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  1. 1. Abuse, Trauma, and DissociationUnderstanding and Working Towards Recovery Jacqui Dillon www.jacquidillon.org www.jacquidillon.org
  2. 2. The Personal is Political www.jacquidillon.org
  3. 3. The Personal is PoliticalThe experiences, feelings, and possibilities of our personal lives are not just a matter of personal preferences and choices but are limited, moulded, and defined by the broader political and social setting. They feel personal, and their details arepersonal, but their broad texture and character, andespecially the limits within which these evolve, are largely systemic. www.jacquidillon.org
  4. 4. Jacqui aged 5 www.jacquidillon.org
  5. 5. Experiences Survival StrategiesAbuse Hearing VoicesBetrayal Self HarmNeglect Eating ‘Disorder’Denial CreativityBlame ResourcefulnessThreats Sense of Justice www.jacquidillon.org
  6. 6. My experiences of the Mental Health System• Pathologised ‘You are ill. Everything that you say and do will be seen as a consequence of your illness. ‘• Denial ‘It never happened’ or ‘It did happen but you will never recover’.• Medication ‘You are resistant and the fact that you don’t want to take medication is evidence that you are ill’ .• Dependency & Compliance ‘You must accept the psychiatric diagnosis and medication and we will give you benefits and a bus pass’.• Disempowered ‘You will never recover. You will always have this illness. You won’t be able to work’.• Passive ‘You do not know what is best for you. We know what is best for you’. www.jacquidillon.org
  7. 7. Finding a new paradigm• Trauma & Recovery• Understanding Dissociation• Attachment Theory• The Personal Is Political www.jacquidillon.org
  8. 8. Trauma and Recovery (Judith Herman)‫‏‬• Safety• Remembering & Mourning• Reconnection www.jacquidillon.org
  9. 9. Trauma and Recovery• Safety• feeling safe and feeling protected• To talk - need a language to describe what has happened – time, space, safety, protection and an empathic witness• To know that I am not alone• To know that I am not crazy• To know that my responses are normal in abnormal circumstances• To know that recovery is possible as others have recovered• To accept support as an act of courage and commitment to life and the future rather than as a sign of weakness www.jacquidillon.org
  10. 10. Trauma and Recovery• Remembering & Mourning• ‘When the truth is finally recognised, survivors can begin their recovery’ (Herman, 1992).• Restorative power of truth telling• Reconstructing the story of the trauma in the presence of an empathic witness/witnesses• Mourning, to truly honour what has been lost• Integrating the experience – putting the new and the old together and moving through to the future www.jacquidillon.org
  11. 11. ‘Voices’ Dissociated selves that became internal representations of my external world• Children/Teenagers • Hold memories of trauma - victims • Hold memories of trauma – perpetrators –• Abusers mother, father, ‘main abuser’, selves created to handle the abuse,• Deniers & Blamers • Mother, grandmother, main abuser, confused selves, psychiatrists, society• Comforters & Protectors • Imaginatively created selves i.e., ‘great mother’, old man,• Intellect guides • Pure intellect…free from feeling • Higher power, connection to the world,• Spiritual nature, my own innocence, my survival instinct, love is my religion! www.jacquidillon.org
  12. 12. Changing my relationship with my ‘voices’:• Needed to listen to them and understand them and the context in which they emerged• Greet them with compassion and understanding• Honour them - they helped me to survive• Work towards supporting and understanding each other• Increase the sense of connectedness and wholeness• Life becomes a shared, mutual collaboration www.jacquidillon.org
  13. 13. Trauma and Recovery• Reconnection• ‘Helplessness and isolation are the core experiences of psychological trauma. Empowerment and reconnection are the core experiences of recovery’ (Herman).• Reconnecting with ordinariness and the sense of being like others• There is more to life than the trauma• Finding a ‘survivor mission’ www.jacquidillon.org
  14. 14. Join The Last Great Civil Rights Movement!• Collective Responsibility: Responsible Society, Responsive Citizens• Awareness of dominant ideologies that redefine reality• Oppression, power, social norms and inequalities• Paradigm Shift www.jacquidillon.org
  15. 15. “The human animal is a unique being,endowed with an instinctual capacity to heal, as well as an intellectual spirit to harness this innate capacity.” Peter Levine (1997) www.jacquidillon.org
  16. 16. What is Trauma? www.jacquidillon.org
  17. 17. TraumaFirst used in a psychological sense in 1908 by William James: “Certain reminiscences of the shock fall into subliminal consciousness … If left there they act as permanent ‘psychic traumata’, thorns in the spirit, so to speak.” www.jacquidillon.org
  18. 18. Shattered AssumptionsTrauma shatters assumptionspeople hold about the world,other people and themselves – assumptions needed in order to feel safe, dealcomfortably with others and have confidence in oneself. www.jacquidillon.org
  19. 19. Childhood MaltreatmentNeglect• Failure to provide adequate food, clothing, or hygiene (physical); failure to provide nurturing or affection (emotional); failure to enrol a child in school (educational); failure to provide or maintain necessary healthcare (medical).Sexual Abuse• Asking or pressurising a child to engage in sexual activities (regardless of outcome); actual sexual contact with a child; indecent exposure towards a child; displaying pornography to a child; using a child to produce pornography.Physical Abuse• Physical aggression, including: punching, kicking, bruising, pulling hair or ears, biting, slapping, burning, stabbing, choking, or shaking.Psychological Abuse• Emotional violations, including: name-calling; ridicule; degradation; destruction of personal belongings; harming pets; excessive criticism; inappropriate or excessive demands; routine humiliation; withholding communication. www.jacquidillon.org
  20. 20. Post Traumatic Stress Disorder (PTSD) & Complex Post Traumatic Stress Disorder (CPTSD)While PTSD is understood as the consequence of single-incident trauma, CPTSD is used to capture the sequela of exposure to prolonged, repeated, coercive trauma.Characterised by a loss of control, disempowerment, andin the context of captivity or entrapment (lack of escape): – Childhood abuse – Organised sexual exploitation – Domestic violence – Torture – Hostages/prisoners of war – Survivors of religious cults – Bullying – ‘Gaslighting’ (violations of personal boundaries, such as serial, intimate betrayals that are discovered and denied www.jacquidillon.org
