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Title: Restoring the Shattered Self: Complex Traumatic Stress Disorder (CTSD) and Missionaries Mental Health and Missions, 2013


1
Restoring the Shattered Self Complex Traumatic
Stress Disorder (CTSD) and MissionariesMental
Health and Missions, 2013
  • Heather Davediuk Gingrich, Ph.D.
  • Denver Seminary
  • heather.gingrich_at_denverseminary.edu
  • www.heathergingrich.com

2
My Background in this Specialization
  • Sexual abuse survivors
  • Dissociative disorders
  • Other trauma survivors (see Gingrich, 2002)
  • Research on dissociation and trauma in the
    Philippines
  • Recognition of overlap in treatment techniques

3
www.heathergingrich.com
4
Trauma Field
  • Complex Traumatic Stress Disorder
  • (Disorders of Extreme Stress)
  • - multiple exposures
  • - incest survivors
  • - child abuse and rape
  • - multi-faceted treatment approaches
  • - International Society for the Study of Trauma
    and Dissociation (ISSTD)
  • Posttraumatic Stress Disorder
  • - even single exposure
  • - natural disasters
  • - rape incident
  • - witnessing violence
  • - combat veterans
  • - primarily cognitive-behavioral treatments
  • - International Society for Traumatic Stress
    Studies (ISTSS)

Trauma Psychology, Division 56, APA
5
Posttraumatic Stress DisorderDSM-IV Criteria
  • Exposure to traumatic event
  • Reexperiencing
  • Memories, thoughts, mental images, dreams,
    flashbacks
  • Avoidance/Numbing
  • thought stopping, social withdrawal, amnesia for
    the trauma, constriction of affect
  • Hyperarousal
  • Irritability, explosive anger, hypervigilance,
    problems with concentration, difficulty falling
    and staying asleep
  • Symptom duration of more than 1 month
  • Clinically significant distress/impairment in
    functioning

American Psychiatric Association, 2000
6
DSM-5 Selected Changes inCriteria for PTSD
  • Criterion A
  • Sexual assault listed as a possible traumatic
    event
  • Additional symptom cluster
  • Negative thoughts and mood or feelings
  • an inability to remember key aspects of the
    event.
  • Dissociative subtype
  • chosen when PTSD is seen with prominent
    dissociative symptoms
  • depersonalization
  • experiences of feeling detached from ones own
    mind or body
  • derealization
  • experiences in which the world seems unreal,
    dreamlike or distorted.

http//pro.psychcentral.com
7
DSM-5 PTSD Dissociative Subtype
  • chosen when PTSD is seen with prominent
    dissociative symptoms
  • depersonalization
  • experiences of feeling detached from ones own
    mind or body
  • derealization
  • experiences in which the world seems unreal,
    dreamlike or distorted.

http//pro.psychcentral.com
8
What about Missionaries?
  • Exposure to multiple traumatic events not
    uncommon
  • Increases risk of PTSD
  • Complex traumatic stress may go unnoticed
  • History of complex trauma can make a missionary
    more susceptible to being triggered as a result
    of trauma on the field

9
Purpose of this Presentation
  • Identify complex traumatic stress disorder (CTSD)
    in missionaries
  • Outline the entire long-term treatment process
  • Focus on how a missionary counselor or a member
    care worker can help further healing and contain
    symptoms even with short-term interventions

10
Importance of Subjective Evaluation of Event
  • No trauma is so severe that almost everyone
    exposed to the experience develops PTSD
    (McFarlane Gerolama, 1996, p. 148)
  • Only 25-35 of people who are exposed to a
    potentially traumatic experience develop PTSD
    (Carlson, 1997, p. 4)
  • A history of complex trauma increases this
    probability

11
Role of Peritraumatic Dissociation
  • Dissociation at the moment of trauma appears to
    be the single most important predictor for the
    establishment of chronic PTSD. (Van der Kolk,
    Weisaeth, van der Hart, 1996, p. 66)
  • If a missionary has already learned to dissociate
    as a result of an earlier history of complex
    trauma they will likely already have learned how
    to dissociate

