Published on March 10, 2014
Lecture 2 Understanding the Role of Dissociation and Attachment. Module: Complex Case Work Kevin Standish
Learning outcomes To explore and understand dissociation. To describe Attachment theory and attachment disorders. Assess the neuropsychological impact of trauma. Explore the case studies in relation to dissociation and attachment.
1. 2. 3. 4. 5. 6. 7. 8. Defining dissociation The spectrum of dissociation Continuum of dissociation Clinical dissociation Structural association High functioning dissociation The range of dissociative disorders Working with dissociation 1. DISSOCIATION.
1. Defining dissociation Is a defense against trauma that helps persons remove themselves from trauma as it occurs & delays the working through of the trauma Patients have lost sense of having ones consciousness Dissociation is an adaptive survival mechanism in the presence of overwhelming externally threatening experiences from which the victim cannot escape physically, but may escape psychologically by splitting off from the experience and associated sensations, feelings, thoughts and memories.
1. Defining dissociation “It’s as if your mind is not in your body; as if you are looking at yourself from a distance; like looking at a stranger”.
1. Defining dissociation Dissociation is a normal response to trauma. Survivors inhabit their head and lose contact with their body Frequent detachment from bodily experiences results in loss of reality, and uncertainty about whether the experience actually happened Dissociation is a form of emotional anaesthetic to aid survival.
2. The spectrum of dissociation A degree of dissociation is normal and adaptive. Getting lost in a book, being immersed in a film are examples. Children's absorption in play fantasy and imagination is a healthy adaptive form of dissociation Some children continue to dissociate when there is a need to escape their environment. Escape into dissociative imagination with imaginary companions.
3. Continuum of dissociation Dissociation is a continuum across a range from normal to severe dissociative identity disorder Within the normal range there is an experience of related states of alertness and detachment. It is normal to move through multiple experiential states with the continuous sense of core identity.
3. Continuum of dissociation Clinical dissociation: the degree of detachment becomes increasingly severe as a person is immersed in their internal world, losing contact with reality, their body and sense of self for periods of time. The range of dissociation goes from distraction, to depersonalisation, dissociative/psychogenic amnesia, dissociative/ psychogenic fugue, to finally dissociative identity disorder
3. Continuum of dissociation There are five types of dissociation: 1. Amnesia This is when you can’t remember incidents or experiences that happened at a particular time, or when you can’t remember important personal information. 2. Depersonalisation A feeling that your body is unreal, changing or dissolving. It also includes outof-body experiences, such as seeing yourself as if watching a movie. 3. Derealisation The world around you seems unreal. You may see objects changing in shape, size or colour, or you may feel that other people are robots. 4. Identity confusion Feeling uncertain about who you are. You may feel as if there is a struggle within to define yourself. 5. Identity alteration This is when there is a shift in your role or identity that changes your behaviour in ways that others could notice. For instance, you may be very different at work from when you are at home.
4. Clinical dissociation Three types of dissociation of associated with trauma order which aid survival Primary dissociation occurs in the face of overwhelming trauma preventing the individual from integrating what is happening to the extent that experience remains fragmented Secondary or peritraumatic Association is activated during trauma winning is no escape and represents a psychological flight when a physical flight is not possible. Accompanied by after body experiences and sense of leaving the body
4. Clinical dissociation Tertiary dissociation is associated with severe childhood abuse and complex trauma, in which distinct ego states emerged to contain traumatic experiences, which can result in dissociative identity disorder
4. Clinical dissociation Dissociation is mediated through the release of endorphins. Children are particularly vulnerable, and can result in traumatic experience becoming locked into the right brain preventing access to left brain processing and analysis Whilst initially adaptive, dissociation becomes maladaptive in becoming a learned response to all feelings and sensations even positive ones. This leads to impaired emotional processing, impaired thinking and cognitive processing resulting in cognitive distortions and dichotomous thinking.
5. Structural association A vertical split in consciousness as a way of shielding oneself from overwhelming fear of annihilation and cognitive knowledge of traumatic events A separation of mental and experiential contents that would normally be connected This lack of integration and disowning of conceptual experiences, prevents the integration of self states in young children, or the fragmentation of integrated systems and decoupling of self states in adults
5. Structural association Structural dissociation is a split between "apparently normal personality" (ANP) and the "emotional personality" (EP). ANP detaches and avoid any contact with trauma related alternatives and is highly functional in managing daily life in a emotionally and physically numb manner Ep: remains embedded in the trauma, reliving the trauma through post-traumatic symptoms such as flashbacks, hyper arousal, disorientation
ANP VS EP
6. High functioning dissociation Some survivors extremely high functioning with successful careers but have great difficulties in close personal relationships There is a split in the attachment style where the ANP is avoidant and dismissive of attachment needs, while the EP is insecurely dependent upon and preoccupied with attachment needs. By separating the two States survivors get on with daily life without being overwhelmed by the internal stresses caused by the trauma
6. High functioning dissociation The survivors developed a phobia of inner experience. Emotions are rarely "felt" and commonly of as "thought emotions" in which the right emotion is cognitively identified rather than experience. It is crucial that survivors become aware of in experience and learn to tolerate and regulate it, in order to facilitate change Survivors will often create a fantasy world which is beautiful, benign and harmonious in order to escape the real world of despair trauma and abuse.