  21. 21. Characteristics of CPTSD• Attachment: unstable relationships, lack of trust, social isolation, difficulty perceiving and responding to other’s emotional states.• Dissociation: amnesia, voice hearing, traumatic flashbacks, and dissociative trance.• Behaviour: sleep problems, aggression, poor impulse control, and difficulties with self-soothing.• Cognition: problems with a variety of ‘executive functions’, such as planning, judgement, concentration.• Emotion: difficulty in identifying and expressing emotions and internal states, and in communicating needs, wants, and wishes.• Self-concept: fragmented, disconnected sense of self, disturbed body image, self-injury, low self-esteem, and excessive shame. Individuals often receive a diagnosis of BPD, schizophrenia, or DID All the first-rank symptoms of ‘schizophrenia’ are prevalent in individuals meeting the criteria for CPTSD www.jacquidillon.org
  22. 22. Victim Blaming“I couldn’t understand how six or eight Nazi soldiers could lead 150 people into vehicles and take themaway … Why not fight back? … I feel very connected to the people who fought here [in Israel] two thousand years ago, and less attached to the Jewswho went like sheep to the slaughter – this I couldn’t understand.” Moshe Tavor, Mossad agent responsible for the capture of Adolf Eichmann www.jacquidillon.org
  23. 23. “Boys will be boys, so girls must take care” “A gay man drinking in a pub in that part of town. I mean, really, what did he expect would happen?” “Yes, it’s terrible, but she should have left him when she had the chance.”“She got raped because she walked home alone after midnight. And she was drunk! Id never do anything so stupid.” www.jacquidillon.org
  24. 24. Divided World Them UsAbnormal Normal www.jacquidillon.org
  25. 25. United World Extreme Experience Continuum - of Extraordinary Experience ReactionModerateExperience - Ordinary Reaction www.jacquidillon.org
  26. 26. “One of the first things you need to ask is, how did you survive this? This is amazing that you’re stillhere. It’s amazing that you still have the guts to goon with your life. What is allowing you to function?What are you good at? What gives you comfort?” Bessel van der Kolk www.jacquidillon.org
  27. 27. Attachment www.jacquidillon.org
  28. 28. What is Attachment?• Our early attachment styles are established in childhood through the infant/caregiver relationship and have an important influence on development and behaviour later in life.• John Bowlby, considered the father of attachment theory, devoted extensive research to the concept of attachment, describing it as a “lasting psychological connectedness between human beings.”• In addition, Bowlby believed that attachment had an evolutionary component: “The propensity to make strong emotional bonds to particular individuals [is] a basic component of human nature.” www.jacquidillon.org
  29. 29. Impact of our Attachments• Early interactions between babies and their caregivers have lasting and serious consequences.• Recent crucial evidence has shown that children with secure attachments do not release high levels of cortisol under stress, whereas insecure children do. There is a powerful link between emotional insecurity and cortisol dysfunction.• Lack of affection and/or attunement shapes our brains and our ability to regulate emotions and manage stress.• Our early attachment experiences form our beliefs about ourselves, others and the world.• “Attachment is a memory template for human relationships. This template serves as your primary ‘world view on human relationships” (Perry, 2008). www.jacquidillon.org
  30. 30. Attachment Behavioural System Child is playful, smiling, Child feels Is the attachment figure exploring, sociable, security, sufficiently near, showing a basic sense of Yes love, trust of self and others. responsive and attuned? self- confidence. No Child is avoidant, watchful, wary, showing a basic distrust of others Defence/ Child uses attachment Fear & survival seeking behaviours: visual anxiety strategy checking, signalling a need for contact, pleading, clinging etc. Child is ambivalent, alternately angry and clinging, showing a basic mistrust of self. www.jacquidillon.org
  31. 31. Basis of Attachment• Attunement - interact in face-to-face contact. As this proceeds at tolerable levels for the infant, it remains in contact.• Misattunement - when arousal level goes too high – either because of excitement or because of anger or disapproval on the part of the caretaker – the infant breaks contact.• Reattunement - when infants level of arousal reduces again to a tolerable range, it re-establishes contact with caretaker- usually at a higher level of arousal than was previously tolerated. This type of interaction forms the basis of attachment and may be critical to increasing the child’s (and later the adult’s) capacity to regulate stress, emotion, and pain. www.jacquidillon.org
  32. 32. Attachment Styles Secure AmbivalentAttachment Style Attachment Style Avoidant DisorganisedAttachment Style Attachment Style www.jacquidillon.org
  33. 33. Ainsworth’s ‘Strange Situation’ Assessment www.jacquidillon.org
  34. 34. Secure Attachment Equipped to face challenges & take risksChild Caregiver Uses caregiver as a secure base for exploration. Responds Protests caregivers appropriately, departure and seeks proximity and is comforted promptly and on return, returning to exploration. May be consistently to needs. comforted by the stranger but shows clear preference for the caregiver. www.jacquidillon.org
  35. 35. Ambivalent Attachment Don’t abandon me!Child Caregiver Distressed on separation with ambivalence, anger, Inconsistent between reluctance to warm to appropriate, caregiver and return to play on return. overprotective and Preoccupied with neglectful responses. caregivers availability, seeking contact but resisting angrily when it is achieved. Not easily calmed by stranger. www.jacquidillon.org
  36. 36. Avoidant Attachment The Hardened HeartChild Caregiver Little or no distress on departure, little or no visible response to return, ignoring or Little or no response turning away with no effort to maintain contact if picked up. Treats the stranger to distressed child. similarly to the caregiver. These children appear to be emotionally comfortable in Discourages crying their mothers absence however, studies have repeatedly shown that when these and encourages babies are hooked up to physiological measures of emotional distress, they are just as aroused as other babies when independence. their mothers leave. They just suppress their feelings. www.jacquidillon.org
  37. 37. Disorganised Attachment The grass is always dead on both sides of the fenceChild Caregiver Their actions and responses to Frightened or frightening caregivers are often a mix of behaviours, including avoidance or behaviour, intrusiveness, ambivalence. Shown by contradictory, withdrawal, negativity, role disoriented behaviours such as confusion, affective approaching but falling over, or with the back turned or averted gaze. These communication errors and children display dazed behaviour, maltreatment. Parents who sometimes seeming either confused or act as figures of both fear and apprehensive in the presence of a reassurance to a child caregiver. Some show frank fear, standing motionless as if terrified or contribute to a disorganized disorientated. Others sought refuge in attachment style. Because the the stranger seated in the room. child feels both comforted and frightened by the parent, confusion results. www.jacquidillon.org
