The trauma model

In Trauma and Recovery (1998), Judith Herman devotes three chapters to outlining a three-stage framework for recovering from trauma – the three stages are explained briefly below.

1. The establishment of safety

The therapist aims to provide a safe haven for the acutely traumatised client and to establish a strong therapeutic alliance. Within this secure and trusting relationship, the client is empowered to develop the capacity for self-protection, self-soothing and self-care outside of the therapy environment. According to Herman, the first stage of recovery can be difficult, challenging and cannot be rushed.

2. Remembrance and mourning

Reconstructing and integrating the traumatic experience is an important aspect of the second stage of recovery. However, early exploratory work should be avoided until the foundations of safety are firmly erected, cautions Herman. In the second stage, the therapist’s task is one of spectator and helper, enabling the client to tell the untold. Telling the traumatic story may be pieced together through verbal communication by the client, or conveyed through non-verbal methods such as drawings, paintings or writings. For a therapeutic outcome though, explains Herman, the eventual goal is to put the traumatic experience into words (including describing any painful emotions, haunting images and bodily sensations associated with the trauma). Through the process of narrating the traumatic story, feeling the feelings associated with it, and being heard, the client is able to move forward and reconnect with life, rather than being shackled by the pain of the past.

Another essential facet of the second stage is mourning the inevitable losses that result from trauma. For example, in the case of abuse survivors, this involves grieving the loss of childhood, the loss of innocence, the loss of safety and trust, and letting go of the belief that a parent was kind, caring and considerate, etc. The second stage of recovery can be a protracted, painstaking, and intricate process, advises Herman.

3. Reconnection with ordinary life

The third phase of recovery is about developing a new sense of self, building a new future and forming new relationships, taking tangible steps to build up strategies for self-protection against possible future perils, enhancing one’s sense of power, control and self-esteem, strengthening associations with people that can be trusted, and perhaps revitalising previous life aims and goals.

To quote Herman ‘No single course of recovery follows these stages through a straightforward linear sequence.’ (p.154)

She also assigns a chapter to discussing the dynamics of her concept of complex post-traumatic stress disorder, used to discern symptoms and circumstances of CPTSD from those of PTSD, as well as presenting the diagnostic criteria for the theory.

Helpful aspects of therapy

Helpful aspects identified by the sample group who completed the survey for Healing the Hurt Within, 1st edition (Sutton, 1999) included:

• Being trusted to take care of one’s own wounds.
• Unconditional acceptance.
• Feeling valued and respected.
• Exploring unresolved issues from the past.
• Being assured feelings are normal.
• Being able to talk openly and honestly about issues.
• Feeling understood in spite of self-injury.
• Space to explore why self-injury happens.
• Regular time set aside, and privacy.
• Feeling safe to cry.
• Being taken seriously.
• Revealing scars for the first time.
• Speaking to a non-judgmental person.
• Being treated with firmness and gentleness.
• Learning to understand thought processes more.
• Working out how to cope with difficult situations.
• Keeping a journal/diary.
• Drawing painful and shameful experiences.
• Setting small targets and goals.
• Monitoring self-injury and working out the triggers.
• No pressures to stop self-injury until other coping strategies are firmly in place.
• Learning assertiveness, anger management, and stress management techniques.

Unhelpful aspects included:

• Personal prejudices, preconceived ideas, and stereotyping.
• Lack of continuity.
• Lack of empathy.
• Not feeling heard.
• A dictatorial, arrogant, and judgemental approach.
• Self-injury not recognised as a problem.
• Deeply-ingrained issues not being addressed.
• Ban on self-injury.
• Left alone to cope with the aftermath.
• The traditional 50-minute hour (considered sacrosanct by some therapists).

