory".  The Core Concept here is "Flashbacks should be contained and the patient grounded in the present.  These are overwhelming experiences in which the patient is outside the window of tolerance, and thus not a good place to begin work on a traumatic memory."

"The presence of dissociative parts adds an additional complexity to managing flashbacks." 

This next sentence resonated with me - and it says "Sometimes patietnts have the experience of a perpretator-imitating part evoking flashbacks intentionally as a punishment, perhaps as a reminder not to tell, or as a way to control other parts through fear.  In these cases the therapist must work directly with the perpetrator-imitating part in order to explore the reasons for the flashbacks and to find cooperative ways to stop them."

The Core Concept on p.187 is "Patients generally have strong inner conflicts among dissociative parts between knowing and not knowing, telling and not telling.  These are essential to acknowledge and resolve."

I related to this paragraph on p.188 where it says "Many patients come to therapy with the idea that they can "get over" their childhood and "get the trauma out", they will have a better life.  So some practically abandon their lives and jump headfirst into their inner world. "  This sentence is particularly powerful to me "As one patient said 'I am realizing I need to take ownership of my life, because I am really sick of spending all my time living like I was still in the past.'

They say "Therapy must help patients not only explore their inner world and overcome their past but improve the quality of their lives now.  This involves a complex balance of being present with an inner and outer focus, or at least the ability to effectively alternate the two."

A section on p.189 is entitled "The Central Role of Trauma-Related Phobias in Phase-Oriented Treatment" - and in this they say "Avoidance and lack of realization must be continually assessed and approached within the tolerance of the patient."

They list the Trauma Related Phobias in Phase 1 as:

The phobia of inner experience.  They say "A central problem for dissociative patients is their ongling avoidance of various aspects of their inner experience, including memories, thoughts, emotions, sensations, reactions to relationships, and dissociative parts.  A phobia of the body is a major challenge in the treatment of patients with dissociative disorders.  Many patients are extremely avoidant and fearful (and sometimes ashamed) of their sensations.  Many, if not most, regulation skills have sensory components, and being present requires bodily awareness, so this phobia is partiuclarly essential to overcome."

Other phobias include:

Phobia of attachment and attachment loss

Phobia of dissociative parts

Dilemmas between knowing versus not knowing and true versus not true

Phobia of change

The next section on p.190 is entitled "Trauma-Related Phobias in Phase 2" - and mentions "fears of remembering or reliving"  "Phobia of attachment and attachment loss will be addressed in regard to the patient's relationship with the perpetrators".

The next section is entitled "Trauma-Related Phobias in Phase 3" and mentions "successful grieving and more change and growth."  They mention that "The phobia of inner experience may reemerge during this time as a defense against sadness and loss."  "Patients may be challenged to take adaptive risks that they have never been willing to take before.  They must risk vulnerability if they wish to have more and better relationships, which may again evoke the phobia of attachment and attachment loss. The phobia of the body emerges again in Phase 3, with issues around sexuality and coming to terms with the body one owns."

The next section on p.191 is entitled "Working with Dissociative Parts Throughout Phase-Oriented Treatment" and I found this sentence really interesting, where it says "The more the therapist works intensively with child parts, the more hostile parts can be activated, creating a systemic imbalance that can destabilize the patient.  It is not recommended to play with child parts or treat them as literal children."  (Note to self- I would like to write more abotu this in my Journal, because this resonates a lot with me, and I have a personal experience relating to this that I'd like to write more about) ***

"Many patients are afraid and ashamed of angry, self-destructive parts, including parts that imitate the perpetrator."  It goes on to say "It is imperative for both patient and therapist to gradually understand these parts and their functions and learn to communicate and collaborate.  Therapy easily becomes stuck if these parts are not included, as they create ongoing inner turmoil."

I admit, I've skipped over the next couple of pages, but they are very interesting, but my ability to summarise them is not up to it - however, on p.194 I think this sentence is very interesting and relevant "When the patient is dissociative, memories are often quite fragmented, and thus are not available as a whole.  Synthesis involves the bringing togehter fragments of memory into a coherent whole, which is then shared among dissociative parts - a more complex process."

"Certainly, not every detail or every memory of trauma need by synthesized; rather, it is essential for patients to realize their reactions surrounding the event, the most threatening aspects of the memory, and the maladaptive core beliefs and behaviour that evolved from the memory.  Synthesis is the necessary beginning of a difficult and longer course of realization that involves accepting, owning, and adapthing to what was and what is.  Realization continues throughout Phase 2 and long into Phase 3."

p.194 Section entitled "Phase 3: Integration of the Personality and Rehabilitation" "Painful grieving that paves the way for deepening realization, confrontation, of existential crises, relinquishing maladaptive beliefs and behaviours, learning to lieve iwth a (more) unified personality, and ongoing struggles to engage in the world in new and unfamiliar ways."

"Phase 3 involves grieving, as the patient increasingly realizes the cumulative losses suffered as a result of being traumatized and the fact that life at times can continue to be very difficult and painful (Van der Hart 1993, 2006)"  "Yet this integrative grief work can eventually suport the patient in making adaptive changes that can bring greater meaning, balance, and perhaps even pleasure to current life.  The therapist must ensure that grieving is coupled with experiences of success and joy in the present."

p.196 has a section entitled "Termination" (this is a trigger word for me as I find any form of loss or 'goodbye' very upsetting, but I am going to still write it here.

"Termination can be very emotional, as it involves change and loss due to separation from the therapist, who has become a central attachment figure for the patient.  Follow-up is considered essential to monitor full integration - that is , unification of the patient's personality."

The final section, on p.196 is entitled "Case Management Versus Psychotherapy" and then there is a section on 'Further explorations' and that's the end of the chapter.

Hope  :)