  38. 38. Attachment Styles How we develop our core beliefs Self Dimension Other Dimension• Am I worthy of • Are others reliable and trustworthy? being loved? • Are others accessible and willing to respond• Am I competent to to me when I need get the love I need? them to be? www.jacquidillon.org
  39. 39. Secure Attachment Style• Self dimension: Positive• I am worthy of love.• I am capable of getting the love & support I need.• Other dimension: Positive• Others are willing and able to love me. www.jacquidillon.org
  40. 40. Ambivalent Attachment Style• Self dimension: Negative• I am not worthy of love.• I am not capable of getting the love I need without being angry and clingy.• Other dimension: Positive• Others are capable of meeting my needs but might not do so because of my flaws.• Others are trustworthy and reliable but might abandon me because of my worthlessness. www.jacquidillon.org
  41. 41. Avoidant Attachment Style• Self dimension: Positive• I am worthy of love.• I am capable of getting the love and support I need.• Other dimension: Negative• Others are either unwilling or incapable of loving me.• Others are not trustworthy ; they are unreliable when it comes to meeting my needs. www.jacquidillon.org
  42. 42. Disorganised Attachment Style• Self dimension: Negative• I am not worthy of love.• I am not capable of getting the love I need without being angry and clingy.• Other dimension: Negative• Others are unable to meet my needs.• Others are not trustworthy or reliable.• Others are abusive, and I deserve it. www.jacquidillon.org
  43. 43. “Uncontrollable disruptions or distortions of attachment bonds precede the development of psychiatric breakdown” (van der Kolk, 1999)Attachment styles are working models of thought about: (1)relationships, (2) emotional regulation, (3) cognition and(4) mentalization (ability to infer mental state of oneself orothers).Individuals with psychosis generally have major problemswith all four.Typical attachment pattern: – Disorganised in infancy – Controlling in childhood – Unstable in adulthood www.jacquidillon.org
  44. 44. There Is Hope! Via the Therapeutic Alliance• The missing experience of having feelings recognised and acknowledged by another person, particularly of having strong feelings tolerated by another person – (usually a therapist) is essential to healing.• When therapist & client fail to understand each other about something important and there is a ‘rupture’ in the relationship, the therapist demonstrates that relationships can be ‘repaired’.• This cycle of rupture and repair is the key to secure relationships.• Slowly, through these types of experience, a new muscle develops, an ability to be heard and to listen, to listen and be heard.• Our brains can change shape!• It is not enough to organise new networks in the brain by offering new emotional experiences.• For these networks to become established, the new from of regulation must happen over and over again until they are consolidated.• But once they are, the individual has a portable regulation system that can be used with other people to maintain mental well-being. www.jacquidillon.org
  45. 45. What attachment style do you have? Being aware of our predominant adult attachment style can help us recognize and understand the enactments that we are drawn into within our personal relationships, with our therapist/clients - and inform how best to repair suchruptures to the working alliance and our relationships. www.jacquidillon.org
  46. 46. Low Avoidance Secure AmbivalentLow Anxiety High Anxiety Avoidant Disorganised High Avoidance www.jacquidillon.org
  47. 47. Stages of Recovery www.jacquidillon.org
  48. 48. “One of the most important psychiatric works to be published since Freud.” - New York Times 1. Establishing safety. 2. Remembrance and mourning for what was lost. 3. Reconnecting with community and society.www.jacquidillon.org
  49. 49. 1. Establishing Safety www.jacquidillon.org
  50. 50. Safety – For Supporters• Establishing safety - both within and outside of therapy.• A good rapport and collaborative alliance needs to be established before exploring any traumatic material.• Identify and build on client’s internal and external resources.• Regard defences as resources. Never ‘get rid of’ coping strategies/defences. Instead, create more choices. www.jacquidillon.org
  51. 51. Safety – For Supporters• Adapt the support/therapy to the client, rather than expecting the client to adapt to the therapy.• Regard the client with his/her individual difference and do not judge her for non-compliance or for the failure of the intervention. Never expect one intervention to have the same result with two clients.• Use of transitional objects.• When the risk of misattunement is high, it can be a good idea to prepare clients for periods of perceived (or real) injury, betrayal or failure by the therapist/supporter. Actual planning for such occurrences can go a long way toward turning them into constructive events. www.jacquidillon.org
  52. 52. Safety – For Survivors• Feeling safe and feeling protected, both within and outside of therapy.• Becoming active.• Creating sanctuary.• Back to basics.• ‘As If’ principle.• Living well is the best revenge. www.jacquidillon.org
  53. 53. A List of 20 Things to do When Desperate• Actively need to find alternative ways of keeping safe without relying on the mental health system.• Write a list of things that might help, if the person feels distressed/ like self harming/suicidal.• Keep it somewhere safe. Keep it by the phone.• Give copies to people who support the person so that they can remind her/him of things to do.• The list might look something like this…. www.jacquidillon.org
  54. 54. A List of 20 Things to do When Desperate1. Get into bed and wait for it to pass2. Stay in the day, the hour, the minute, the moment. This will pass – it always does. Don’t look too far ahead, it often increases my sense of despair and helplessness3. Breathe, deep, slow breaths. Imagine my breath flowing from my chest, up to head and down to the tips of my toes and filling me with calmness and peace4. Phone Martin – 0207 888 88885. Phone Jane – 0208 777 77776. Phone Peter - 0114 999 99997. Phone The Samaritans - 08457 90 90 90 www.jacquidillon.org
  55. 55. A List of 20 Things to do When Desperate8. Make a cup of tea9. Write a list of all the other times I have felt desperate and what I would have missed if I had succumbed to the despair10. Draw11. Have a bath12. Listen to some relaxing /inspiring music13. Take a homeopathic remedy14. Do housework or some other mindless task15. Go out for a walk16. Water the plants17. Try and read something that calms me18. Pray19. Breathe20. Go to the top of the list www.jacquidillon.org
