PTSD

1
PTSD

• Daniel Brown, Ph.D.

2
Types of Traumatization

• Natural acts
• Earthquakes, fires, floods, hurricanes, tornados
• Industrial accidents, motor vehicle accidents,
  plane crashes
• Interpersonal violence
• Combat trauma
• Political imprisonment, interrogation, torture
• Terrorist acts hostage-taking
• Rape crime victimization
• Sexual misconduct harassment
• Domestic, school, worksite violence
• Childhood maltreatment
• Attachment disruption neglect
• Physical sexual abuse

3
Information-Processing Model of Trauma
(Horowitz, 1976)

• Stages of processing a traumatic event
• Outcry
• Denial
• Intrusion
• Alternation between denial intrusion
• Working through symptom reduction
• Trauma as a crisis in information-processingdisru
  pted processing
• Treatment as providing the recovery conditions to
  process the traumatic experience

4
Information-Processing ModelSymptom
Manifestations

• Intrusion phase
• Hypermnesic flooding
• Affect storms
• Behavioral enactments
• Denial/Numbing phase
• Amnesia (full, partial, trauma-specific)
• Affective numbing
• Behavioral inhibition

5
Psycho-biological Model(Kolb et al., 1982 van
der Kolk, 1984)

• Dysregulation of the autonomic nervous system
• Continuous arousalhypervigilance
• Discontinuous arousalphysiological reactivity to
  external trauma triggers internal intrusive
  memories/feelings
• Behavioral signs
• Disturbances in attention concentration
• Sleep disruption
• Startle stimulus sensitivity
• Sensation seeking addiction to trauma
• Dysregulation of the central nervous system
• Predominantely processing trauma in the emotional
  brain (amygdala) vs. the narrative areas
  (hippocampus)

6
Janets Dissociation Model

• Failure to take adaptive action in face of trauma
  
• Intensification of affect (vehement emotions
• Disaggregation (dissociation) of consciousness
  with split off nuclei of consciousness
  outside of awareness/control
• Narrowing of field of consciousness
• Re-emergence of split off subconscious fixed
  ideas
• Somnambulistic states
• Hypermnesia amnesia
• Conversion symptoms, e.g. paralysis

7
Dis-integrated ExperienceSpiegel Cardena, 1991

• A structured separation of mental processes
  that are ordinarily integrated.
• Involving at least momentarily unbridgeable
  compartmentalization of experiences

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Structural Model for Dissociation
Autobiographical memory
NM SR
Primary Dissociation (between NM, SR, and TM)
NM TM B A S SR K
Secondary Dissociation (within TM system)
NM
B s a k a k S s A a k b K
s
SR
Tertiary Dissociation (within SR system)
NM
Ss Sk Sb Sb Sa Ss Sk Sb
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Somatoform Dissociation Questionnaire

• It sometimes happens that
• My body, or part of it, is insensitive to pain
  (analgesia)
• It is as if my body, or part of it, has
  disappeared (visual/kinesthetic anesthesia)
• I can not speak (or only with great effort) or I
  can only whisper (motor inhibition)
• I have pain while urinating

10
Domain of Dissociative Symptoms(Nijenhuis)
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Attribution ModelCore Beliefs Re Self, World
World of Others

• Shattered assumptions (Janoff-Bulmann)
• Safety
• Meaningfulness
• Self worth
• Trust
• Future-orientation
• Sense of belonging
• Sense of control
• Independence
• Distribution of power
• Negative schema acquisition (Newman)
• Positive schema acquisition (Frankl)

12
Developmental ModelParson, 1984 Brown Fromm,
1986

• Reversal of gains along developmental lines
• Self pathology
• Self esteem self agency failure
• Self inhibition and self definitional problems
• Self fragmentation structural dissociation
• Relational disturbance
• Trauma bonding
• Disturbed power relationships
• Pathological introjects acquired during trauma
• Affect disturbance
• Alexythymia
• Affect regulatory problemsfeeling too much or
  too little
• Extreme numbing (affect experience problems)

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Acquired Trauma Bonding Stockholm Syndrome in
Hostages Description

