Fiona Kennedy

ACT AND DISSOCIATION
MINDFULNESS EXERCISE
copyright Fiona C Kennedy 2010

WHAT IS DISSOCIATION?


A failure to integrate experiences (memories,
perceptions, etc.) ...
copyright Fiona C Kennedy 2010

WHY IS DISSOCIATION IMPORTANT?


Characteristic of complex psychological
disorders with p...
‘SYMPTOMS’
Spacing out
 Inability to think
 Inability to feel emotions
 Physiological ‘conversion’ symptoms
 Flashback...
copyright Fiona C Kennedy 2010

‘SYMPTOMS’











Amnesia (for past, for present events)
Fugues
Regression
Out...
DISSOCIATIVE PHENOMENA
 memory

 sense

of self
 Consciousness/perception
 Somatic/bodily symptoms
copyright Fiona C Kennedy 2013

Trauma history or other vulnerability
factors
Altered brain structures
‘hardware’

Conditi...
copyright Fiona C Kennedy 2013

Kathy: long term sexual abuse by
adoptive father

Altered brain structures
‘hardware’

Con...
ACT DEFINITION OF DISSOCIATION
threat is a non-arbitrary stimulus
 Evoking responses of inhibitory neurological
excitatio...
TRANSFER OF STIMULUS FUNCTION:
Other stimuli with similarities to the original
threat evoke dissociative responses
 Talki...
RELATIONAL FRAMES
There are relational frames around the
experience of dissociative reactions which
may also require thera...
copyright Fiona C Kennedy 2013

TYPES OF DISSOCIATION
(KENNEDY ET AL (BTEP 2004))
I

automatic :

Inhibition of early pro...
POSITIVE

NEGATIVE

AUTOMATIC

intrusive images
flashbacks,
hallucinations

detachment numbing,
spacing out, fragmented
me...
THE SELF AND DISSOCIATION


Piagetian construction of the self
C(carer)

A(mom)

B(dad)
ATTACHMENT
Abuse by carer
 Produces conflict:


attachmen
t

Selfpreservation

This leads to damage to the sense of self...
RFT
I am a murderer
 Murderers are terrible
 I am terrible
 Experiential avoidance:
 That murderer is not me
 I am no...
RFT AND CONSTRUCTED SELF
The person who did the murder was not me
 But it was my hand that held the knife
 Therefore som...
RFT AND AMNESIA
There are other people in my body
 They have done things I do not know about
 They do things I do not kn...
PTSD

Daily life

trauma



Apparently
normal
personality

Emotional
Personality
DID

ANP

ANP

EP

EP
Contact with the
Present Moment

Acceptance

Values

Psychological
Flexibility

Defusion

Committed
Action

Self as
Contex...
copyright Fiona C Kennedy and David
Pearson 2013

SONYA (AUTOMATIC DISSOCIATION)
Sculptor
 Intrusive visual images of sel...


SONYA WDS Profile

4
3.5

1

3

Patient

2.5

Clinical

2

Non-Clinical

1.5
1
0.5
0
Automatic
Function
(CX=1.5)
(SD=0....
ACT FORMULATION
‘Your mind is like a chattering monkey, and a
mischievous one at that........
 One day it sent you a thou...
ACT FORMULATION
So you started to worry not just about the
picture but about why you got it
 So now you spend most of you...
Acceptance

Present moment
Caring for baby
grounding

Noticing Images of
self and baby

Defusion
Not buying bad mom
though...
EXERCISE
Sonya has been asked to make a sculpture
of a loving mother and child, using her newlylearned mindfulness skills ...
copyright Fiona C Kennedy and David
Pearson 2013

AHMED – PTSD/SOMATIC SYMPTOMS
(STRATEGIC DISSOCIATION)
Engineer
 Stabbe...
copyright Fiona C Kennedy 2013

AHMED WDS
4.5

4
3.5
3
2.5
2
1.5
1

0.5
0
I Automatic

II Strategic

III Between -mode
ACT FORMULATION
When this terrible thing happened with your
son, your mind went into overdrive. You
could see yourself bei...
ACT FORMULATION
So when you saw the signs you would be
reminded to be careful
 But the signs would not keep still....they...
MODEL
Engaging Ahmed
 Sharing formulation with Ahmed
 Using creative hopelessness
 ‘In a hole digging’
 Asking for wil...
Acceptance
Son as imperfect
Images of stabbing
Self in wheelchair

Defusion
Not buying bad son
bad father thoughts

Self a...
copyright Fiona C Kennedy and David
Pearson 2013

DOROTHY: COUNSELLOR DID
Markedly different self-states presenting in
the...
copyright Fiona C Kennedy and David
Pearson 2013