  56. 56. Anti-Suicide Note• Write a letter when you are feeling calm and can relate this serenity to yourself at a future time when you are upset, overwhelmed and despairing - feeling as if there is no hope.• Write this letter from you, to you.• List activities you find comforting.• Record names and numbers of supportive people you can call on.• Remind yourself of your strengths, virtues, special abilities, talents and interests.• Remind yourself of some of your hopes and dreams for the future.• Give yourself special advice or other reminders that are important to you. www.jacquidillon.org
  57. 57. My Goals www.jacquidillon.org
  58. 58. Going To A Safe Place (Developing Associational Cues For Comfort & Safety)• Ask the person to relax, close their eyes and to think of an experience of comfort and security. Notice all the details of that experience including sights, sounds, feelings, smells…• Invite the person to take some time to enjoy the experience and then to make any adjustments to the details of the experience which would enhance their comfort and security. www.jacquidillon.org
  59. 59. Going To A Safe Place (Developing Associational Cues For Comfort & Safety)• When the experience is ‘just right’ invite the person to enjoy the experience one more time and then ask them to select a symbol – a ‘souvenir ’ to be used to recall this experience of comfort and security in the future. The symbol may be a sight, a sound or a sensory experience that can be revivified.• Re-orient to external reality, identify the symbol and then gently distract the person from the symbol.• Then ask the person to use the symbol to re-access the state of comfort and security.• The person can use the symbol whenever needed to re- elicit a deep state of comfort and security. www.jacquidillon.org
  60. 60. Grounding ExerciseWith your eyes open:• Find a safe, comfortable spot.• Take a few deep, slow breaths.• Look around and name five things you see, five things you hear and five things you physically feel.• Then go back and name four things you see, four things you hear, and four things you physically feel.• Then three, two, and one … www.jacquidillon.org
  61. 61. Mantras Originally a Hindu word or formula, chanted or sung as an incantation or prayer• A positive, supportive statement.• Words of power that are repeated continuously in your head or said out loud and can also be posted around the house, to counter/contradict negative voices and/or thoughts.• They can be statements that we create or loving/supportive statements that others have said to us.E.g. If a voice keeps saying to me:• “You are a bad mother” I might say, “I love my daughters and they love me.”• Or, if a voice keeps saying, “you are doomed” I might say, “I am safe now and I am free.” www.jacquidillon.org
  62. 62. Diary Work/Keeping a Journal• It can provide a sense of order and structure in what can be a chaotic environment.• Writing can be a way of putting different voices, feelings & experiences that are troubling you, outside of yourself.• Writing can help enable another perspective to be developed by gaining some distance and allowing you to make sense of what is going on.• People can focus on the following areas in their writing:• A description of the experience• What the voices/selves are saying• How they react to different situations, including the diary• Trigger factors• Writing different voices – voice dialogue –asking questions…? Do you have a name? How old are you?• Writing can encourage communication between the different voices/selves and can work towards developing a mutual collaboration.• L-hand/opposite writing – having a dialogue between different voices. www.jacquidillon.org
  63. 63. 2. Remembrance & Mourning www.jacquidillon.org
  64. 64. • Reconstructing the story of the trauma in the presence of an empathic witness or witnesses.• Restorative power of truth telling.• Mourning for what has been truly lost.• Safe release of emotions. www.jacquidillon.org
  65. 65. Write, Read, Burn• Useful exercise in finding relief from intrusive thoughts and traumatic images.• Find a safe place to sit where you will not be disturbed. You will need a piece of paper, a pen and a lighter or matches. 1) Write a description of the intrusive image(s) or thought(s) 2) Read the description aloud to a supportive person, or if no one is available read it aloud to yourself while imagining the support of someone you know would be a compassionate listener. 3) Now take the paper and the description of the intrusive thoughts or image, tear it up, and burn it. www.jacquidillon.org
  66. 66. Drawing Relief• Useful exercise to interrupt the intrusive flow of negative thoughts and provide a healing resolution by creating a new, more affirming ending.• You will need drawing paper and coloured pencils, crayons, pens or paints. Allow at least an hour of free time. You are going to draw or paint 3 pictures in 3 steps. 1) Draw the picture of the image or feelings associated with the intrusive thoughts. Use whatever colours best evoke this for you. Don’t worry about how you choose to represent this artistically. You may draw a literal image or create an abstract representation of lines, shapes, colours. However you express it is the right way because it is your way. www.jacquidillon.org
  67. 67. 2) On a separate piece of paper, draw a secondpicture depicting the absence of the intrusiveimages. This represents what you would prefer to befeeling or thinking instead of the unwanted subjects.Again, don’t worry about style, but concentrate onexpressing your chosen thought or feeling in anyway that fits for you.3) On a third piece of paper, draw a new picturesymbolizing how you imagine you got from the stateof mind depicted in the first picture to the state ofmind depicted in the second picture.4) Now tear up the first picture. www.jacquidillon.org
  68. 68. Rewriting Negative Messages• Inaccurate and unwanted negative messages from parents, ‘care-givers’, teachers, and other authority figures sometimes inadvertently become part of our self-image.• Consider what negative or destructive message from your past interferes with your confidence or your positive feelings about your life. www.jacquidillon.org
  69. 69. Rewriting Negative Messages• Now think of a new and healthy message you would like to receive instead. Write the new message first with your dominant, then with your non-dominant hand several times until it begins to feel like a familiar part of your belief system.• Using the non-dominant hand as well as the one you normally write with connects the message to your right brain, the hemisphere neurologists believe to be associated with unconscious processes. Assuming you took in a negative message on a conscious as well as an unconscious level, using both hands to write the same message more fully integrates the corrective message. www.jacquidillon.org
