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Transcript of Restoring the Shattered Self: Mental Health and Missions, 2013 Restoring the Shattered Self: Complex...
Restoring the Shattered Self: Restoring the Shattered Self: Complex Traumatic Stress
Disorder (CTSD) and Missionaries
Mental Health and MissionsMental Health and Missions, , 20132013
Heather Davediuk Gingrich, Ph.D.Denver Seminary
www.heathergingrich.com
My Background in this Specialization
Sexual abuse survivors Dissociative disorders Other trauma survivors (see Gingrich, 2002)
Research on dissociation and trauma in the Philippines
Recognition of overlap in treatment techniques
www.heathergingrich.com
Trauma Field Posttraumatic
Stress Disorder- even single exposure
- natural disasters- rape incident- witnessing
violence- combat veterans
- primarily cognitive-behavioral treatments- International Society for Traumatic Stress Studies (ISTSS)
Complex Traumatic Stress Disorder
(Disorders of Extreme Stress)- multiple exposures - incest survivors
- child abuse and rape- multi-faceted treatment approaches- International Society for the Study of Trauma and Dissociation (ISSTD)
Trauma Psychology, Division 56, APA
Posttraumatic Stress Disorder:DSM-IV Criteria
Exposure to traumatic event Reexperiencing
– Memories, thoughts, mental images, dreams, flashbacks Avoidance/Numbing
– thought stopping, social withdrawal, amnesia for the trauma, constriction of affect
Hyperarousal– Irritability, explosive anger, hypervigilance, problems
with concentration, difficulty falling and staying asleep Symptom duration of more than 1 month Clinically significant distress/impairment in
functioning
American Psychiatric Association, 2000
DSM-5 – Selected Changes inCriteria for PTSD
Criterion A– Sexual assault listed as a possible traumatic event
Additional symptom cluster– Negative thoughts and mood or feelings– an inability to remember key aspects of the event.
Dissociative subtype– chosen when PTSD is seen with prominent dissociative
symptoms– depersonalization
• experiences of feeling detached from one’s own mind or body
– derealization• experiences in which the world seems unreal, dreamlike or
distorted. http://pro.psychcentral.com
DSM-5 PTSD Dissociative Subtype
chosen when PTSD is seen with prominent dissociative symptoms– depersonalization
• experiences of feeling detached from one’s own mind or body
– derealization• experiences in which the world seems unreal,
dreamlike or distorted.
http://pro.psychcentral.com
What about Missionaries?
Exposure to multiple traumatic events not uncommon
Increases risk of PTSD Complex traumatic stress may go unnoticed History of complex trauma can make a
missionary more susceptible to being triggered as a result of trauma on the field
Purpose of this Presentation
Identify complex traumatic stress disorder (CTSD) in missionaries
Outline the entire long-term treatment process
Focus on how a missionary counselor or a member care worker can help further healing and contain symptoms even with short-term interventions
Importance of Subjective Evaluation of Event
“No trauma is so severe that almost everyone exposed to the experience develops PTSD” (McFarlane & Gerolama, 1996, p. 148)
– Only 25-35 % of people who are exposed to a potentially traumatic experience develop PTSD (Carlson, 1997, p. 4)
– A history of complex trauma increases this probability
Role of Peritraumatic Dissociation
“Dissociation at the moment of trauma appears to be the single most important predictor for the establishment of chronic PTSD.” (Van der Kolk, Weisaeth, & van der Hart, 1996, p. 66)
If a missionary has already learned to dissociate as a result of an earlier history of complex trauma they will likely already have learned how to dissociate
Other Reasons to Learn About Dissociation
Used by victims of all kinds of trauma In addition to the link between
peritraumatic dissociation and PTSD, there is a well-documented association between trauma and posttraumatic dissociation (see Gingrich, 2005)
Dissociative subtype of PTSD in DSM-5 Explanation for why treatment techniques
for dissociative disorders can also be helpful for other trauma survivors
DSM-5-Definition of Dissociation
Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motorcontrol, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience
Normal versus Pathological Dissociation
CONTINUUM OF DISSOCIATION
NORMALDISSOCIA-
TIVEEPISODE
ACUTE STRESS
DISORDER(up to 4 wks.)