• A 131-hour captivity by a prison escapee for 4
  hostages in a bank vault in Stockholm, Sweden in
  1973
• Victims
• Came to fear the police more than the robbers
• Phone call from victim to Prime Minister saying,
  The robbers are protecting us from the police
• Felt no animosity for the robbers
• Were emotional indebted to their captors for
  their generosity of given the victims their
  lives back
• Supported captors defense, visit in jail, or
  became engaged to captor

Strentz, 1979
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Stockholm Syndrome Explanation

• An automatic, often unconscious, emotional
  response to the trauma of becoming a victim
• Very high level of life-threatening stress or
  fear-arousal
• Creates situation of extreme, frightened
  dependency denial of rage in victim
• Re-capitulates early infancy dependency
• The behavior that worked for the dependent
  infant surfaces again as a means to survival (p.
  152)
• Captor is both source of life-threatening and
  life-giving
• Positive contact between victim and captor
  (captor being nice)
• Results in the development of a strong, positive
  emotional bond of victim to captor
• Motivated by survival instinct
• Beyond control of victim
• Belief change
• Identify with human qualities of captors-- a
  process of humanization (p. 159)
• Increased sympathy with/adoption of captors
  belief system
• Increased intolerance for outsiders normal
  societal belief system in general and
  authorities (police, government) in particular
• Development of survival, not escape strategies

Strentz, 1982
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Domestic Stockholm Syndrome(DSS)The Dutton
Painter Trauma Bonding Model

• How strong emotional ties develop in context of
  intermittent marital abuse
• Majority of battered women (87) not physically
  abused in previous relationships
• Unmet dependency needs of both partners
• Two common features
• Power imbalance
• Intermittent reinforcement
• Periodic abuse followed by caretaking (cyclical
  bad/good treatment)
• When the physical punishment is administered at
  intermittent intervals, and when it is
  interspersed with permissive and friendly
  contact, the phenomenon of traumatic bonding
  seems most powerful (p. 149)
• Results in a strong emotional attachment or
  trauma bond
• Strong emotional ties between two persons where
  one person intermittently harasses, beats,
  threatens, abuses or intimidates the other (p.
  147)
• Cognitive changes introjection of self-blame
  lowered self-esteem
• Makes it difficult to leave the abusive
  relationshipelastic band metaphor

Dutton Painter, 1981
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Trauma Bonding and the Difficulty of Leaving an
Abusive Relationship

• This attachment bond is likens to an elastic
  band which stretches away from the abuser with
  time and subsequently snaps the woman back. As
  the immediate trauma subsides, the strength of
  the traumatically-formed bond reveals itself
  through an incremental focus on the desirable
  aspects of the relationship, and a subsequent
  sudden and dramatic shift in the womans belief
  gestalt about the relationshipso that she
  alters her memory for the past abuse, and her
  perceived likelihood of future abuse.

Dutton Painter, 1993, p. 109
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Empirical Test of Trauma Bonding Model of
Domestic Violence

• Intensive interviews of 75 women who recently
  left a physically vs. emotionally abusive
  relationship
• Results
• Evidence of both power imbalance intermittent
  maltreatment by abusive partner
• PTSD symptoms low self-esteem both immediately
  6-months after leaving abusive relationship
• Abusive relationship, not family-of-origin
  variables accounted for most of variance of
  trauma symptoms
• Prolonged effects
• Attachment persisted for these women despite
  their remaining outside the prior relationship

Dutton Painter, 1993
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Cognitive Modifications of the Trauma Bonding
Model for Domestic Violence

• Criticisms
• Intermittent abuse/caring is one key element but
  not the unique cause of trauma bonding
• Power imbalances exist in many relationships that
  are not abusive
• Power imbalance is not a consequence but an
  antecedent of the abuse
• Induction of a mental model in victim
• Network of schemas beliefs
• Traumatic bond protects victims psychological
  integrity

Montero, 2000
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Stages in Development of the Cognitive Bond

• Trigger phase
• Initial physical abuse breaks previous security
  in relationship
• Disorientation and acute stress reaction
• Reorientation
• Cognitive dissonance between abuse evidence and
  her going along with relationship
• Cognitive restructuring to reduce dissonance
• Self-blame cognitions
• Coping
• Managing the abuse potential
• Adaptation
• Assumes abusers beliefs and projects guilt
  outside couple milieu
• Full emergence of Domestic Stockholm Syndrome