  70. 70. Solution Focused• This approach assumes that solution focused behavior already exists for people.• Based on solution-building rather than problem-solving.• Focuses on the desired future rather than on past problems or current conflicts.• People are encouraged to increase the frequency of current useful behaviours.• No problem happens all the time. There are exceptions – that is, times when the problem could have happened but didn’t – that can be used to co-construct solutions.• Small increments of change lead to large increments of change• The goal is to co-construct a vision of a preferred future and draw on the persons past successes, strengths, and resources to make that vision a reality. www.jacquidillon.org
  71. 71. Solution Focused Questions• That situation sounds pretty overwhelming: how do you get by?• What is it that even gives you the strength to get up in the morning?• So what have you been doing to stop things getting even worse?• When are the times when that doesn’t happen?• When are the times that it seems less intense?• When you have faced this sort of problem in the past how did you resolve it?• What other tough situations have you handled?• If you read about a woman who had been through what you have been through, what do you imagine you would think of her? www.jacquidillon.org
  72. 72. Solution Focused Questions• What does this teach you about yourself?• What have you learned from this experience?• Have you always been a survivor or did you learn the hard way?• How did you manage to keep your sense of humour/kindness/sense of justice - is this one of your qualities which has kept you going?• So what has been helping you to survive?• How have you been getting through?• How come you have not given up hope?• So how come you have managed to get here today?• How do you cope? www.jacquidillon.org
  73. 73. Accessing Unconscious Resources & Creating A Positive Future Orientation• Imagine that you have grown to be a healthy, wise old man/woman and you are looking back on this period in your life.• What do you think that this wonderful, old wise you would suggest to you to help you get through this current phase of your life?• What would s/he tell you to remember?• What would s/he suggest that would be most helpful in helping you heal/recover?• What would s/he say to comfort you?• Does s/he have any advice about how our work together could be more useful and helpful? www.jacquidillon.org
  74. 74. What do Your Voices Look Like? Using Creative Approaches• Using art, music and other non-verbal arts can be useful to express thoughts and feelings associated with traumatic experiences.• Art can be a good way of releasing visions or images that are disturbing.• This may be useful if it is difficult to express feelings in words and can also provide distance/another perspective to emerge. www.jacquidillon.org
  75. 75. 3. Reconnection www.jacquidillon.org
  76. 76. The survivor faces the task of creating a future:• Developing a new self.• Developing new relationships.• Developing a sustaining faith. Empowerment and reconnection are the core experiences of recovery. www.jacquidillon.org
  77. 77. Reconciling with Oneself ‘“I know I have myself’… *the survivor+draws upon the aspects of herself she most values from the time before the trauma, from the experience of the trauma itself,and from the period of recovery. Integrating all these aspects, she creates a new self both ideally and in actuality.” Herman (1992, p.202) www.jacquidillon.org
  78. 78. Reconciling with Others• Trauma is no longer a barrier to intimacy.• Includes family, children, friends, partners and helping professionals. www.jacquidillon.org
  79. 79. Finding a Survivor Mission• Social action and a willingness to ‘speak the unspeakable’. It is also a form of pursuing justice.• Public truth-telling – “those who forget the past are condemned to repeat it.”• Not about ‘revenge’ or seeking compensation for an atrocity, but transcending it by making it a gift to others. www.jacquidillon.org
  80. 80. Commonality• Restoring social bonds through discovering that one is not alone, that others have experienced similar events and can understand them. “I will look to this group experience as a turning point in my life, and remember the shock of recognition when I realised that the strength I so readily saw in other women who have survived this… violation was also within me.” www.jacquidillon.org
  81. 81. Beyond survival… …living well is the best revenge “If we stay as survivors only, without moving to thriving, we limit ourselves, and cut our energy to ourselves and our power in the world to less than half.” Clarissa Pinkola Estéswww.jacquidillon.org
  82. 82. Understanding Dissociation
  83. 83. Understanding Dissociation• Dissociation - a term coined by Pierre Janet a French psychiatrist in the early part of 20th century.• The dissociative disorders tend not to be taught in psychotherapy, psychology or psychiatry training, text books aimed at trainees commonly do not include material on DID and there are no NICE guidelines on its treatment in adult populations.• These three factors mean clients are extremely likely to be misdiagnosed and this will occur with greater regularity than clients from other groups. Without an awareness, practitioners will search through what they know and come up with the thing which is closest to their understanding, this typically tends to be: – Borderline personality disorder, – Schizophrenia, – Post traumatic stress disorder, – Mood disorders.• As a consequence, the average length of time it takes a patient to receive a diagnosis of DID is 6.8 years, if at all. Jacquidillon333@aol.com
  84. 84. Understanding Dissociation• Our sense of identity, reality and continuity depend on our feelings, thoughts, sensations, perceptions and memories.• If these become disconnected from each other, or don’t register in our conscious mind, it changes our sense of who we are, our memories, and the way we see things around us. This is what happens during dissociation.• Everyone has periods when disconnections occur naturally and usually unconsciously.• Some people even train themselves to use dissociation to calm themselves, or for cultural or spiritual reasons. Dissociation exists on a continuum.• Many people experience mild dissociation even when there is no stress or danger. Jacquidillon333@aol.com
  85. 85. Understanding Dissociation• At one end - everyday mild dissociative experiences - e.g. daydreaming, not remembering a car journey (‘highway hypnosis’) or getting lost in a good book.• At the other end - dissociation is a self protective mechanism helping people to survive traumatic experiences. – ‘It was like I left my body…’ – ‘Time slowed down…’ – ‘I went dead and couldn’t feel any pain…’ – ‘I watched from the ceiling as it happened to ‘somebody else’...