6. High functioning dissociation When clients dissociate into the fantasy world they create significant barriers in the therapeutic relationship through mis-atunement, defensive reactions, projection and negative transference
7. The range of dissociative disorders Depersonalisation - de realisation disorder Dissociative amnesia Dissociative identity disorder (DID) Dissociative disorder not elsewhere classified (DDNEC)
7. The range of dissociative disorders
8. Working with dissociation Avoidance of in experience and dissociation is highly correlated with some personality disorders in particular borderline personality disorder The role of dissociation is to split off a range of feelings and thoughts such as vulnerability, dependency, hurt, anger and rage The most common self states seen in survivors of complex trauma can be described in Young's terms as abuse child, the angry child, the punitive parent and the detached protector . From schema therapy
8. Working with dissociation Not all survivors are aware of the role of dissociation and how it impacts on them This important familiarise yourself with the hallmark signs of dissociation to assess the degree of dissociation in a client If you suspect a client suffers from chronic dissociation make use of an assessment scale: dissociative experiences scale (DES); Somatoform dissociation questionnaire (SDQ 5), or SDQ 20
Dissociative experiences scales file:///C:/Users/Owner/Downloads/des.pdf http://counsellingresource.com/lib/quizzes/m isc-tests/des/
Useful reading Treating dissociation: Courtis & Ford (2009) chapter 7 Treating Dissociation by Steele & Van der Hart
1. The function of attachment 2. Attachment styles 3. Complex trauma and attachment 2. ATTACHMENT THEORY AND ATTACHMENT DISORDERS.
1. The function of attachment Attachment is an innate psychobiological imperative that aids physical and psychological survival. Attachment bonding shapes the baby's brain to ensure healthy psychological development and provides a secure base in which physical and emotional needs are met. Gerhardt (2004) why those matters: how affection shapes a baby's brain. Primary purpose of early attachment is to support experience dependent maturation of the developing brain before autonomy and affect regulation develop
1. The function of attachment The external caregiver acts as an affect regulating system to facilitate the child's own regulation of arousal and emotional inner psychological mental states It is through consistent appropriate caregiving responses that the infant learns internal states can be soothed and regulated. The bonding process releases critical hormones such as oxytocin which mediate the sense of comfort pleasure and delight in close relationships
1. The function of attachment Bowlby’s concept of inner working models, of what can and cannot be expected in relationships and how others respond to needs, formulate attachment bonds. In complex trauma children are not able to achieve self integration, or develop healthy internal working models necessary to feel safe around others. This leads to disruption in the attachment system giving rise to insecure attachments
1. The function of attachment Secure attachment: associated with a history of warm, responsive and consistent relationships both in childhood and adulthood. They have a positive view of self, others and relationships. Find it easy to be emotionally close to others and being comfortable depending on others and having others depend on them. Insecure attachment: survivors of complex trauma experience relationships as dangerous and terrifying rather than as a source of pleasure.
2. Attachment styles Anxious preoccupied attachment Dismissive avoidant attachment Fearful avoidant attachment Disorganised/disorientated/ dissociated attachment
2. Attachment styles
Childhood to adulthood attachment
Disorganised/disorientated/ dissociated attachment Most commonly associated with emotional or sexual violence and abuse Characterised by dissociation, trancelike states, freezing, hypervigilance, hyperactivity, hyper arousal, were stress tolerance, attention deficit and cognitive deficits, lack of empathy and failure to thrive The individual is put into irreconcilable paradox of approach and avoidance as this significant other is both a safe haven and a source of terror. This leads to "fear without solution". The child cannot form a coherent sense of self or any organised attachment resulting in extremely chaotic attachments in which they isolate between seeking comfort and defending against what they are seeking
3. Complex trauma and attachment Traumatic bonding Traumatic loneliness
Traumatic bonding "Strong emotional ties that developed between two persons where one person intermittently harasses, beats, threatens, abuses or intimidates the other". It is most likely to occur in the presence of inescapable life-threatening trauma which evokes fearful dependency and denial of rage and the victim The core feature of traumatic bonding is that the abuser is both the source of preserving life and destroying life. Therefore any anger or rage by the victim must be denied
Traumatic bonding For traumatic bonding to occur certain dynamics need to be present: 1. An imbalance of power. 2. Abuse is sporadic and intermittent alternating with highly positive and caring behaviour. To survive, reality has to be distorted and the true nature of the abusive relationship has to be seen as normal. This allows abuse to be masked and a high tolerance for abuse to be created
Traumatic bonding The alternation between abuse and loving behaviour becomes "super glue that bonds" the relationship. Any attempts to threaten the bond will be resisted. Survivors adopt the abuser's belief system and come to identify with the aggressor. These cognitive distortions are a central feature that survivors have about self, others and relationships. Otherwise known as the Stockholm syndrome
Traumatic loneliness Survivors of complex trauma learn that they are safer when they are alone The sense of relief and security experienced when alone can become conditioned in the presence of stressful experiences Rather than reach out for the help survivors likely to withdraw and become invisible.