POSTTRAUMATIC
STRESSDISORDER(4 weeks +)
DISSOCIA-TIVE
DISORDER
DISSOCIA-TIVE
DISORDERNOT
OTHERWISESPECIFIED
DISSOCIA-TIVE
IDENTITYDISORDER
• hypnosis
• ego states
• automatisms
• childhood imaginary play
• fear/terror
• repression
• highway hypnosis
• sleepwalking
• !mystical/
• religious experiences (e.g., meditation, ecstatic experiences)
• flashbacks
• numbness, detachment, absence of emotional response
• reduced awareness of surroundings (dazed)
• derealization
• depersonalization
• amnesia for aspects of the trauma
• Dissociative amnesia
• Dissociative fugue
• Depersonali-zation disorder
• DDNOS with features of DID
• Polyfrag-mented DDNOS
• Dissociative trance disorder
• Possession trance disorder
• DID
• Polyfrag-mented DID
Adapted from Braun, B. G. (1988)
Developing the Capacity to Dissociate
We are born unintegrated (i.e., dissociated) Healthy attachment leads to integration of
behavioral states Impact of child abuse Dissociation as a defense Mental disorder
- dissociative disorder/other disorder with dissociative symptoms
Putnam, 1997
Attachment Style and Dissociation
Attuned, “good enough” parenting
Secure attachment style
Integration of self-states Inattentive/neglectful/abusive parenting
Insecure (Ambivalent/Disorganized)
attachment style
Dissociated self-states(Gingrich, 2013)
Dissociative Symptoms Amnesia: A specific and significant block of time that
has passed but that cannot be accounted for by memory
Depersonalization: Sense of detachment from one’s self, e.g., a sense of looking at one’s self as if one is an outsider
Derealization: A feeling that one’s surroundings are strange or unreal.
Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict about one’s identity
Identity alteration: Objective behavior indicating the assumption of different identities or ego states, much more distinct than different roles
Steinberg (1994).
DSM-V Diagnoses Related to Dissociation
Dissociative disorders– Dissociative amnesia– Depersonalization/derealization disorder– Dissociative identity disorder (DID)– Dissociative disorder not otherwise specified
Selected other disorders with significant dissociative symptoms– Post-traumatic stress disorder (PTSD)– Somatic symptom and related disorders– Schizophrenia – Borderline personality disorder (BPD)– Others (e.g., eating and feeding, anxiety)
BASK MODEL OF DISSOCIATION
BehaviorAffect (emotions)Sensation (physical)Knowledge
Full, integrated memory includes all four re-associated components.
Braun, 1988
BASK - KNOWLEDGE
Trauma survivor has full or partial cognitive knowledge of traumatic event
Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation
Generally what people mean when they say “I remember”
BASK - BEHAVIOR Behavior is dissociated from other aspects
of memory Individual acts in a certain manner without
knowing why Examples:
-avoiding intimate relationships
-vomiting after sexual intercourse
-dislike of particular foods
BASK - AFFECT
Affect is dissociated from other aspects of memory
Example: feeling of fear for no apparent reason
BASK – AFFECT(continued)
There are no feelings attached to the cognitive knowledge of the memory
-flat affect-matter-of-fact tone of voicee.g., can talk about being raped as
though discussing the heat of the coming summer
BASK - SENSATION Physical sensation is dissociated from other
aspects of memory Individual may have cognitive knowledge of the
traumatic event, be aware of related affect, and understand some behavior, but not remember the pain or pleasure associated with the trauma
Examples:
-body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained
-sexual excitement
BASK ModelBASK Model
Gingrich, H. D., 2013, p. 107
Three-Phase Treatment Process
Premature trauma processing can lead to destabilization
– Hospitalization– Inability to function in job– Difficulty parenting– Basic coping capacities can be overwhelmed
Rationale for Phase-Oriented Model
Phase I – Safety and Stabilization Phase II – Processing of Traumatic
Memories Phase III – Consolidation and Restoration
Three Phases
Phase 1: Safety and Stabilization
Where most missionary counselors/member care workers can be helpful
Developing rapport– Facilitative conditions
Becoming a safe person– Remember that every client is unique– Know your limitations– Give advance warning
Remaining a safe person– Keep appropriate therapeutic boundaries– Consult– Protect confidentiality
Safety within the Therapeutic Relationship
Helping individuals find physical safety
Identifying healthy vs. unhealthy relationships
Looking for signs of spiritual abuse
Safety from Others
Making sense of symptoms– Symptoms as attempts at coping– Warning signals
Therapeutic use of dissociation– Potentially assess use of dissociation
• Somataform Dissociation Questionnaire (SDQ-5 or SDQ-20) (Nijenhuis, 1999)
• Dissociative Experiences Scale-II (DES-II) (Putnam, 1997)
• Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg, 1993)
– Use of parts of self language– Contracting
• symptom management• day to day activities• suicide
– Ideomotor signaling
Safety from Self and Symptoms
Readiness for Phase II Work Memory Work
– Nature of memory– Accessing dissociated memories
• Deciding where to start• When specific memories do not surface
– Is memory recovery the goal?– Facilitating the integration of experience
• The importance of details• Titrating the process• Extent to which reexperiencing is necessary• Grounding techniques• Checking in• Memory containment• Structuring the session and counseling relationship
Phase II - Processing of Traumatic Memories
BASK ModelBASK Model
Gingrich, H. D., 2013, p. 107
Facilitating Integration of Self and Identity Working through Intense Emotions
– General principles– Understanding and dealing with specific emotions
• Mourning: Denial, anger, and depression• Guilt, shame, and self-hatred• Fear of abandonment• Anxiety, terror, and fear
Roadblocks for counselors Keeping Perspective
Phase II - Processing of Traumatic Memories (cont’d)
Levels of Integration of SelfLevels of Integration of Self
No Integration Partial Integration Full Integration
Gingrich, H. D., 2013, p. 121
Integration of Self and ExperienceIntegration of Self and Experience
Gingrich, H. D., 2013, p. 122
Is the Goal Full Integration?