  86. 86. Understanding Dissociation“Dissociation appears to be the mechanismby which intense sensory and emotionalexperiences are disconnected from thesocial domain of language and memory .” (Judith Herman) Jacquidillon333@aol.com
  87. 87. Understanding Dissociation“*Dissociation+... begins with the childsself-hypnotic assertion ‘I am not here; thisis not happening to me; I am not in thisbody.’” (Phil Mollon, 1996, p.15) Jacquidillon333@aol.com
  88. 88. Understanding Dissociation• Dissociation is an automatic, self protective alteration of consciousness in the face of overwhelming stress, a form of mental flight.• Research suggests that some children repeatedly exposed to severe trauma - for example, sexual, physical and/or emotional abuse - develop the gift of dissociation - a creative survival strategy that enables children to switch off psychologically from the traumatic experience. Jacquidillon333@aol.com
  89. 89. Understanding Dissociation• Although dissociation mentally removes you from painful experience, it can undermine your functioning when it develops into a habitual way of coping with anxiety or stress.• Over time, dissociation can develop into a conditioned response to any stressful situation. Thus what served effectively as a problem- solving strategy in childhood can become a debilitating, complex experience that may seriously impede healthy adult functioning. Jacquidillon333@aol.com
  90. 90. Compartmentalisation Involves keeping conflicted feelings, disquieting thoughts, behaviour andknowledge in separate compartments from normal consciousness. Jacquidillon333@aol.com
  91. 91. Dissociative DetachmentFeeling disconnected from yourself or theouter world, for example in a trance like ordream like state. Feelings of unreality. Jacquidillon333@aol.com
  92. 92. Depersonalization• Involves feelings of unreality regarding your sense of self. You may feel like you are on autopilot, you are an actor in a play, you are disconnected from your body, or that you are observing yourself from outside your body.• It can also include feeling so detached from your emotions that you can feel like a robot or machine.• People may have ‘out of body’ experiences.• Some people report profound alienation from their bodies – a sense that they do not recognise themselves in the mirror, recognize their face, or simply do not feel connected to their own bodies. Jacquidillon333@aol.com
  93. 93. Derealisation• Involves a sense that the outer world is not real. You may feel as if other people are actors in a play or as if youre looking at the world through a tunnel.• Familiar people may appear to be strangers.• Often it can feel as though everything appears as through a fog or even the opposite – everything including colours may appear more intense.• Extreme detachment involves feeling as if youre gone, in the blackness, or in a void.• When youre very detached, you may have trouble remembering what you’ve said or done; you may have not encoded it well into memory and therefore cannot retrieve it. Jacquidillon333@aol.com
  94. 94. Dissociative Amnesia• Involves blocking out frightening or stressful events from consciousness which can result in an inability to recall important personal information.• This can manifest itself as having gaps in your memory or the experience of ‘losing time’.• Micro amnesias are common where a conversation is not remembered or the content of a conversation is forgotten from one moment to the next. Jacquidillon333@aol.com
  95. 95. Dissociative FugueInvolves losing your sense of identity andmemory of your past. People can findthemselves in a place with no memory ofgetting there and sometimes no knowledgeof who they are.
  96. 96. Dissociative Identity ‘Disorder’• Is characterised by two or more separate identities or personality states that recurrently take control of the individuals behaviour, accompanied by a loss of memory of significant personal information that is too all-embracing to be explained by normal absent- mindedness.• There may be an observable shifts in identity such as changes in behaviour - mood swings - and can include using different names. It is often experienced as a loss of control within or can occur during an amnesiac episode. Jacquidillon333@aol.com
  97. 97. Dissociative Identity ‘Disorder’• There can be confusion about ‘who you are’ which can include confusion about sexual identity.• Another example of identity confusion is when a person sometimes feels a thrill when engaged in an activity (e.g. reckless driving, drug use, sexual behaviour), which at other times would be repugnant. Jacquidillon333@aol.com
  98. 98. Dissociative Identity ‘Disorder’• Subtler forms of identity alteration can be observed when a person uses different voice tones, range of language or facial expressions. These may be associated with changes in the persons world view.• E.g. during a discussion about a frightening experience a person may initially feel/appear young, vulnerable and frightened followed by a sudden shift to feeling hostile and murderous.• The person may feel confused about their feelings and perceptions and have difficulty remembering what they have just said.• The person may be able to confirm the experience of identity alteration but may be unaware of the existence of dissociated self states. Jacquidillon333@aol.com
  99. 99. Dissociation/Association• One of the core problems for the person with a dissociative ‘disorder’ is difficulty tolerating and regulating intense emotional experiences.• This problem results in part from having had little opportunity to learn to soothe oneself or modulate feelings.• Problems in affect regulation are compounded by the sudden intrusion of traumatic memories and the overwhelming emotions accompanying them. Jacquidillon333@aol.com
  100. 100. Dissociation in Relation to Self-Injury“Survivors who self-mutilate consistentlydescribe a profound dissociative statepreceding the act. Depersonalisation,derealisation, and anaesthesia areaccompanied by a feeling of unbearableagitation and a compulsion to attack the body.The initial injuries often produce no pain atall.” (Herman. p.109) Jacquidillon333@aol.com
  101. 101. Dissociation/Association• The inability to manage intense feelings may trigger a change in self-state from one prevailing mood to another.• Depersonalization, derealisation, amnesia and identity confusion can all be thought of as efforts at self-regulation when affect regulation fails.• Each psychological adaptation changes the ability of the person to tolerate a particular emotion, such as feeling threatened.• As a last alternative for an overwhelmed mind to escape from fear when there is no escape, a person may unconsciously adapt by believing, incorrectly, that they are somebody else.• Becoming aware of this kind of fear is terrifying.• Therein lies one of the central problems in treatment for a person with a dissociative ‘disorder’:• “How do I learn to approach things I fear when to understand that I am afraid is itself frightening?” Jacquidillon333@aol.com
  102. 102. The SIBAM Model
