Welcome to the Winter edition of Blue Knot Review, an electronic journal chronicling recent developments and new perspectives around complex trauma and trauma-informed practice. What is Dissociation and Why do we Need to Know about It?Recent editions of Blue Knot Review introduced the just released Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation (2020). These guidelines are different from, but also complement, the updated Practice Guidelines for Clinical Treatment of Complex Trauma (2019). Both sets of guidelines, and also others, are available for free download and/or purchase here. This month we provide a dot point summary of the first chapter of the new Yet dissociative symptoms are often misdiagnosed or not accounted for at all. This is because many mental health professionals `do not know what dissociation looks like or how to assess for it’ (Danylchuk & Connors, 2017: 39). The following dot point summary is of the content of the first chapter of the new Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation (2020). In subsequent editions of Blue Knot Review, we will present content summaries of the remaining two chapters of these guidelines. Content summary of Chapter 1 of Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation, 2020: • The importance of dissociation is increasingly but insufficiently recognised within and outside the field of mental health. • While often associated with disorder, dissociation can be expressed in many forms (`healthy and adaptive, pathological and self-protective...’ Bromberg, 2001: 310); `it makes a vast difference how and in what context dissociation is
used’ (Goldman, 2016:98). • Dissociation can be understood in several ways – as a lack of integration of the mind and mental states, as an altered state of consciousness, as a defence mechanism and structure, and as a normative process (`even in the most well-functioning individual, normal personality structure is shaped by dissociation’; Bromberg, 2001). • When dissociation is persistent it is often, although not always, trauma-related. Persistent inability to connect, access, and move between different registers of functioning impedes health and well-being. If severe, unrecognised and untreated, it can erode quality of life and pose serious health risks. • Repression occurs when `single or a few memories, perceptions, affects, thoughts, and/or images are thought to become relatively unavailable to full conscious awareness’ (Loewenstein, 1996). Dissociation, in contrast, relates not only to content but also to state of mind. When trauma-related, it is often associated with distinct gaps and deletions in continuous memory for life history and/or experience. This is much less common in repression, where `the material that is unavailable is so limited in scope’ (Loewenstein, ibid: 311). • The motive for repression is avoidance of conflict. In dissociation, however, internal conflict is not experienced because the experience which would give rise to it is not formulated: `It is not that [conflict] is `moved’ to a hidden location in the mind…it is simply not allowed to come into being’ (Stern, 2010: 92). • Repression relates to experience which was pre-formulated and unpleasant while dissociation relates to experience which was unformulated because it was unbearable (`not me’; Sullivan, 1953 in Howell, 2005; `[r]epression is always something that one does, but dissociation can happen to one’; Howell, ibid: 199). • The pioneer of understanding of trauma-related dissociation was Pierre Janet (1859-1947) whose ideas prefigure contemporary views of it. • Integration, coherence, and self-continuity are not innate but rather result from developmental and relational experience (`Constructing a mental self-continuity of consciousness, memory and identity is a task, not a given’; Spiegel, 2018:4). • Links between mental states are fostered by interpersonal connections. States are the building blocks of consciousness and behaviour, and self, identity and well-being depend on linkage between self-states (Howell, 2005, ref. Putnam, 1992, 1997). • Impediments to linkage of self-states can occur in various ways. Research shows that `[t]he best predictor of adult dissociation is emotionally unresponsive parenting’ (Lyons-Ruth et al, 2006, in Chefetz, 2015: 89). • Chronic dissociation in childhood comes at great cost. This is because the coping strategy that permits continued attachment to care-givers impedes the ability to attach securely later on: `The drastic means an individual finds to protect his sense of stability, self-continuity, and psychological integrity, compromises his later ability to grow and to be fully related to others’ (Bromberg, 2001:6). • It is possible for childhood trauma and other developmental deficits to be resolved and for secure attachment to be achieved (Siegel, 2003). • When generated by stress that is overwhelming (i.e. trauma) the ability to move flexibly between self-states is impeded substantially (`the person surrenders self-state coherence to protect self-continuity’; Bromberg, 2011:68). The capacity to access thoughts, feelings, and important registers of functioning is limited or lost (Chu, 2011:41). • Studies show that dissociation features in many disorders: `dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry’ (Sar, 2014:171). • The significance of dissociation as a transdiagnostic presence and its correlation with suicide attempts and non-suicidal self-injury (Calati, Bensassi et al, 2017) has implications for diagnosis, health risk, and effective treatment/s. It also has implications for treatment response per se (Price, Kearns et al. 2014). • A continuum model of dissociation, while not subscribed to by all, has a number of benefits. When conceptualised as a continuum, and as a normal psychological capacity and process which can become problematic in particular circumstances (e.g. unresolved trauma, in which the dissociative response was initially protective) we can begin to understand the contexts which contribute to maladaptive coping and ways of managing stress which can become dysfunctional. • One description of problematic dissociation - and its progression to disorder - is `a healthy defense gone wrong’ (Steinberg & Schnall, ibid: 8) is helpful. • Dissociation can be regarded as an inherent capacity of the