Summary

The foregoing emphasises the importance of the client and counsellor relationship, as well as suggesting that the presence of Roger’s ‘core conditions’ are necessary to achieve a successful therapeutic outcome. The need to explore past unresolved issues indicates that psychodynamic counselling has a key place in the healing process; further that cognitive behavioural techniques can also play a valuable role in assisting clients to challenge self-defeating or unrealistic thinking, goal setting, monitoring thoughts, feelings, actions and self-injury triggers, learning to become more assertive, and developing constructive anger management strategies and the art of relaxation. Moreover, as previously mentioned, it appears as if expressive therapies such as art therapy for example, can also be helpful.

The overall picture suggests that an eclectic approach (combining useful therapeutic techniques that already exist) or an integrative approach (integrating therapies or helpful aspects of therapy to create a new model [DBT and EMDR are examples]) is needed.

Dissociation

Rosemary Bray

Dissociation is a continuum, something we all experience at some level, a response to the fact that we ‘have other things on our mind’. All of us have experienced times when we ‘don’t feel like ourselves’, ‘were daydreaming’ or realise, in retrospect that we have been functioning on ‘automatic pilot’. This can be viewed as normal or simple dissociation.

Dissociation is a means of survival

For some children however, who are subjected to abuse, neglect, chaos or other stressful childhood experience, dissociation is more than a normal defence mechanism. It is a means of survival, a coping technique in a situation that is intolerable, a creative and highly effective learned response born of the child’s self-hypnotic statement (made originally during experienced danger) ‘I am not here’. It involves both denial of and detachment from the trauma whether the experience is current, real, threatened or remembered. It enables the child to escape, to not know, not feel and not be.

How dissociation is experienced

Dissociation may be experienced by the child as observing oneself from outside the body as if ‘floating on the ceiling while watching one’s other self being abused in the room below’. It is often said ‘It wasn’t me it happened to, it was a dream’, and described as ‘a feeling of everything being unreal even though recognised’.

As the degree of dissociation increases (this appears in general to be relative to the extent and frequency of the trauma) the individual may experience dissociative amnesia and dissociative fugue. This is a trance-like state, which provides ‘escape’ during the traumatic experience after which there is usually total amnesia both regarding events and the passage of time. The same trance state is often witnessed by the therapist as a client accesses the memory of the traumatic experience.

At the extreme end of the continuum of dissociation is Dissociative Identity Disorder (DID). The primary criteria for DID (DSM-IV-TR, 2000, p 529) is ‘the presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self)’.

Dissociation can become a habitual trigger response

For the child under threat of actual or perceived danger, internal or external, to dissociate may become a habitual trigger response; thus dissociation can occur frequently even when actual danger is not present. As with the ‘fight or flight’ response to trauma, when an individual dissociates, physiological and psychological processing is shut down to a minimum and bodily and mental functioning suspended. Recovery starts as soon as the danger is past and processing of the traumatic event can then take place.

The effects of repeated trauma

When an individual is subjected to repeated traumatic events, which keeps them in a state of dissociation or denial concerning the experience, processing of the trauma is unable to take place. This results in the splitting off not only of the actual experience but also of part of the self. This is often experienced by the child as ‘I went away and someone else came to take over’.

The role of the splits is to protect the host personality. This they do very effectively. However, the more parts that split off the greater the internal conflict and uncertainty, and the smaller and less cohesive the sense of self is (identity confusion). The very nature of dissociation requires the core person to be ‘missing’ and therefore means that it becomes impossible for the individual to maintain the consistent and continuous sense of self and time that is fundamental to the normal development of the psyche. This results in a ‘vertical’ splitting. Instead of the sense of self being continuous and connected through the passage of time, dissociation creates a pattern of separate, unconnected ‘snapshots’ of different selves.

This vertical splitting of the self differs from the horizontal splitting Freud described as repression in that with DID we become aware that the unconscious is actually easy to access in a safe therapeutic relationship.

Dissociation provides a means to separate the abused and non-abused child

Attachment is an innate response. A fundamental problem with dissociation is attachment to the perpetrator. For a child who is offered abuse and caring, good and bad, life and death inseparably from the same source, dissociation provides a means to separate the abused and the non-abused child and to live in the ‘now’ in isolation from either past or future.