Immediate goal is better functioning Some highly dissociative clients never
fully integrate– May be afraid to (i.e., fear of death of parts of
self)– Too much work and time
The process of integration can begin to happen from the beginning of therapy
Dealing with Spiritual Issues (1)
All phases, but particularly Phases II and III Gradual, often difficult process Allow client to set pace Often are questions re: why God did not protect
from the trauma In time clients can often see that God was there,
and is currently involved in their healing process In highly dissociative clients, some parts of self
may have a relationship with Christ, while others may not– E.g., internal Bible study
Dealing with Spiritual Issues (2)
Distinguish between parts of self and demonic– Ultimately gift of discernment necessary– Potentially VERY destructive to attempt deliverance
ministry If any kind of deliverance/exorcism ritual is
decided upon make sure that the following factors are incorporated (Bull, Ellason, & Ross, 1998):– Permission of the individual– Noncoercion– Active participation by the individual– Understanding of DID dynamics by those in charge– Implementation of the procedure within the context of
psychotherapy See my article “Not all voices are demonic”
(Gingrich, 2005b)
Consolidating changes Development of new coping strategies Learning to live as an integrated whole Navigating changing relationships
– Marriage and parenting – Friendships– Relationship to God and church congregations– Community– Family of origin
Employment Confronting the perpetrator Forgiveness
Phase III – Consolidation and Resolution
How the Church/Member Care Organization Can Help …1
Educating about CTSD– Process of healing for the missionary– How they can be of help– Length of commitment– Setting of appropriate boundaries– Self-care for helpers
How the Church/Member Care Organization Can Help …2
Providing emotional and spiritual support– Formal care– Groups– Lay counseling– Mentoring, spiritual direction and life
coaching– Assigned helpers– Informal care
How the Church/Member Care Organization Can Help …3
Availability in times of crisis– Phone, email, Skype, prayer chains
Churches, member care organizations and Christian mental health professionals in partnership
Therapist should have one key contact person (e.g., pastor, elder, designated lay helper) who then communicates with other support people
What Can I Do with This Info?
Counselor – Be informed– Get training on how to work with CTSD
Pastor/Member Care Provider– Understand the process of healing
• Be more empathic• Know what to look for in making a counselor referral• Help gather other resources• Use some grounding techniques
References American Psychiatric Association (2000). Diagnostic and
statistical manual of mental disorders (text revision). Washington, DC: Author.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed). Washington, DC: Author.
Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16-23.
Bull, D., Ellason, J., & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26, 188-196.
Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press.
Gingrich, H. D. (2002). Stalked by Death: Cross-cultural Trauma Work with a Tribal Missionary. Journal of Psychology and Christianity, 21(3), 262-265.
Gingrich, H. D. (2005a). Trauma and dissociation in the Philippines. In G. F. Rhoades, Jr. and V. Sar (2005), Trauma and dissociation in a cross-cultural perspective: Not just a North American phenomenon. New York, NY: Haworth Press.
Gingrich, H. (2005b). Not all voices are demonic. Phronesis, (Asian Theological Seminary/Alliance Graduate School, Philippines)12, 81-104.
Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: InterVarsity Press
McFarlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press.
Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum.
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press.
Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press.
van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.