Montero, 2000
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Modifications of the Trauma Bonding Model for
Domestic Violence

• Similarities to hostages
• Victimizers usually male
• Domination strategies
• Victim as symbolic target (blame women as group)
• Victim uses active strategies to stay alive
• Attuned to what pleases displeases victimizer
• Submission
• Counter-productive denial of danger failure to
  see available options
• Survival as success
• Differences from hostages
• Voluntary nature of initial relationship
• Unlikely that outsides negotiate for release

Graham, Rawlings Rimini, 19??
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Modifications of the Trauma Bonding Model for
Domestic Violence Dissociation

• 49-item assessment scale of possible cognitive
  distortions and coping strategies in young women
  abused when dating
• Results
• Core Stockholm Syndrome
• Victim is in a dissociated state characterized
  by
• Attachment to positive aspects of relationship
• Compartmentalization of violent part of
  relationship
• Psychological damage
• Depression low self-esteem
• Loss of sense of self
• Love-dependence
• Feeling cannot survive without partner

Graham et al., 1995
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Reactivation of Attachment Representations in
Domestic Violence Both Partners

• Assessment of level of object relations
  development in abusive partner relationships
• 81 men women reporting physical abuse vs. 13
  women reporting no partner violence
• Significantly lower level (more primitive) object
  representations in both men women in abusive
  vs. non-abusive relationships
• More highly malevolent
• Less differentiated, integrated, or complex
• Men and women in abusive relationships exhibit
  more primitive levels of representations of
  themselves and others than do men and women in
  non-abusive relationships (p. 112)

Cogan Porcerelli, 1996
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Traumatic Incestuous Bonding Cycle

• A Build-up
• B Overt sexual abuse
• C Emotional relief
• D Downsideguilt or shame
• E Build up again

deYoung Lowry, 1992
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Contextual Model of Trauma

• Pre-emigration stress
• Trauma
• Loss of home, livelihood, social position,
  family, community, homeland
• Customs beliefs
• Emigration relocation stress
• Post-emigration stress
• Safety sanctuary issues
• Living situation
• Cultural customs beliefs
• Language education
• Relationships
• Acculturation issues

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Effects of Traumatization5 Domains, 3 Areas
Affect dysregulation
Intrusive Re-experiencing
Self pathology
Numbing
Relational disturbance
Physiological reactivity
Shattered core beliefs
Consciousness
Acquisition of negative beliefs
Memory
Acquisition of positive beliefs
Identity
Motor disturbances
Sensory disturbances
Functional medical illnesses
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Simple vs. Complex Trauma

• Simple trauma
• Typically single-incident trauma
• Fits the information-processing model
• Provide recovery environment to process the
  traumatic experience
• Little emphasis on treatment frame or
  stabilization
• Interaction of trauma and personality addressed
• Complex trauma
• Processing trauma per se often insufficient for
  recovery
• Treatment frame issues important
• Elaboration of stabilization skills
• Addressing developmental issues necessary
• Relational-based treatment critical to recovery

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Assessment of PTSD 1.

• Multi-method assessment
• Structured InterviewsCAPS SCID-D
• Psychometric testing
• PTSD
• Impact of Events
• Traumatic Stress Inventory (TSI)
• Dissociation
• Dissociative Experiences Scale
• Somatoform Dissociation Questionnaire
• Coping
• Ways of Coping
• Peritraumatic Dissociative Experiences
  Questionnaire

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Assessment of PTSD 2.

• Beliefs Schemas
• Young Schema Questionnaire
• 232 questions, 18 domains
• Traumatic Attachment Belief Scale
• 5 basic needs
• Relational Disturbance
• Relationship Questionnaire
• Adult Attachment Inventory
• Psycho-physiological testing
• Personality factors
• Memory suggestibility
• Fantasy-proneness
• Malingering
• Structured Interviews of Reported Symptoms
• Malingering Probability Scale

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Assessment of PTSD 3.