For abused and neglected children it is within an environment where others are cruel, uncaring or helpless and there is pleasure in pain that they must develop a sense of self in relation to others; where intimate relationships are corrupt and the child itself defined as ‘a thing’, ‘a slave’, or ‘a whore’, they develop their capacity for intimacy. In a world where their body is at the disposal of others and there is no solace they are required to develop a capacity for body self regulation and self soothing. In this environment where absolute conformity to the mind of the abuser ensures the child’s survival the child has to develop a capacity for initiative.

Although the core self may be separated from the splits by a total amnesiac barrier, and there is likely to be some amnesia between groups of splits (normal world and abusive world, victim and perpetrator) there is some degree of awareness between splits of the existence of each other; particularly between those who hold similar memories.

Expression of the splits

The split-off parts of the self seek opportunity of expression in a response to the blocked-off part of the psyche’s attempts to process the trauma. These different identity states compete for control of the body resulting in the individual often presenting as completely different people. Each split has one way of being. Mood, speech, skills, age and name may change dramatically as different splits take over. Each split has a life experience only of their personal existence and, although they may observe from their inner place, their personal truth, and life view may come from a very brief window of time. A central paradox of dissociative identity disorder is that the splits are not ‘real’, as in being a whole person with an independent mind and body, but they are experienced by the self and others as real.

Dissociative Identity Disorder is frequently misdiagnosed

Frequently clinically misdiagnosed, frequently judged as mad within the community the dissociative individual has in fact developed a life saving technique. However, with changing circumstances and environment, the very response that has been the solution often becomes a problem.

Dissociative Identity Disorder in relation to self-harm

Self-harm features very frequently in the history of dissociative individuals, often in extreme forms. Many of the issues in relation to this mirror those already discussed in this book; the reliving, addictive effect, toxic shame, expression of rage and self-loathing.

There are however some issues more specific to the dissociative client one of which is that self-harm is sometimes used as a tool to ‘get back’ from a period of dissociation into the here and now, rather like an extreme grounding technique.

Self-destructive inner voices can be held not only by the core personality but by some of the splits (each of the splits has a specific function within the system). Until some level of integration has taken place, each identity believes themselves to have, on one level, an independent existence, thus there is an absence of understanding that harm to the self, equals harm to the whole system.

Another issue specific to dissociative individuals is that of hypnosis. If we understand dissociation as a type of highly effective self-hypnosis we can understand the ease with which a perpetrator could both sow seeds of self-harm in an existing split or create a split expressly for this purpose.

Working with dissociative clients

Undeniably the complex concepts of dissociation hold a fascination for those working in this area, not to mention the privilege of a therapeutic partnership with individuals of such immense courage and resourcefulness. However, no counsellor should lightly undertake a commitment to work with a client with DID. Inevitably the work will be long term, intense and demanding and the subject matter of disclosures often extreme and perverted. A background of sound practice including specialist supervision and a stable and supportive personal life is essential.

Boundary issues are constantly challenged by dissociative clients who are highly skilled at manipulation and have the resources of a whole range of splits (identities) to draw from. In many ways the dynamics of working with DID are similar to those encountered in group work.

It is impossible within the limitations of a few hundred words to give more than the smallest insight into this complex subject, and indeed into the issues of and approaches to working with DID clients. A relationship of trust between the client and counsellor is however the single most important feature.

Distorted cognitive thinking, double binds and attachment to the perpetrator are all major issues in this work. Working with abreaction and controlled regression can be beneficial to the individual as can painting, writing, and other alternative forms of expression and healing. The client may experience flashbacks and body memories. These are splinters of traumatic memory, which filter through the amnesiac wall. Often they re-trigger the dissociative state thus providing some kind of containment for the memory.

Dissociation allows the knowledge, bodily sensations, affect, and behaviour associated with the event, which would normally be integrated, to be separated. The bringing together of these in therapy allows the individual to know, feel, process and integrate the experience.