  103. 103. SIBAM MODEL• Peter Levine’s SIBAM model is a useful tool for conceptualising dissociation.• It is based on the thesis that any experience is comprised of several elements.• Complete memory of an experience involves integrated recall of all the elements. Jacquidillon333@aol.com
  104. 104. SIBAM Model• SIBAM is the acronym for:• SENSATION: The bodily sensations experienced at the time of trauma. Examples are: muscle tension, muscle tiredness or weakness, racing heart, perspiration, defecation, sinking feeling in the stomach etc.• IMAGE: What was observed? The awareness of what was happening externally. Can the person replay a movie of what was going on around them? Does a scene or image keep replaying or intruding into consciousness?• BEHAVIOUR: What did the person do or FAIL not to do?• AFFECT: What did the person feel? Fear, disbelief, panic, anger, resignation, helplessness, vulnerability etc.• MEANING: How did the person make sense of what was happening? E.g. This is my fault, I could have protected myself, why has this happened to me? Jacquidillon333@aol.com
  105. 105. SIBAM Model• During traumatic experience, elements of the experience can become disconnected from each other.• Someone might describe having a visual memory (image) and a strong emotion connected to it (affect) but cannot make any sense of it (dissociated meaning).• A child might exhibit repetitive play after a disturbing event (behaviour), but doesn’t display any emotion (dissociated affect) or appear to remember it at all (image). Jacquidillon333@aol.com
  106. 106. Jacquidillon333@aol.com
  107. 107. SIBAM Model• The SIBAM model can be an effective way to help identify which elements of an experience are associated and which are dissociated.• The aim is for the experience to reside in the memory as a past event without intruding into the present in the form of distressing voices, sensations, overwhelming emotion, etc. Jacquidillon333@aol.com
  108. 108. The Dissociative Experiences Scale (DES-II)A reliable, valid, convenient way to quantifythe frequency of dissociative experiences (in both clinical and non-clinical populations) www.jacquidillon.org
  109. 109. DES-II (Carlson & Putnam, 1993)• “Dissociation Continuum” – previous scales used present/absent responses.• Total score and three sub-scales – Amnesia (e.g., “Some people have the experience of finding new things among their belongings that they do not remember buying”). – Depersonalization/derealization (e.g., “Some people have the experience of looking in a mirror and not recognizing themselves”). – Absorption (“Some people sometimes find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them”). www.jacquidillon.org
  110. 110. Average DES-II Scores for Different Clinical and Non-Clinical Groups60 57504030 3120 1410 7 40 Non-Clinical Adults Agoraphobic Patients Non-Clinical PTSD Patients DID Patients Adolescents www.jacquidillon.org
  111. 111. Scoring the DES-II• Scored by totalling the percentage answered for each question (from 0-100%) and then dividing by 28. – This yields a score in the range of 0-100.• A screening test (not a diagnostic test) although scores >30 indicate high likelihood the person has a dissociative disorder. – Individuals with lower scores above normal may have other post-traumatic conditions. www.jacquidillon.org
  112. 112. DES Subscales• Amnesia: Questions 3-5, 8, 25 & 26• Depersonalisation/derealisation: Questions 7, 11-13, 27 & 28• Absorption: Questions 2, 14-15, 17-18 & 20• DES Taxon: Questions 3, 5, 7-8, 12, 13, 22 & 27 www.jacquidillon.org
  113. 113. VicariousTraumatisation www.jacquidillon.org
  114. 114. Vicarious Traumatisation• Vicarious trauma is the process of change that happens because you care about other people who have been hurt, and feel committed or responsible to help them. Over time this process can lead to changes in your psychological, physical, and spiritual well-being.• When you identify with the pain of people who have endured terrible things, you bring their grief, fear, anger, and despair into your own awareness and experience.• Your commitment and sense of responsibility can lead to high expectations and eventually contribute to your feeling burdened, overwhelmed, and perhaps hopeless.• Vicarious trauma, like experiencing trauma directly, can deeply impact the way you see the world and your deepest sense of meaning and hope. www.jacquidillon.org
  115. 115. Risk Factors• Vicarious traumatisation may be more problematic for people who tend to avoid problems or difficult feelings, blame others for their difficulties, or withdraw from others when things get hard.• Added stress in other areas of your life can make you more vulnerable to vicarious trauma.• Not addressing your own unresolved trauma makes you more vulnerable to vicarious trauma.• Lack of good social support puts you at increased risk for vicarious trauma.• A lack of connection with a source of meaning, purpose, and hope is a risk factor for developing more problematic vicarious trauma.• Unsustainable professional and work-life boundaries and unrealistic ideals and expectations about work can contribute to more problematic vicarious trauma.• Mental health work as a profession is often characterized by self- neglect, toughing it out, risk-taking, and denial of personal needs. All of these can contribute to more severe vicarious trauma. www.jacquidillon.org
  116. 116. Vicarious Traumatisation Truth & Reconciliation The lack of processing of countertransference experiences by the TRC staffmanifested in the symptom of a pervading boredom. Staff often discussed being utterly“bored” by the repetitive and relentless nature of the deponents personal stories. Theybecame inured and emotionally blunted. Although there was liberal discussion of thingslike ‘vicarious traumatisation’ this happened at an intellectual level and there remainedthe unspoken fear of dealing with this knowledge at an emotional and organisationallevel. A core dimension of the primary task of the TRC was to create a space for voice.In so doing it paradoxically silenced the articulation of the consequential emotionalstory of the organisation itself. The intersubjectivity of the process remainedunacknowledged and silenced. Flight from the “impossible primary task” took severalforms. This disavowal of the impact of the process on the organisation was challengedat a critical point in one hearing where Tutu was presiding. It was a ‘typical’ story ofyet another victim. However this time it was all too much. Desmond Tutu as he buriedhis head in his hands and simply broke down, sobbing inconsolably as a colleagueplaced her hand on his back and passed him a tissue. www.jacquidillon.org