• Depression
• Beck Depression Inventory
• Automatic Thought Questionnaire
• Dysfunctional Attitude Scale
• Index of Self Esteem
• Anxiety
• Beck Anxiety Scale
• Penn Worry Scale
• State-Trait Anxiety Scale
• SCL-90
• Axis II
• SCID-II
• MCMI-3

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Simple PTSDAcute vs. Chronic PTSD

• 8-9 of traumatized individuals develop chronic
  PTSD (25 for war trauma)
• Predictors of chronic PTSD
• Severity of exposure (duration, severity,
  cumulative, destructiveness, conflict)
• Age of traumatization
• Betrayal trauma
• Extremes of arousal (disrupted processing)
• Disruptive effects of extreme fear arousal
• Dissociative coping style disrupted processing
• Coping style
• Cultural context

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Disrupted Trauma Processing
More
Extreme Fear Arousal
Severity of PTSD
Dissociation
Less
Low
High
Fear Arousal
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Part 2.

• Treatment of Single-Incident Trauma

33
Treatment of Single-Incident Trauma

• Dynamic psychotherapy (meaning-making)
• Hypnotherapy
• Cognitive-behavioral therapy
• EMDR
• Common ingredients

34
Psychodynamic Treatment of Trauma(Horowitz, 1976)

• Trauma defined as incomplete information-processin
  g
• Traumatic stress activates conflict according to
  character style
• Goals of dynamic treatment
• Complete information-processing of trauma
• Meaning-making
• Identify character/defensive style resolve
  conflicts that interfere with trauma processing

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Hypnotherapy for PTSD(Brown Fromm, 1986)

• Stabilization skills
• Trauma processing with hypnosis
• State of heightened attentional focus
• Richness of imagery
• Greater access to under current of affective
  states
• Greater access to inner resources for coping
  mastery in context of permissive relational
  context

36
Exposure-Based Treatment of Rape(Foa et al, 1995)

• Im going to ask you to recall the details of
  the assault. It is best for you to close your
  eyes so you wont be distracted. I will ask you
  to recall these painful memories as vividly as
  possible. We call this reliving. I dont want you
  to tell a story about the assault in the past
  tense. Rather, I would like you to describe the
  assault in the present tense, as if it were
  happening right now. Id like you to close your
  eyes and tell me what happened during the assault
  in as much detail as you remember. This includes
  details about the surroundings, your activities,
  the perpetrators activities, how you felt
  including your physiological responses like your
  heart beating fast, and what your thoughts were
  during the assault. If you start to feel
  uncomfortable and want to run away or avoid it by
  leaving the image, I will help you to stay with
  it.

37
Exposure-Based Treatment of Rape(Foa et al, 1995)

• Im going to ask you to recall the details of
  the assault. It is best for you to close your
  eyes so you wont be distracted. I will ask you
  to recall these painful memories as vividly as
  possible. We call this reliving. I dont want you
  to tell a story about the assault in the past
  tense. Rather, I would like you to describe the
  assault in the present tense, as if it were
  happening right now. Id like you to close your
  eyes and tell me what happened during the assault
  in as much detail as you remember. This includes
  details about the surroundings, your activities,
  the perpetrators activities, how you felt
  including your physiological responses like your
  heart beating fast, and what your thoughts were
  during the assault. If you start to feel
  uncomfortable and want to run away or avoid it by
  leaving the image, I will help you to stay with
  it.

38
Effectiveness of Rape Trauma Treatment

• 9 biweekly (90 minute) sessions resulted in
• Increased organization of rape memory
• Increase narrative length detail of memory
• Increased emotions and thoughts about rape
• Reduction in trauma-related symptoms
• Reduction in depression correlated with
  meaning-making

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Summary of Exposure-Based Rape Treatment

• The employment of exposure techniques with
  trauma victims consists of engaging the patient
  in the trauma memories with the intent of
  habituating intense fear responses to trauma
  remindersthe treatments should be directed
  toward both organizing the memory and correcting
  the maladaptive schemas (Foa, 1993, pp. 294-296)