DOROTHY WDS
4.5

4
3.5
3
2.5
2
1.5
1

0.5
0
I Automatic

II Strategic

I...
VIDEO
ACT FORMULATION (PERSONALITY)
All of us have more than one self
 Many people join those selves together as
they grow up, ...
ACT FORMULATION
Which is fine, if it allows life to be lived as
desired/valued
 But for you, the selves are arguing a lot...
ACT FORMULATION
So all of you can choose to keep on fighting
and trying to get rid of each other..........
 Or you can gr...
copyright Fiona C Kennedy 2010

TOP TIPS FOR TREATMENT
Formulatie-function of different selves
 Normalise and Validate
 ...
Acceptance
Mapping system

Defusion
Not buying bad
me/them
thoughts/feelings

Self as context
Chessboard or other
metaphor...
copyright Fiona C Kennedy 2010

AMNESIA
Puzzle: how can client forget?
 Metaphors: jigsaw puzzle, lego
bricks, library, v...
copyright Fiona C Kennedy 2010

AMNESIA
Validate memories
 Emphasise reconstructive nature of
memories
 E.g daddy put a ...
CLIENT RELEVANT METAPHORS
Eg flipping tracks on CD
 Lots of people trying to drive one car
 Russian dolls
 Blasted tree...
copyright Fiona C Kennedy 2010
CHESSBOARD METAPHOR
Imagine (or physically show) chessboard
 Players = self states
 Oppositional, fighting for control
...
EXERCISE
In pairs
 Use the chessboard metaphor to discuss
different self-states
 Ask the client to use mindful awareness...
FEED BACK
ROUTLEDGE
http://www.routledge
mentalhealth.com/b
ooks/details/978041
5687775/

USE CODE
MHAUTH0513

For 20% discount!
EVALUATION, GOODBYE!


Please fill in evaluation form and collect your
flyer on way out
ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality
ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality
ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality
ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality
ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality
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ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality

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Learn how to make ACT formulations and treatment plans for the many and puzzling consequences of real and perceived threat including child abuse......amnesia, detachment, PTSD, borderline personality disorder, conversion symptoms, dissociative identity disorder, psychosis

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ACT and Dissociation Acceptance and Commitment work with the consequences of trauma likes amnesia and fragmented personality