  117. 117. Signs of Vicarious Traumatisation• Experiencing the “silencing response” - finding yourself unable to pay attention to other’s distressing stories because they seem overwhelming and incomprehensible; and directing people to talk about less distressing material.• Difficulty managing boundaries - taking on too much responsibility, difficulty leaving work at the end of the day, trying to step in and control others lives.• Difficulty with core beliefs and resulting difficulty in relationships reflecting problems with security, trust, esteem, intimacy and control.• Decreased interest in activities that used to bring pleasure, enjoyment, or relaxation.• Guilt at your own survival, good fortune or pleasure.• An unexplained general sense of tiredness, boredom & lethargy.• This in turn can be projected out onto the organisation and lead to increased negativity and cynicism towards aims of the organisation.• In severe cases it can lead to depression, loss of meaning in one’s life and even to use of substances to help sleep and control anxiety states. www.jacquidillon.org
  118. 118. Signs of Vicarious Traumatisation• The impact of vicarious trauma parallels that of direct trauma, although it tends to be less intense. Common signs include, but are not limited to:• Sleep difficulties - increase in sleepless nights or changes in sleep patterns.• Intrusive images or dreams of stories that may have been recounted.• Social withdrawal, mood swings, difficulty managing your emotions, cynicism.• Somatic symptoms, aches, pains, illnesses, accidents, sexual difficulties.• Greater sensitivity or numbness to violence.• Unexplained loss of sense of aliveness and increased sense of numbness, often accompanied by questioning whether this is the right career in a role that has been previously enjoyed. www.jacquidillon.org
  119. 119. Mechanism for Vicarious Traumatisation• The posited mechanism for vicarious traumatisation is empathy.• Different forms of empathy may result in different effects on helpers.• Trauma helpers need to be aware of the ways to manage empathic connection constructively.• If helpers identify with their trauma survivor clients and immerse themselves in thinking about what it would be like if these events happened to them, they are likely to experience personal distress, feeling upset, worried, distressed.• On the other hand, if helpers instead imagine what the client experienced, they may be more likely to feel compassion and moved to help. www.jacquidillon.org
  120. 120. Addressing Vicarious Traumatisation• Vicarious traumatisation is not the responsibility of clients.• Organisations that provide trauma-related services bear a responsibility to create policies and work settings that facilitate staff (and therefore client) well-being.• Each trauma worker is responsible for self-care, working reflectively and engaging in regular, frequent, trauma-informed supervision.• There are many ways of addressing vicarious traumatisation.• All involve awareness, balance, and connection. www.jacquidillon.org
  121. 121. Addressing Vicarious Traumatisation• One set of approaches can be grouped together as coping strategies.• A second set of approaches can be grouped as transforming strategies. Transforming strategies aim to help workers create community and find meaning through the work.• Strategies may be applied in ones personal life and professional life. www.jacquidillon.org
  122. 122. Addressing Vicarious Traumatisation• Personal & Professional Development.• Personal Therapy.• On-going training.• Support & Supervision.• Work/life balance. – Escape: Getting away from it all, physically or mentally (books or films, taking a day or a week off, playing music, talking to friends about things other than work). – Rest: Having no goal or time-line, or doing things you find relaxing (lying on the grass watching the clouds, sipping a cup of tea, taking a nap, getting a massage). – Play: Engaging in activities that make you laugh or lighten your spirits (sharing funny stories with a friend, playing with a child, being creative, being physically active). www.jacquidillon.org
  123. 123. Spirituality & Social Activism Actively seeking out things and activities that make us feel whole, alive, joyful, and connected with something beyond ourselves• Prayer, meditation, solitude, guided imagery, relaxation, yoga.• Reading inspirational texts.• Listening to lectures or inspirational speakers.• Listening to music, singing, dancing.• Being creative — writing, drawing, composing music.• Spending time in nature.• Contemplating art.• Spending time with the people most dear to you.• Creating community and meaning through your work - connecting with others who share your values.• Participating in a collective change. www.jacquidillon.org
  124. 124. Regularly Clarifying Your Values Values clarification involves seeking a clearer understanding of what we value in life and why. This is a unique source of energy - it fuels purpose, focus, direction, passion and perseverance. Clarifying your values means asking and answering questions that help you clarify your life mission and your road map. Questions such as:• What am I doing? Why am I doing it? How is it coming along?• What do I embody most? What is it I want to embody most? What are the things, qualities, attributes, attitudes I value most in life?• What do I wish I was doing more? Why?• Who am I at my best?• Think of someone you deeply respect. Describe three qualities in this person that you most admire.• What one sentence inscription would I like to see on my gravestone that would capture who I really was in life?• When I look back at the end of my life, what do I expect the three most important lessons I’ve learned to be, and why are they so important? www.jacquidillon.org
  125. 125. Vicarious Transformation Beyond vicarious traumatisation lies vicarious transformation.• This is the process of transforming ones vicarious trauma, leading to spiritual growth.• Vicarious transformation is a process of active engagement with the negative changes that come about through trauma work.• It can be recognized by a deepened sense of connection with all living beings, a broader sense of moral inclusion, a greater appreciation of the gifts in ones life, and a greater sense of meaning and hope.• Vicarious transformation is a process, not an endpoint or outcome. If we can embrace, rather than fending off, our clients’ extraordinary pain, our humanity is expanded.• In this receptive mode, our caring is deepened. Our clients feel that we are allowing them to affect us. This reciprocal process conveys respect.• We learn from our trauma survivor clients that people can endure horrible things and carry on.• This knowledge is a gift we can pass along to others. www.jacquidillon.org
  126. 126. Barriers to ChangeHow can we incorporate changes withinour own personal or professional lives? www.jacquidillon.org
  127. 127. In Groups…1. How you can implement what you’ve learnt from this course within your own work setting or personal life?2. What barriers might you face, and how could you overcome them? www.jacquidillon.org
  128. 128. Possible Ideas• Access to appropriate support and supervision.• Using the NGO sector.• Co-counselling.• Acknowledge your frustration that services aren’t trauma-based.• Self-help groups.• Training.• Sharing power and expertise.• Reflectiveness.• Taking care of ourselves• Rejecting the ‘can of worms’ fallacy!• Multi-level change – individual, organisational, social, and political www.jacquidillon.org
  129. 129. Further information: www.jacquidillon.org www.jacquidillon.org