Treating Dissociation from the SelfTrauma Perspective

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Treating Dissociation from the Self-Trauma
Perspective

• John Briere, Ph.D.
• Departments of Psychiatry and Psychology
• University of Southern California
• and
• Psychological Trauma Program
• Los Angeles County USC Medical Center

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Dissociation

• Significant, often temporary, changes in normal
  consciousness or awareness that arise from
  reduced or altered access to ones thoughts,
  feelings, perceptions and/or memories. These
  changes involve a context that is not noteworthy
  for dementia, traumatic brain injury, epilepsy,
  or other organic disturbance.

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Dissociation

• Dimensionality
• Dissociative continuum
• Different symptoms as function of severity
• Dissociative dimensionality
• DSM-IV-TR
• Factor analyses of the DES Absorption,
  depersonalization-derealization, amnesia
• Factor analyses of MDI

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Dissociation

• Factor analyses of the MDI (N 1,326)
• Five factors, average r .39.
• Dissociative symptom groups
• Disengagement
• Identity dissociation
• Emotional constriction
• Memory disturbance
• Depersonalization-derealization

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Dissociation

• Etiology
• Trauma Dissociative symptoms as emotional
  avoidance of trauma-related distress
• Attachment Dissociative symptoms associated with
  an insecure (especially "disorganized")
  parent-child attachment in the early years.
• Does not contradict trauma model Childhood abuse
  and neglect as etiology of insecure attachment

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Dissociation

• The data trauma and dissociation
• Van IJzendoorn and Schuengel (1996) meta-analysis
  of 26 DES studies Trauma exposure accounted for
  4 (r .21) to 8 (r .28) of  the variance in
  dissociative symptoms.
• MDI studies
• Trauma accounted for only 4.4 percent of unique
  variance in dissociative symptom scales
• Clinically significant dissociative symptoms were
  present in only 8 percent of trauma-exposed
  individuals

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Dissociation

• Yet, dont give up on trauma as etiology
• Most (90) of those with clinical levels of
  dissociation reported having experienced a
  traumatic event
• Trauma as necessary but insufficient
• What intensifies relationship between trauma and
  dissociation?
• greater levels of posttraumatic stress
• Reduced affect regulation capacities

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Dissociation revisited

• Trauma probably part of picture
• Probably most impactful when
• early in development, when may produce insecure
  attachment
• results in (or occurs in context of) reduced
  affect regulation capacities
• Trauma produces substantial posttraumatic stress
• Dissociation as defensive down-regulator of
  distress, perhaps in individuals with reduced
  (attachment-related) identity disturbance

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Dissociation

• Implications for treatment
• Dissociative symptoms as
• adaptive, defensive
• Reflection of underlying dysfunction
  (posttraumatic stress, affect dysregulation,
  identity disturbance
• Treatment should alter conditions that support
  dissociation, not remove dissociation, per se

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Dissociation

• Three targets
• Traumatic stress
• Affect regulation
• Attachment
• Identity
• Relationality

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TreatmentIntroduction to the Self-Trauma Model

• Integrated approach to complex posttraumatic
  outcomes, including dissociation
• Cognitive-behavioral and psychodynamic
• Takes comorbidity into account
• Titrated exposure to traumatic material
• Relational
• Often longer-term

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Processing traumatic stress

• Exposure
• Activation
• Disparity
• Nonreinforcement of CERs (safety)
• Titration of distress through low-level avoidance
• (Counterconditioning)
• Extinction/resolution

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The therapeutic window

• Titrated exposure
• Limiting factors for dissociative disturbance
• CER intensity, implicit/isolated memories
• Affect regulation deficits
• Balance between therapeutic challenge and
  overwhelming internal experience
• Overshooting vs. undershooting the window

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Processing within the therapeutic window

• Repetitive exposure to trauma memories via
  questions/facilitation of disclosure
• Activation control
• Greater vs. lesser detail
• Time/tense focus here-and-now vs. there-and-then
• Emotional vs. cognitive
• Careful intervention in avoidance
• Safety, support, validation, encouragement
• Emotional discharge/expression

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Increasing affect regulation capacities

• Repeated activation and down-regulation during
  titrated trauma processing
• Labeling and differentiation of feeling
• Focus on feelings
• Identification via detective work
• Careful therapist identification
• Learning to self-soothe/stress-reduce
• Reducing catastrophizing cognitions
• Trigger identification and management

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Intervening in attachment disturbance

• Identity/Self-awareness
• Exploration of self in relation to therapist
• Deceased pressure for other-directedness
• Nonleading questions/exploration
• Avoidance of excessive interpretation
• Continual examination of hidden observer
  underlying dissociative alterations
• Identification of self during dissociation
• Switching as facets of self, not separate
  entities

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Intervening in attachment disturbance

• Relationality
• Therapeutic relationship as activator and
  resolver of relational schema
• Titrated exposure to relational gestalts in the
  context of the therapeutic relationship
• Exposure, activation, disparity,
  counterconditioning
• Window parameters
• Adapting treatment to predominant schema
• The therapists correct relational distance

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Processing relational gestalts

• Benefits and difficulties of activating
  attachment patterns
• Triggered and relived relational gestalts
• Infantile, dependent, entitled activations
  (relational dissociation)
• Proximity-seeking
• Growing activation of inherent, positive
  attachment affects