  1. 1. Fiona Kennedy ACT AND DISSOCIATION
  2. 2. MINDFULNESS EXERCISE
  3. 3. copyright Fiona C Kennedy 2010 WHAT IS DISSOCIATION?  A failure to integrate experiences (memories, perceptions, etc.) that are normally associated (e.g. Janet, 1889)  Symptoms such as amnesia, depersonalisation, derealisation & identity confusion serve to REDUCE AWARENESS of intolerable information
  4. 4. copyright Fiona C Kennedy 2010 WHY IS DISSOCIATION IMPORTANT?  Characteristic of complex psychological disorders with poor therapeutic outcome PTSD, BPD, DID)  is a mediator in trauma-psychopathology link  If not addressed, seriously therapy interfering
  5. 5. ‘SYMPTOMS’ Spacing out  Inability to think  Inability to feel emotions  Physiological ‘conversion’ symptoms  Flashbacks  Identity alteration (‘switching’ between states)  Identity disturbance/unstable sense of self eg sexual orientation, morals, opinions, career 
  6. 6. copyright Fiona C Kennedy 2010 ‘SYMPTOMS’         Amnesia (for past, for present events) Fugues Regression Out of body experiences Hallucinations : auditory, visual, somatic, olfactory, tactile Non organic epileptic seizures Panic attacks Behavioural re-enactment
  7. 7. DISSOCIATIVE PHENOMENA  memory  sense of self  Consciousness/perception  Somatic/bodily symptoms
  8. 8. copyright Fiona C Kennedy 2013 Trauma history or other vulnerability factors Altered brain structures ‘hardware’ Conditioned dissociative responses to real/perceived threat ‘software’ Reduce awareness and prevent exposure and learning Mental Health Problems Dissociative disorders Conversion disorders Psychosis BPD PTSD Prevent therapeutic change Prevent adaptation to new (safe) environment Fight/Flight/Freeze Vulnerability to further real/perceived trauma
  9. 9. copyright Fiona C Kennedy 2013 Kathy: long term sexual abuse by adoptive father Altered brain structures ‘hardware’ Conditioned responses hiding, out of body, amnesia Mental Health Problems Depression Psychosis BPD features Flashbacks Vulnerability alcoholism, failure to protect child lead to loss of child Reduce awareness and prevent exposure and learning Ambivalent about whether she was abused, stayed in abusive relationship, did not see CSA threat from husband
  10. 10. ACT DEFINITION OF DISSOCIATION threat is a non-arbitrary stimulus  Evoking responses of inhibitory neurological excitation (switching off)  Which enables experiential avoidance 
  11. 11. TRANSFER OF STIMULUS FUNCTION: Other stimuli with similarities to the original threat evoke dissociative responses  Talking or thinking about threatening stimuli evokes dissociative responses 
  12. 12. RELATIONAL FRAMES There are relational frames around the experience of dissociative reactions which may also require therapeutic attention  E.g. People who dissociate are......mad/special/different  Dissociating is better than experiencing pain  There is a particular set of relational frames around the construction of the self or selves 
  13. 13. copyright Fiona C Kennedy 2013 TYPES OF DISSOCIATION (KENNEDY ET AL (BTEP 2004)) I automatic : Inhibition of early processing because of perceived threat  II schematic Inhibition of affective, behavioural, cognitive, physiological schemata  III personality: Evolution of separate selves and/or inhibition of links between personality structures
  14. 14. POSITIVE NEGATIVE AUTOMATIC intrusive images flashbacks, hallucinations detachment numbing, spacing out, fragmented memory SCHEMATIC intrusive experiences thoughts, behaviours, affect; somatic symptoms (pain, NES) absence of experience inability to think (amnesia), inability to do things, inability to feel, paralysis PERSONALITY identity disturbance: Identity confusion State switching, Multiple self states Absence of continuous consciousness losing time, fugue, amnesia,
  15. 15. THE SELF AND DISSOCIATION  Piagetian construction of the self C(carer) A(mom) B(dad)
  16. 16. ATTACHMENT Abuse by carer  Produces conflict:  attachmen t Selfpreservation This leads to damage to the sense of self  One ‘self’ attaches to good parent  One self detaches, ‘holds’ abuse 
  17. 17. RFT I am a murderer  Murderers are terrible  I am terrible  Experiential avoidance:  That murderer is not me  I am not terrible 
  18. 18. RFT AND CONSTRUCTED SELF The person who did the murder was not me  But it was my hand that held the knife  Therefore someone else is using my hand (taking over my body) 
  19. 19. RFT AND AMNESIA There are other people in my body  They have done things I do not know about  They do things I do not know about  There are people in my body I do not know about   (they are spirits, devils, watchers, aliens......)
  20. 20. PTSD Daily life trauma  Apparently normal personality Emotional Personality
  21. 21. DID ANP ANP EP EP
  22. 22. Contact with the Present Moment Acceptance Values Psychological Flexibility Defusion Committed Action Self as Context
  23. 23. copyright Fiona C Kennedy and David Pearson 2013 SONYA (AUTOMATIC DISSOCIATION) Sculptor  Intrusive visual images of self abusing baby  Self reported risk  Mother left her when she was six; father ‘absent’ academic  Sonya believed mum left because she was ‘bad = dangerous’ 
  24. 24.  SONYA WDS Profile 4 3.5 1 3 Patient 2.5 Clinical 2 Non-Clinical 1.5 1 0.5 0 Automatic Function (CX=1.5) (SD=0.8) Within-mode Dissociation (CX=2.1) (SD=0.9) Between-mode Dissociation (CX=2.1) (SD=0.9) Average Total (CX=1.9) (SD=0.8)
  25. 25. ACT FORMULATION ‘Your mind is like a chattering monkey, and a mischievous one at that........  One day it sent you a thought, a full colour glossy illustration of you abusing Ben  You were so shocked, you locked it up in a heavy safe and threw away the key  But you were worried about this, ‘why have I been sent this picture? I must be interested somehow, I must secretly want to abuse Ben 