© 1999 Rosemary Bray

Used with permission

Therapeutic precautions to help prevent false memory allegations

George F. Rhoades, Jr., Ph.D., Clinical Psychologist There is never a guarantee that one will not be sued for ‘implanting false memories’ within the context of one’s therapeutic work. The following twenty precautions were developed subsequent to the review of False Memory Syndrome Foundation (FMSF) literature and court cases wherein therapists were sued for the reported ‘implantation’ of false memories.

• 1.Don’t accuse an individual of sexual abuse, but comply with the abuse reporting laws in your jurisdiction.
• 2.Don’t over estimate the accuracy of ‘recovered’ memories.
  • (a)Be aware of the process of memory.
  • (b)Be aware of possible contamination effects on memory.
  • (c)Be willing to educate your client regarding memory.
• 3.Don’t tell your clients that you ‘know’ that their memories are true.
  • (a)Unless you were physically present or had confirmed corroborating evidence at the time of the abuse, you cannot verify that abuse.
  • (b)You may give your opinion regarding diagnostic impressions of the client, the process of the patient’s memory recovery, and the relation of his/her account to current research and/or knowledge of memory and abuse.
• 4.Don’t tell your clients to ‘cut off’ their reported abusers/families. The therapeutic environment may be used to discuss the possible implications of major life changes, before choosing and acting on said changes.
• 5.Don’t lead your client in the recovery of his or her memories.
  • (a)Some clients may embellish memories to please your quest for more details.
  • (b)Don’t suggest types of abuse or possible perpetrators.
  • (c)Don’t jump to conclusions; allow the client to recover their own memories.
  • (d)Don’t push a client to discover and process memories too quickly.
  • (e)Don’t tell your client that he/she has the characteristics of an abuse victim.
• 6.Don’t recommend books, support groups to your clients that you are unfamiliar with.
• 7.Don’t breach confidentiality.
  • (a)Adult clients have the right of confidentiality (given the limits of abuse reporting laws). Don’t speak to family members without written permission.
  • (b)Written permission obtained, inform concerned parties regarding the therapeutic process and therapist’s limits in disclosure.
• 8.Don’t encourage the confrontation of reported abusers.
• 9.Don’t encourage legal action/retribution of clients against reported abusers.
• 10.Don’t look at your client(s) as a possible ‘good article’, subject for a ‘good book’, and/or to be interviewed by the media.
• 11.Don’t search for ‘dissociated’ memories.
• 12.Remember your role, that of a therapist not a police officer, investigator, etc.
• 13.Document the history of the recall of the ‘recovered’ memories.
• 14.Document treatment process.
  • (a)Treatment goals and progress towards goals.
  • (b)Therapeutic interventions.
  • (c)Patient’s statements regarding progress and interventions.
• 15.Obtain records of previous therapists.
• 16.Don’t utilise hypnosis without adequate training and supervision.
• 17.Be a reality check for your client.
• 18.Seek supervision/consultation.
• 19.Obtain Informed Consent.
  • (a)Hypnosis
  • (b)Innovative techniques
  • (c)Working in the area of ‘recovered memories’.
• 20.Be willing to refer a client.

© 1998 George F. Rhoades

Used with permission

Key points

• Don’t be afraid to enquire about self-injury – it gives the client permission to talk about it (if not at that moment, later on).
• Typically, counselling with people that self-injure is long-term.
• There is no blueprint for working with people that self-injure. The overall picture suggests an eclectic or an integrative approach is needed.
• Addressing the underlying issues that are motivating self-injury is a primary goal of therapy.
• Don’t expect self-injury to stop straight away – giving up self-injury can be a slow process.
• Exploring difficult feelings or traumatic experiences may lead to a short-term increase in the client’s self-injury.
• Typically, individuals who self-injure are sensitive to other people’s reactions, and trust is often a key issue. Building trust takes time – it cannot be rushed. It’s also vital to be genuine with clients about your reactions to their self-injury; otherwise trust can be easily broken.
• ‘No self-injury contracts’ invariably do not work and can be counterproductive.
• If a client is self-injuring at an unsafe level and is at risk of becoming a danger to herself/himself, then hospitalisation may be necessary, but in general hospitalisation is not recommended for the majority of people that self-injure.
• Working with trauma survivors who self-injure can be taxing, and the risk of vicarious traumatisation (VT) should not be underestimated.
• Self-harm frequently features in the lives of individuals with a history of dissociation.
• A further risk of working with trauma survivors is the prospect of being sued for ‘implanting false memories’.
• Regular supervision, support and therapist self-care are crucial for therapists working in the area of self-injury and trauma.