12
Other Reasons to Learn About Dissociation
  • Used by victims of all kinds of trauma
  • In addition to the link between peritraumatic
    dissociation and PTSD, there is a well-documented
    association between trauma and posttraumatic
    dissociation (see Gingrich, 2005)
  • Dissociative subtype of PTSD in DSM-5
  • Explanation for why treatment techniques for
    dissociative disorders can also be helpful for
    other trauma survivors

13
DSM-5-Definition of Dissociation
Disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity,
emotion, perception, body representation,
motor control, and behavior. Simply put
Dissociation is compartmentalization, or
disconnection among aspects of self and
experience
Normal versus Pathological Dissociation
14
CONTINUUM OF DISSOCIATION
NORMAL DISSOCIA-TIVE EPISODE ACUTE STRESS DISORDER (up to 4 wks.) POST TRAUMATIC STRESS DISORDER (4 weeks ) DISSOCIA-TIVE DISORDER DISSOCIA-TIVE DISORDER NOT OTHERWISE SPECIFIED DISSOCIA-TIVE IDENTITY DISORDER
   

hypnosis ego states automatisms childhood imaginary play fear/terror repression highway hypnosis sleepwalking !mystical/ religious experiences (e.g., meditation, ecstatic experiences) flashbacks numbness, detachment, absence of emotional response reduced awareness of surroundings (dazed) derealization depersonalization amnesia for aspects of the trauma Dissociative amnesia Dissociative fugue Depersonali-zation disorder DDNOS with features of DID Polyfrag-mented DDNOS Dissociative trance disorder Possession trance disorder DID Polyfrag-mented DID
Adapted from Braun, B. G. (1988)
15
Developing the Capacity to Dissociate
  • We are born unintegrated (i.e., dissociated)
  • Healthy attachment leads to integration of
    behavioral states
  • Impact of child abuse
  • Dissociation as a defense
  • Mental disorder
  • - dissociative disorder/other disorder with
    dissociative symptoms

Putnam, 1997
16
Attachment Style and Dissociation
  • Attuned, good enough parenting
  • Secure attachment style
  • Integration of self-states
  • Inattentive/neglectful/abusive parenting
  • Insecure (Ambivalent/Disorganized)
  • attachment style
  • Dissociated self-states
  • (Gingrich, 2013)

17
Dissociative Symptoms
  • Amnesia A specific and significant block of time
    that has passed but that cannot be accounted for
    by memory
  • Depersonalization Sense of detachment from ones
    self, e.g., a sense of looking at ones self as
    if one is an outsider
  • Derealization A feeling that ones surroundings
    are strange or unreal.
  • Identity confusion Subjective feelings of
    uncertainty, puzzlement, or conflict about ones
    identity
  • Identity alteration Objective behavior
    indicating the assumption of different identities
    or ego states, much more distinct than different
    roles

Steinberg (1994).
18
DSM-V Diagnoses Related to Dissociation
  • Dissociative disorders
  • Dissociative amnesia
  • Depersonalization/derealization disorder
  • Dissociative identity disorder (DID)
  • Dissociative disorder not otherwise specified
  • Selected other disorders with significant
    dissociative symptoms
  • Post-traumatic stress disorder (PTSD)
  • Somatic symptom and related disorders
  • Schizophrenia
  • Borderline personality disorder (BPD)
  • Others (e.g., eating and feeding, anxiety)

19
BASK MODEL OF DISSOCIATION
  • Behavior
  • Affect (emotions)
  • Sensation (physical)
  • Knowledge
  • Full, integrated memory includes all four
    re-associated components.
  • Braun, 1988

20
BASK - KNOWLEDGE
  • Trauma survivor has full or partial cognitive
    knowledge of traumatic event
  • Cognitive knowledge of the trauma is dissociated
    from behavior, affect and sensation
  • Generally what people mean when they say I
    remember

21
BASK - BEHAVIOR
  • Behavior is dissociated from other aspects of
    memory
  • Individual acts in a certain manner without
    knowing why
  • Examples
  • -avoiding intimate relationships
  • -vomiting after sexual intercourse
  • -dislike of particular foods

22
BASK - AFFECT
  • Affect is dissociated from other aspects of
    memory
  • Example feeling of fear for no apparent reason