40
Outcome Studies on PTSD Treatment

• Brom, Kleber Defares (1989)
• Behavioral desensitization, Hynotherapy,
• Psychodynamic therapy
• All 3 treatments efficacious (60) vs. controls
  (26) over 15 sessions
• Behavioral hypnotherapy better for intrusions,
  dynamic better for avoidance
• Some methods better suited to a particular case
• Figley (1999)
• Comparable efficacy for 4 different types of
  innovative trauma treatments because each
  contains similar active treatment components

41
Differential Response to Trauma Treatment
(Jaycox, Foa Morral, 1998)

• 9 Bi-weekly sessions (90 minutes) of PET exposure
  for rape trauma
• Treatment effect
• Engagement habituation 57
• Engagement non-habituation 15
• Low engagement non-habituation 11

42
Active Treatment Ingredients

• Stabilization skills
• Habituation of phobic and/or anxiety response to
  traumatic memory
• Emotional engagement
• Modification of trauma-specific cognitive
  distortions
• Integration of dissociated states
• Personification realization
• Return to normal self, affective, relational
  development

43
Part 3.Treatment of Complex Trauma
44
Treatment of Complex Trauma

• Treatment Frame
• Stabilization
• Memory Representational Integration
• Post-integrative recovery

45
Treatment Frame Issues 1.

• Re-traumatization potential
• Environmental interventions
• Dissonance-evoking interventions
• Keep conflict within system avoid induction
• Use language of parts in conflict
• Establish adaptive function of each part
• Framing the conflict to heighten dissonance
• Resolution strategies
• Activating the part that knows the solution
• Conference table technique
• Working with skewed solutions
• Stating the parameters of an acceptable solution
• Re-balancing the system

46
Treatment Frame Issues 2.Behavioral Contracting

• Self/other harmfulness
• Therapy-interfering behaviors
• Trust in the treatment relationship
• Lying
• Factitious behavior
• Refusing to discuss certain topics
• Not giving consent to talk with other treaters
• External threats to treatment
• Leaving town
• Decreasing frequency of sessions
• Financial interferences

47
Treatment Frame Issues 3.Behavioral Contracting

• Behavioral threats to treatment
• Not showing up
• Coming late
• Not leaving the session
• Contractual breaches
• Not taking medications or doing homework
• Not following treatment recommendations
• Behavioral problems in treatment hour
• Toxic, abusive behavior
• Sexualizing the treatment

48
Treatment Frame Issues 4.Behavioral Contracting

• Behavioral problems between sessions
• Drugs sexual acting out
• Extra-therapeutic demands
• Regression in level of functioning
• Boundary violations of therapists privacy
• Not working in the treatment hour
• Constant crises
• Trivial themes
• Journaling instead of working

49
Bimodal Distribution of Hypnotizability Scores
N 533
60
50
High Range
40
NUMBER OF CASES
30
20
10
0
0
1
2
3
4
5
6
7
8
9
10
11
12
HYPNOTIC RESPONSIVENESS
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The Domain of Hypnosis
Altered State of Consciousness
Hypnotic Relationship
Attention Skill Arousal Shift Time Distortion
Dissociation Trance Logic GRO Fading Involuntarism
Access to Imagery, Memory, Affect
Hypnotic Role-Taking Hypnotic Transference Allianc
e Communicative influence
Expectancies
Motivation Attitude Response Expectancies Efficacy
51
Hypnotizability Trauma

• Response to the SHSSC
• Normals 5.5 of 12 Hilgard, 1966
• PTSD 8.5 Frankel, 1976
• DID 10.5 Bliss, 1984

52
Stabilization Skills

• Physiological reactivity
• Continuous arousal
• Discontinuous arousal
• Core skills
• Self observational capacity
• Affect regulation skills
• Trauma-specific skills
• Coping enhancement
• Trauma-specific beliefs
• Everyday functioning

53
Classification of Anxiety Disorders

• Continuous arousal GAD
• Hyperarousal
• Excessive thought-realistic worry
• Excessive thought-unrealistic
• Avoidance OCD
• Discontinuous arousal
• External Phobia
• Internal Panic
• Avoidance Agoraphobia
• Both PTSD

