Dillon

Abuse, Trauma, and Dissociation
Understanding and Working Towards Recovery

Jacqui Dillon
www.jacquidillon.org


The Personal is Political


The Personal is Political
The 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 are
personal, but their broad texture and character, and
especially the limits within which these evolve, are
largely systemic.


Jacqui aged 5

Experiences Survival Strategies

Abuse Hearing Voices
Betrayal Self Harm
Neglect Eating ‘Disorder’
Denial Creativity
Blame Resourcefulness
Threats Sense of Justice


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’.


Finding a new paradigm
• Trauma & Recovery

• Understanding Dissociation

• Attachment Theory

• The Personal Is Political


Trauma and Recovery
(Judith Herman)‫‏‬
• Safety

• Remembering & Mourning

• Reconnection


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


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


‘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!


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


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’

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


“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)


What is Trauma?


Trauma
First 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.”

Shattered Assumptions

Trauma shatters assumptions
people hold about the world,
other people and themselves
– assumptions needed in
order to feel safe, deal
comfortably with others and
have confidence in oneself.


Childhood Maltreatment
Neglect
• 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.


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, and
in 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


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


Victim Blaming
“I couldn’t understand how six or eight Nazi soldiers
could lead 150 people into vehicles and take them
away … 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 Jews
who went like sheep to the slaughter – this I couldn’t
understand.”

Moshe Tavor, Mossad agent responsible
for the capture of Adolf Eichmann


“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! I'd never do anything so stupid.”


Divided World

Them Us

Abnormal Normal


United World

Extreme
Experience
Continuum -
of Extraordinary
Experience Reaction
Moderate
Experience
-
Ordinary
Reaction

“One of the first things you need to ask is, how did
you survive this? This is amazing that you’re still
here. It’s amazing that you still have the guts to go
on with your life. What is allowing you to function?
What are you good at? What gives you comfort?”

Bessel van der Kolk


Attachment


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.”


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).


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.

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.

Attachment Styles

Secure Ambivalent
Attachment Style Attachment Style

Avoidant Disorganised
Attachment Style Attachment Style


Ainsworth’s ‘Strange Situation’ Assessment


Secure Attachment
Equipped to face challenges & take risks

Child Caregiver
Uses caregiver as a secure
base for exploration. Responds
Protests caregiver's 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.


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.
caregiver's availability,
seeking contact but
resisting angrily when it is
achieved. Not easily
calmed by stranger.


Avoidant Attachment
The Hardened Heart

Child 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.


Disorganised Attachment
The grass is always dead on both sides of the fence

Child 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.


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?


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.


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.

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.

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.

“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 or
others).

Individuals with psychosis generally have major problems
with all four.

Typical attachment pattern:
– Disorganised in infancy
– Controlling in childhood
– Unstable in adulthood


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.


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 such
ruptures to the working alliance and
our relationships.


Low Avoidance

Secure Ambivalent

Low Anxiety High Anxiety

Avoidant Disorganised

High Avoidance

Stages of Recovery


“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.


1. Establishing Safety


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.

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.


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.


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….


1. Get into bed and wait for it to pass
2. 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 helplessness
3. 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 peace
4. Phone Martin – 0207 888 8888
5. Phone Jane – 0208 777 7777
6. Phone Peter - 0114 999 9999
7. Phone The Samaritans - 08457 90 90 90


8. Make a cup of tea
9. Write a list of all the other times I have felt desperate and
what I would have missed if I had succumbed to the
despair
10. Draw
11. Have a bath
12. Listen to some relaxing /inspiring music
13. Take a homeopathic remedy
14. Do housework or some other mindless task
15. Go out for a walk
16. Water the plants
17. Try and read something that calms me
18. Pray
19. Breathe
20. Go to the top of the list


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.


My Goals


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.


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.

Grounding Exercise
With 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 …


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.”


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.


2. Remembrance & Mourning


• 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.


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.


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.