  26. 26. ACT FORMULATION So you started to worry not just about the picture but about why you got it  So now you spend most of your time shutting the picture out, but the more you try the more it comes back in  And while you’re spending all this time trying to shut out the picture, you’re not spending time with Ben 
  27. 27. Acceptance Present moment Caring for baby grounding Noticing Images of self and baby Defusion Not buying bad mom thoughts images Self as context I am not the mom not the child I am the studio P F Values Good mother Committed action Spending time with child
  28. 28. EXERCISE Sonya has been asked to make a sculpture of a loving mother and child, using her newlylearned mindfulness skills as she goes along  In pairs, one as therapist other as Sonya, place the sculpture between you and look at it, touch it if you wish  Hold it lightly as a goal, mindfully notice any judgements thoughts feelings images that pass through your awareness 
  29. 29. copyright Fiona C Kennedy and David Pearson 2013 AHMED – PTSD/SOMATIC SYMPTOMS (STRATEGIC DISSOCIATION) Engineer  Stabbed in spine by son during argument; had images of being in wheelchair forever  Recovered well physically, some PTSD symptoms  Saw son again....could not walk, in wheelchair  Intermittently had to use wheelchair 
  30. 30. copyright Fiona C Kennedy 2013 AHMED WDS 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 I Automatic II Strategic III Between -mode
  31. 31. ACT FORMULATION When this terrible thing happened with your son, your mind went into overdrive. You could see yourself being paralysed for life and felt horror and helplessness  This was so bad that your mind decided to bury the whole experience, and put up a bunch of signs around the burial site saying ‘danger! Don’t go here!’ 
  32. 32. ACT FORMULATION So when you saw the signs you would be reminded to be careful  But the signs would not keep still....they grew legs and invaded your whole life, marching about shouting ‘danger! danger!’  And the more you try to avoid them, the more just pop up  And when they pop up they don’t just remind you, they paralyse you! 
  33. 33. MODEL Engaging Ahmed  Sharing formulation with Ahmed  Using creative hopelessness  ‘In a hole digging’  Asking for willingness 
  34. 34. Acceptance Son as imperfect Images of stabbing Self in wheelchair Defusion Not buying bad son bad father thoughts Self as context I am not the guy who walks I am not the guy in the wheelchair I am constantly reincarnated Present moment Contact with material Values Loving father forgiveness Committed action Watching football with son
  35. 35. copyright Fiona C Kennedy and David Pearson 2013 DOROTHY: COUNSELLOR DID Markedly different self-states presenting in therapy, amnesia for other states  ‘haunted’ by menacing human figures she saw and heard, interacting with them  Losing time, amnesia for childhood, often forgot last session  Multiple diagnoses 
  36. 36. copyright Fiona C Kennedy and David Pearson 2013 DOROTHY WDS 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 I Automatic II Strategic III Between -mode
  37. 37. VIDEO
  38. 38. ACT FORMULATION (PERSONALITY) All of us have more than one self  Many people join those selves together as they grow up, to make one ‘I’, more or less  But for some people, it works better not to join them up, their minds make a number of different selves (or identities or people) each with their own role to play 
  39. 39. ACT FORMULATION Which is fine, if it allows life to be lived as desired/valued  But for you, the selves are arguing a lot and messing life up, for example in your job  And none of the selves really have a full picture of the life being lived (blind men and elephant)  And some dangerous things keep happening which are beyond anyone’s control at the moment 
  40. 40. ACT FORMULATION So all of you can choose to keep on fighting and trying to get rid of each other..........  Or you can grow some mutual respect and try working as a team  But for a team to work well we need........ 
  41. 41. copyright Fiona C Kennedy 2010 TOP TIPS FOR TREATMENT Formulatie-function of different selves  Normalise and Validate  Risk management  Amnesia  Grounding  Imagery work  Therapist support 
  42. 42. Acceptance Mapping system Defusion Not buying bad me/them thoughts/feelings Self as context Chessboard or other metaphors Present moment Simultaneous presenc e of self states P F Values Tricky...use values bull’s eye Committed action e.g. Dealing with social worker to keep child
  43. 43. copyright Fiona C Kennedy 2010 AMNESIA Puzzle: how can client forget?  Metaphors: jigsaw puzzle, lego bricks, library, video store, computer memory storage 
  44. 44. copyright Fiona C Kennedy 2010 AMNESIA Validate memories  Emphasise reconstructive nature of memories  E.g daddy put a knife in my bottom 
  45. 45. CLIENT RELEVANT METAPHORS Eg flipping tracks on CD  Lots of people trying to drive one car  Russian dolls  Blasted tree  Chameleon  people within one body  chess 
  46. 46. copyright Fiona C Kennedy 2010
  47. 47. CHESSBOARD METAPHOR Imagine (or physically show) chessboard  Players = self states  Oppositional, fighting for control  When one is knocked off she climbs back onto board  Fight can never be won  And life is passing by  ‘I’ am not the pieces; I am not the player...I am the chessboard 
  48. 48. EXERCISE In pairs  Use the chessboard metaphor to discuss different self-states  Ask the client to use mindful awareness of herself as chessboard 
  49. 49. FEED BACK
  50. 50. ROUTLEDGE http://www.routledge mentalhealth.com/b ooks/details/978041 5687775/ USE CODE MHAUTH0513 For 20% discount!
  51. 51. EVALUATION, GOODBYE!  Please fill in evaluation form and collect your flyer on way out

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