THE NEUROPSYCHOLOGICAL IMPACT OF TRAUMA
BIOLOGICAL FACTORS There is growing evidence of the role of trauma on intricate neurobiological and neuroanatomical structures in dissociative disorders. Early childhood trauma, witnessing or exposure to traumatic or violent incidents, apparently has the potential to produce enduring alterations on brain chemistry, neuroendocrine processes, and memory.
The neuropsychological impact of trauma. Psychological traumas are developmentally adverse if they disrupt normal development in acquiring the necessary foundations: 1. Attention and learning. 2. Working memory, narrative memory,. 3. Emotion regulation. 4. Personality formation and integration. 5. Relationships and attachment.
Impact of psychological trauma of early childhood development: the survival brain With trauma there is a shift from the brain focused on learning to brain focused on survival The learning brain is engaged in exploration reinforced by searching for balance between novelty and familiarity Survival brain seeks to anticipate prevent and protect against damage caused by potential dangers, reinforced by search to identify threats and to mobilise bodily resources in defence
Impact of psychological trauma of early childhood development: the survival brain This available brain relies on rapid automatic processes that involve the more primitive parts of the brain bypassing areas in the more complex cognitive components of the brain The survival response is the stress response system operating automatically to maintain homoeostasis stress response system overrides the functionality of the brain systems for learning, reward seeking, stress management, planning and judgment. The executive functions of the brain development are impaired
the survival brain
Read Hudon-Allez, G (2009) Read Hudon-Allez, G (2009) Infant Losses; Adult Searches: a neural and developmental perspective of psychopathology and sexual offending. Chapter 1 and chapter 2.
Two defining characteristics of post-traumatic survival brain 1. Emotional dysregulation: when abuse prolongs, exacerbates or prevents the learning of ways behaviourally and biologically to modulate fear of the unfamiliar, novelty they become a source of unmanageable distress. This is because the the child failed to learn how to regulate the body when experiencing fear of the unfamiliar
Two defining characteristics of post-traumatic survival brain 2. Dysregulated information processing: exposure to traumatic stresses in early childhood reduce the brain's ability to create neural networks to support reflective self awareness because the neural networks are prepared for survival of danger rather than learning. Without the capacity to observe one's own thought processes, it is not possible to create a new knowledge. It results in reactiveness to experiences with automatic, chaotic and fixed perceptions, thoughts and actions
Neurocircuitry System There is strong clinical evidence that indicates that the amygdala is a central structure in the brain neurocircuitry and plays a pivotal role in conditioned or (learned) fear responding. Dysregulation of the amygdala or the hippocampus, or both, results in poor contextual stimulus discrimination (misinterpretation) and leads to overgeneralization of fear responding cues.
Neurocircuitry System Because the limbic system is where memories are processed, early trauma experiences will remain unassimilated to the degree the stress of detachment affected the limbic system. Significant early traumatic experiences and the lack of attachment have also been demonstrated to have longterm effects on neurotransmitters, especially serotonin, which has been identified as a primary neurotransmitter involved in the regulation of affect. Clients with dissociative disorder often present with a multitude of somatic complaints. The somatic complaints may be representative of a memory laid down along primitive neurological pathways that is being stimulated by something in the current environment.
Neurocircuitry System Prolonged sleep deprivation, fever, and hyperventilation can present with symptoms of amnesia, depersonalization, or identity disturbance. Clients with head injuries, seizure disorders, or brain lesions can present with symptoms of dissociation. In the nineteenth century, Charcot and others attributed dissociative processes to various forms of epilepsy involving the temporal lobe. Research on stress and trauma has also demonstrated altered limbic system function in response to chronic stress, with concurrent suppression of hypothalamic activity and dysregulation of the neurocircuitry systems.
1. Sanderson (2013) chapter 3 understanding the role of the dissociation and dissociative disorders. Chapter 4 understanding the role of attachment 2. Courtois & Ford (2009) Chap 2: Ford, J. Neurobiological and Developmental Research: Clinical Implications. Chap 6 Assessment of Attachment and Abuse History, and Adult Attachment Style, Daniel Brown & Treating Dissociation, Kathy Steele and Onno van der Hart 8. Cultural Competence, Laura S. Brow 3. Courtois & Ford (2013) chapter 8 into the breach: Voids, absences, and the post-traumatic/dissociative relational field READINGS
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