About the contributors

Tracy Alderman, Ph.D. Tracy is a licensed clinical psychologist, leading expert in the field of self-injury, and author of The Scarred Soul: Understanding and Ending Self-Inflicted Violence (New Harbinger Publications, 1997), co-author of Amongst Ourselves: A Self-Help Guide for Living with Dissociative Identity Disorder (New Harbinger Publications, 1998), and numerous articles on the topic of self-injury. She provides training, workshops, and consultations nationwide and internationally.

Karen Marshall, LCSW. Karen is currently in private practice in San Diego where she specialises in treatment of self-injury, dissociative disorders, trauma, and sexual identity issues. She has been in private practice since 1991. Karen has consulted and presented on these topics nationally for over a decade. She is co-author (with Tracy Alderman) of Amongst Ourselves: A Self-Help Guide for Living with Dissociative Identity Disorder (New Harbinger Publications, 1998).

George F. Rhoades, Jr., Ph.D., Clinical Psychologist, is Chair of the International Society for Study of Dissociation World (ISSDWorld) and an International Speaker and Author on Trauma and Dissociation.

Rosemary Bray is an independent therapist. She lives in the UK, and has considerable experience of working with dissociative clients.

Useful resources

The following web pages were all retrievable at June 04, 2007.

Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy
Behavioral Tech, LLC
Founded by Dr. Marsha Linehan
DBT resources, products and training
http://www.behavioraltech.com/

Dialectical Behaviour Therapy: An Overview of Dialectical Behaviour
Therapy in the Treatment of Borderline Personality Disorder
Barry Kiehn and Michaela Swales
http://www.priory.com/dbt.htm

Eye Movement Desensitisation and Reprocessing (EMDR)

EMDR Institute, Inc. http://www.emdr.com/

Flashbacks

Coping with flashbacks: goals and techniques for handling the memories
Mental Health Matters
by Sean Bennick
http://www.mental-health-matters.com/articles/
article.php?artID=154
Ideas for coping with flashbacks
Bristol Crisis Service for Women
http://www.users.zetnet.co.uk/bcsw/leaflets/flashbacks.htm

Vicarious traumatisation/secondary stress/traps for therapists

A Phenomenological Study of Vicarious Traumatisation Amongst
Psychologists and Professional Counsellors Working in the Field of
Sexual Abuse/Assault
Lyndall G Steed and Robyn Downing, School of Psychology, Curtin
University of Technology, Perth, Western Australia.
http://www.massey.ac.nz/˜trauma/issues/1998–2/steed.htm

Chu, J.A. (1988). Ten Traps for Therapists in the Treatment of Trauma
Survivors. Dissociation, Vol. 1, No. 4.
https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1393/1/Diss_1_4_5_OCR.pdf

Special Considerations in the Treatment of Traumatised Patients
http://www.psychiatrictimes.com/p020292.html

Secondary Stress and the Professional Helper
http://www.ctsn-rcst.ca/Secondary.html

Vicarious Trauma: Bearing Witness to Another’s Trauma
http://www.uic.edu/orgs/convening/vicariou.htm

Therapy

British Association for Counselling and Psychotherapy (BACP)
Explanation of theoretical approaches
http://www.bacp.co.uk/seeking_therapist/theoretical_approaches.html