54
Anxiety Dimensions of PTSD

• Continuous arousal hypervigilance
• Like GAD
• Discontinuous arousal
• Triggered by external reminders of trauma
• Like phobia
• Triggered by internal memories emotions
• Like panic
• Progressive phobic avoidance
• Phobia of memory, dissociative identities,
  normalcy

55
Treatment of Physiological Arousal

• Continuous hyperarousal
• Drug treatment
• Modulated hypnotic relaxation
• Elevator technique
• Affect dial
• Dyadic regulation
• Discontinuous/episodic arousal
• External trauma triggers
• Self monitoring cue induced relaxation
• Displacement technique
• Desensitization
• Internal intrusions (memories affects)
• Cue induced safe places
• Exposure treatment (fear-of-fear hierarchy)

56
Core Skills

• Self observational capacity
• Self-monitoring
• Mindfulness
• Affect regulatory skills
• Self soothing
• Coping enhancement
• Affect dial
• Exposure-based treatment

57
Trauma-Specific Skills 1.

• Scene generation
• a scene will come to you that is somehow about
• Affect amplification
• Direct
• more clearly and intensely
• Time distortion
• Although only a short amount of clock time will
  pass it will seem to you that a much longer time
  has elapsed, long enough to completely feel
• Expanding duration and context of state-of-mind
• Cue utlization

58
Trauma-Specific Skills 2.

• Safety re fear
• completely safe and secure
• Problems
• Disconnection safe and connected
• Intrusive shifting even safer place
• Soothing re dysphoric states
• deep sense of comfort or soothing
• Use of sandwiched interventions
• Grounding re dissociative states
• sense of being grounded or solid within
  yourself
• Problems boundary diffusion
• Closeness/distance regulation
• Bubble imagery

59
Trauma-Related Symptoms

• Self-monitoring re triggering events
• Displacement technique
• Scene generation re displaced other who
  effectively copes with problem
• Graded suggestions for insight
• Rehearsal in fantasy
• Post-hypnotic reinforcement re jns
• Emphasis on using inner resources for mastery

60
Treatment of Ancillary Symptoms

• Depression
• Anxiety-spectrum symptoms
• Pain
• Sexual dysfunction
• DIMS (night awakenings)
• Grief
• Use of displacement technique

61
Treatment of Addictive Behaviors

• Motivation and stage of change
• Stabilizationrole of relaxation treatment
• Self monitoring of urges behaviors
• Self regulation skills
• Affect regulation skills
• Cognitive interventions
• Exploratory hypnotherapy with dissociative
  re-enactments
• Relapse prevention skills

62
Working with Trauma-Specific Beliefs

• Exposure-based methods
• Exploratory methods
• Dissonance-evoking methods
• Future-time orientation
• Attachment-related methods
• Ideal parent figure technique

63
Self Relational Development

• Self development
• Self esteem especially good about self
• Self agency
• especially effective
• eliciting exactly the kind of response
• Self definition
• real most you qualities uniquely you
• Secure attachment

64
Enhancing Everyday Functioning

• Preventing treatment regression
• Dangers of restricting life to trauma work
• Meaningful work
• Social support network

65
Common Problems During Stabilization

• Triggering in everyday life
• Shifting to unsafe mode
• Rapid switching
• Dissociative re-enactments
• Depression following disclosure
• Behavioral distance regulation
• Noxious trance
• Blocking and acting out alters
• Phobic avoidance

66
Signs of Stabilization

• Patient feels more settled
• Decrease fear/reactivity to what comes up
• Comfortable with hypnosis
• Spontaneous use of trauma-specific skills
• Security of attachment, at least in therapy
• Enhanced self-esteem
• Decreased core PTSD symptoms
• Enhanced coping with ancillary symptoms
• Modification of trauma-specific beliefs
• Curiosity to uncover in context of mastery
  stabilization

67
Memory Integration

• Structural integration
• Processing explicit, narrative memory
• Memory recovery dissociative amnesia
• Processing implicit, enacted memory
• Transference work