2) On a separate piece of paper, draw a second
picture depicting the absence of the intrusive
images. This represents what you would prefer to be
feeling or thinking instead of the unwanted subjects.
Again, don’t worry about style, but concentrate on
expressing your chosen thought or feeling in any
way that fits for you.

3) On a third piece of paper, draw a new picture
symbolizing how you imagine you got from the state
of mind depicted in the first picture to the state of
mind depicted in the second picture.

4) Now tear up the first picture.


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.


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.

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.

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?


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?

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?


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.

3. Reconnection


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.


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)

Reconciling with Others

• Trauma is no longer a
barrier to intimacy.
• Includes family,
children, friends,
partners and helping
professionals.


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.


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.”


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 Estés

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.

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• 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.


• 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’...


“Dissociation appears to be the mechanism
by which intense sensory and emotional
experiences are disconnected from the
social domain of language and memory .”
(Judith Herman)



“*Dissociation+... begins with the child's
self-hypnotic assertion ‘I am not here; this
is not happening to me; I am not in this
body.’”
(Phil Mollon, 1996, p.15)


• 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.

• 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.


Compartmentalisation

Involves keeping conflicted feelings,
disquieting thoughts, behaviour and
knowledge in separate compartments
from normal consciousness.


Dissociative Detachment

Feeling disconnected from yourself or the
outer world, for example in a trance like or
dream like state. Feelings of unreality.


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.


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 you're 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 you're
gone, in the blackness, or in a void.
• When you're 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.


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.


Dissociative Fugue

Involves losing your sense of identity and
memory of your past. People can find
themselves in a place with no memory of
getting there and sometimes no knowledge
of who they are.

Dissociative Identity ‘Disorder’
• Is characterised by two or more separate identities or
personality states that recurrently take control of the
individual's 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.


• 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.


• 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.


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.


Dissociation in Relation to Self-Injury
“Survivors who self-mutilate consistently
describe a profound dissociative state
preceding the act. Depersonalisation,
derealisation, and anaesthesia are
accompanied by a feeling of unbearable
agitation and a compulsion to attack the body.
The initial injuries often produce no pain at
all.”
(Herman. p.109)


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?”


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.


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?


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).


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.


The Dissociative Experiences Scale
(DES-II)

A reliable, valid, convenient way to quantify
the frequency of dissociative experiences (in
both clinical and non-clinical populations)

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”).


Average DES-II Scores for Different Clinical and Non-Clinical Groups

60
57

50

40

30 31

20
14
10
7
4
0
Non-Clinical Adults Agoraphobic Patients Non-Clinical PTSD Patients DID Patients
Adolescents


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.


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


Vicarious
Traumatisation


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.


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.


Vicarious Traumatisation
Truth & Reconciliation
The lack of processing of countertransference experiences by the TRC staff
manifested in the symptom of a pervading boredom. Staff often discussed being utterly
“bored” by the repetitive and relentless nature of the deponents personal stories. They
became inured and emotionally blunted. Although there was liberal discussion of things
like ‘vicarious traumatisation’ this happened at an intellectual level and there remained
the unspoken fear of dealing with this knowledge at an emotional and organisational
level.

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 emotional
story of the organisation itself. The intersubjectivity of the process remained
unacknowledged and silenced. Flight from the “impossible primary task” took several
forms. This disavowal of the impact of the process on the organisation was challenged
at a critical point in one hearing where Tutu was presiding. It was a ‘typical’ story of
yet another victim. However this time it was all too much. Desmond Tutu as he buried
his head in his hands and simply broke down, sobbing inconsolably as a colleague
placed her hand on his back and passed him a tissue.


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.


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.

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.


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.



• 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 one's personal life
and professional life.


• 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).


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.

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?


Vicarious Transformation
Beyond vicarious traumatisation lies vicarious transformation.
• This is the process of transforming one's 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 one's 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.


Barriers to Change
How can we incorporate changes within
our own personal or professional lives?


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?


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


Further information:



Dillon

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