mind, whereby `mind’ comprises self-states which are variously linked. Primary care-giving relationships in childhood are initially and powerfully formative in shaping the degree to which the interplay between self-states is flexible and adaptive but maladaptive impacts are potentially amenable to being resolved. • The greater the need to defend against overwhelming experience, the greater the need for dissociation and increased potential for compromised psychological functioning. • An understanding of dissociation in its various forms, both clinical and non-clinical, needs to be integrated into the public domain in general and within and across health sectors and services in particular. References Bowlby, J. (2006) A Secure Base New York: Routledge. Brand, B.L. (2012) `What We Know and What We Need to Learn About the Treatment of Dissociative Disorders’, Journal of Trauma & Dissociation, 13:4, 387-396. Calati, R., Bensassi, I. & Courtet, P. (2017) `The Link between Dissociation and both Suicide Attempts and Non-Suicidal Self-Injury: Meta-analyses’, Psychiatry Research (Vol 251), pp. 103–114. https://doi.org/10.1016/j.psychres.2017.01.035 Danylchuk, L.S. & Connors, K.J. (2017) Treating Complex Trauma and Dissociation: A Practical Guide to Navigating Therapeutic Challenges New York: Routledge. Howell, E. (2005) The Dissociative Mind New York: Routledge. Howell, E. & Itzkowitz, S. (2016) The Dissociative Mind in Psychoanalysis: Understanding and Working with Trauma New York: Routledge. Loewenstein, R.J. (2018) `Dissociation Debates: everything you know is wrong’, Dialogues in Clinical Neuroscience (20, 3), pp.229-242. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296396/ Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation (2020) Blue Knot Foundation https://www.blueknot.org.au/resources/Publications/Practice-Guidelines Sar, V. (2014) `The Many Faces of Dissociation: Opportunities for Innovative Research in Psychiatry’, Clinical Psychopharmacology and Neuroscience, 12, 3, pp.171-179. Schwarz, L., Corrigan, F. et al (2017) The Comprehensive Resource Model: Effective therapeutic techniques for the healing of complex trauma New York: Routledge. Spiegel, D. (2018) `Integrating Dissociation’, American Journal of Psychiatry, 175:1, pp.4-5. Steinberg, M. & Schnall, M. (2001) The Stranger in the Mirror Dissociation, The Hidden Epidemic New York: HarperCollins. Stern, D. (2010) Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment New York: Routledge. A Lived Experience JourneyIf you tweak the tail of the tiger, you’d better know where you are running to.Blue Knot would like to thank the author of the following article for so generously sharing the challenges of finding practitioners who have experience and expertise in supporting people with experiences of complex trauma and dissociation. The author’s experience attests to the importance of practitioners being dissociation- as well as trauma-informed. As the lead article indicates we will be including summaries of all 3 chapters in our new Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation (2020) to assist in this process. * Trigger Warning: This article may contain content that could disturb some readers. You may choose not to read it. If you do read this story and reading it causes you distress and you need support, please call the Blue Knot Helpline on 1300 657 380 (9am-5pm AEST, 7 days). In 2004, when I was 51, working as a rehabilitation consultant I found interpersonal difficulties with clients a source of shame and embarrassment. I wanted to “improve” myself and also get to the bottom of “what was wrong with me” as this had been a long- term issue. I sought help from a GP who referred me to a Psychologist (not clinical) who was in his 70s but had a good reputation for helping people, despite being at the end of his career. I told him of a background trauma that had sporadically surfaced throughout my life and recent severe anxiety. After several months I said I would leave now and he said, “well this is what therapy is all about”. So despite not knowing what he meant I continued to see him until I noticed a “relationship”
with him emerging within my body, heart and mind. This concerned me greatly as I thought it was forbidden. He continued to encourage me toward emotional expression. He recorded cassette tapes of the Relaxation Response which I dutifully listened to at night before going to sleep. This is how he got deep into my emotional brain. The physical contact continued despite being clearly dangerous and brought about the full exposure for the first time of the traumatic physical incident as a very young child. I knew I was in serious trouble emotionally and psychologically. I became alarmed at the development of PTSD resulting in the dramatic unfolding of images, sensations, and awareness of what had been deeply buried for 50 years. I thought he would talk it through with me, giving