68
Structural Model for Dissociation
NM SR
Primary Dissociation (between NM, SR, and TM)
NM TM B A S SR K
Secondary Dissociation (within TM system)
NM
B s a k a k S s A a k b K
s
SR
Tertiary Dissociation (within SR system)
NM
Ss Sk Sb Sb Sa Ss Sk Sb
69
Treatment Implications of Structural Dissociation

• Structuralization of the traumatic memory, not
  content-related memory recover
• Putting the Humpty Dumpty of the
  dis-integrated memory system and the self
  representational system back together

70
Processing Explicit Narrative Memory for Trauma

• Indications
• Full or partial dissociative amnesia
• Predominately behavioral, not narrative memory
  for trauma e.g. early age of trauma
• Goals
• Maximize organization, completeness, accuracy
  of narrative memory
• Minimize memory error rate
• Personification realization
• Meaning-making narrative construction

71
Methods for Memory Retrieval

• Hierarchy of methods
• Free recall
• Context reinstatement
• Dyadic regulation transference work
• Risks of increasing the memory error rate
• Personality traits
• High memory suggestibility
• Psychopathology severe cognitive distortion
• Borderline, factitious, psychotic disorders
• Treatment methods
• Therapist systematically supplying content about
  abuse-related themes

72
Stages of Memory Integration

• Early phase
• Symbolized retrieval
• Normal vs. trauma dreamwork
• Free recall and symbolization
• Successive scenes reveal more, conceal less
• Embedded memory episodes within symbolization
• Fragmented recovery
• Open-ended free recall

73
Stages of Memory Integration 2.

• Middle phase
• Retrieval with BASK dissociation
• Organization within episodes
• Problem of disconnection

74
Stages of Memory Integration 3.

• Late phase
• Retrieval without BASK dissociation
• Organization across episodes
• Developing a comprehensive picture of the abuse
• Personification realization
• Progressive interiorization
• Changes in type of memory content
• Coping and aftermath memories

75
Implicit Memory Processing

• Transference re-enactment as implicit memory for
  abuse (Davies Frawley)
• Unnecessary to recover narrative abuse memories
  because the abuse memory is already expressed
  within the transference re-enactments
• Neglected child/ uninvolved parent
• Enraged victim/sadistic abuser
• Seduced child/seducing parent
• Entitled child/omnipotent rescuer

76
Representational Integration

• Types
• Victim self
• Abuser self
• Failed protector self
• Nature of dissociated representational parts
• Endure as compartmentalized self states
• Dissociated from conscious self representation
• Rigidly defended against
• Quasi-autonomous existence (implicit influence)
• Can be activated
• Signs of activation

77
Representational IntegrationTherapeutic
Strategies

• Working with impulses
• Revenge fantasies
• Working with self states
• Ego state therapy
• Fusion and integration rituals
• Secure attachment imagery
• Problem of disavowal of abuser states or sadistic
  aggression

78
Signs of Representational Integration

• Ownerships
• Integrative dreams
• Acceptance of realistic harm caused to others
• Increased mastery over aggression in fantasy
• Decreased dissociation
• Increased behavioral assertiveness

79
Treating Psycho-Physiological Reactivity

• Basic pattern
• Elevated ANS activation across indices
• Over- and under- reactivity
• Failed habituation
• Treatment
• Desensitization
• Cue induced calming
• Calming with stimulus challenge

80
Treatment of DDNOS/DID

• Handling discontinuous awareness
• Expanding field of consciousness
• Personification realization (self)
• Stabilizing dissociative shifts in state
• (voluntary control)
• Problem of learned phobias
• Disavowal of mental contents
• Structural integration

81
Working with Sadistic Abuse

• Sadistic use as domination and power via
  infliction of physical and emotional suffering
• Necessity of transference work
• Exploratory work contra-indicated
• To be known is to be controlled

82
Structural Integration Treatment Strategies

• Memory processing over time The puzzle analogy
  (Braun)
• Identification, accessing, communication
• Therapist-to-part- The relational model
• Part-to-part- The dissonance model of ego state
  therapy (Watkins, Brown)
• Part-to-part- The suggested co-presence model
• (van der Hart Steele)
• Whole-to-part- Internal Family Systems model
• (R. Schwartz)
• Whole-to-part- Attachment Model
• (Brown)