me a current perspective. He did not engage or ask me what was going on. Each weekly session, I began to freeze before sessions, vomiting on one occasion. I arrived and left his room in a chronic state of distress and ran through the car park back to work. I was physically, emotionally and psychologically unravelling to my core. However this had replayed the original traumas of both a very early physical incident and disorganised attachment including long term maternal neglect and persecution. I was trying to keep all this as close to my chest as possible because I was so ashamed of needing this connection and genuinely didn’t realise it was allowed in a professional setting. I had grabbed a copy of Peter Levine “Waking the Tiger” from a massage therapist’s shelf and thus began my journey of trying to find out what was going on. I became catatonic in the car when driving home at excessive speeds. When home I would fall on the floor and be startled by family members walking into the room. Comfort and connection were very hard to find, as my husband was frightened by my state. I was distraught with grief. I felt so ashamed of needing that connection, I couldn’t tell anyone. I continued in a acutely distressed emotional and psychological state for 2 and a half years when he retired. The classic environment ensued for the maintenance of long term Complex PTSD. As complex PTSD developed, I became emotionless in my presentation. In 2006, The Psychiatrist I was referred to, was understanding of the trauma but not aware of the mental unfolding happening before her eyes as I walked through the door. The dramatic initiation and continuing development of neuroplastic pathways was apparently not evident despite me saying it was happening. Such a total collapse had required me to spend most of the time on big cushions on her floor over the 2 years I consulted her. She bought “The Haunted Self” 2006 by Van der Hart, Nijenhuis and Steele and showed me as if I was able to utilise the knowledge inside the book. When she finally said “What am I going to do with you?”, I felt rejected and amazed by the lack of response given my severe symptoms. I was not aware of where I sat on the continuum of consciousness. I had to take a year of leave from work, to try and sort myself out. I used books to help me understand. Judith Herman’s Trauma and Recovery was a lifesaver. In 2008 still feeling overwhelmed, I consulted a Clinical Psychologist this time with a focus on mindfulness and body scan techniques. I thought to myself that this will work because the trauma is in my body. This relationship lasted 4 years during which time I became seriously suicidal. I pleaded with him to talk about what I was experiencing. How could he not be curious about what was happening to me as I walked through the door using all my strength to remain upright. His treatment tool was mindfulness meditation which was limited in meeting my needs. I said to him, “can’t you see”? I was desperate for emotional and psychological recognition and contact. It became so critical he engage with me, that I had to stop myself from running in front of the cars outside his office. By 2012, it was incredibly difficult to leave when I continued in such an emotionally distraught state. But it felt right somehow because I was not getting what I needed. During this time in 2010 my father died and then in 2012 my brother died. My eldest son got married in 2011. I had been hoping to be well for these major family events. In late 2012 I saw a male Psychiatrist who made an assessment after a few sessions without asking questions and said to me. “There is no one in this city/state who can help you”!!! Crikey, how to make someone feel abandoned. Now I was in more trouble, despite all my strength to keep myself going, I could not believe my ears. As I slinked out through the door he quietly said “oh come back and see me if you need to”!!! I was having to find my own way toward the next mental health professional who may or may not be able to help me. Unfortunately I was not aware of the Blue Knot Foundation. My husband and I had couple counselling which did not meet my needs. I felt ashamed when she referred to my “my broken brain”. I took this personally and as an outrageous comment in the circumstances. I told her so, to no avail. By 2015 I presented to a female Psychiatrist who specialised in complex trauma and had a good reputation. The receptionist said “You’ll be right now”. I had my fingers and toes crossed. At least I still had hope. At my first appointment I was emotionally distraught. There was no initial “interview” as such which concerned me. I knew from experience she was not going to help me without an extensive getting to know me approach. A deep investigation into my history was required. I said I needed help with both the primary and secondary trauma, but this was not taken seriously enough. Although the role of the “non verbal” aspect was recognised I felt I was having to role reverse and look after her. This was a familiar emotional setting for me. During 2016 my youngest son was married and my mother died. During these crucial family events, I was embarrassed by the emotional limbo I was in while still far from being well. About this time I read Norman Doidge “The Brain That Changes Itself” 2010. It became clear to me since 2004 my mental-emotional neuroplasticity was developing toward the present moment, desperately seeking “a person”! I now understand that in 2004 I presented with a dissociative personality structure. I of course could not have realised it was actually all of me that was cut off. I was just a very good survivor. I was dependent on the treaters to diagnose accurately as the developmental trauma occurred when I was very young. Given I told all the practitioners over 15 years about the previous lack of full awareness of the childhood trauma, I thought the role of dissociation was obvious, that they would be putting dissociation front and centre while working toward helping me into a coherent place in the present where I would at last be allowed to feel. As of March 2020, I now feel free that I am functioning without consulting any mental health professional. Despite not being dissociated, the original trauma remains untreated. Understanding Trauma as a System of Psycho-Social Harm: |