23
BASK AFFECT(continued)
  • There are no feelings attached to the cognitive
    knowledge of the memory
  • -flat affect
  • -matter-of-fact tone of voice
  • e.g., can talk about being raped as though
    discussing the heat of the coming summer

24
BASK - SENSATION
  • Physical sensation is dissociated from other
    aspects of memory
  • Individual may have cognitive knowledge of the
    traumatic event, be aware of related affect, and
    understand some behavior, but not remember the
    pain or pleasure associated with the trauma
  • Examples
  • -body memories physical symptoms such as
    bleeding or severe pain occur in the present but
    are unexplained
  • -sexual excitement

25
BASK Model
Gingrich, H. D., 2013, p. 107
26
Three-Phase Treatment Process
27
Rationale for Phase-Oriented Model
  • Premature trauma processing can lead to
    destabilization
  • Hospitalization
  • Inability to function in job
  • Difficulty parenting
  • Basic coping capacities can be overwhelmed

28
Three Phases
  • Phase I Safety and Stabilization
  • Phase II Processing of Traumatic Memories
  • Phase III Consolidation and Restoration

29
Phase 1 Safety and Stabilization
  • Where most missionary counselors/member care
    workers can be helpful

30
Safety within the Therapeutic Relationship
  • Developing rapport
  • Facilitative conditions
  • Becoming a safe person
  • Remember that every client is unique
  • Know your limitations
  • Give advance warning
  • Remaining a safe person
  • Keep appropriate therapeutic boundaries
  • Consult
  • Protect confidentiality

31
Safety from Others
  • Helping individuals find physical safety
  • Identifying healthy vs. unhealthy relationships
  • Looking for signs of spiritual abuse

32
Safety from Self and Symptoms
  • Making sense of symptoms
  • Symptoms as attempts at coping
  • Warning signals
  • Therapeutic use of dissociation
  • Potentially assess use of dissociation
  • Somataform Dissociation Questionnaire (SDQ-5 or
    SDQ-20) (Nijenhuis, 1999)
  • Dissociative Experiences Scale-II (DES-II)
    (Putnam, 1997)
  • Structured Clinical Interview for DSM-IV
    Dissociative Disorders-Revised (SCID-D-R)
    (Steinberg, 1993)
  • Use of parts of self language
  • Contracting
  • symptom management
  • day to day activities
  • suicide
  • Ideomotor signaling

33
Phase II - Processing of Traumatic Memories
  • Readiness for Phase II Work
  • Memory Work
  • Nature of memory
  • Accessing dissociated memories
  • Deciding where to start
  • When specific memories do not surface
  • Is memory recovery the goal?
  • Facilitating the integration of experience
  • The importance of details
  • Titrating the process
  • Extent to which reexperiencing is necessary
  • Grounding techniques
  • Checking in
  • Memory containment
  • Structuring the session and counseling
    relationship

34
BASK Model
Gingrich, H. D., 2013, p. 107
35
Phase II - Processing of Traumatic Memories
(contd)
  • Facilitating Integration of Self and Identity
  • Working through Intense Emotions
  • General principles
  • Understanding and dealing with specific emotions
  • Mourning Denial, anger, and depression
  • Guilt, shame, and self-hatred
  • Fear of abandonment
  • Anxiety, terror, and fear
  • Roadblocks for counselors
  • Keeping Perspective

36
Levels of Integration of Self
Partial Integration
Full Integration
No Integration
Gingrich, H. D., 2013, p. 121
37
Integration of Self and Experience
 
Gingrich, H. D., 2013, p. 122
38
Is the Goal Full Integration?
  • Immediate goal is better functioning
  • Some highly dissociative clients never fully
    integrate
  • May be afraid to (i.e., fear of death of parts of
    self)
  • Too much work and time
  • The process of integration can begin to happen
    from the beginning of therapy

39
Dealing with Spiritual Issues (1)
  • All phases, but particularly Phases II and III
  • Gradual, often difficult process
  • Allow client to set pace
  • Often are questions re why God did not protect
    from the trauma
  • In time clients can often see that God was there,
    and is currently involved in their healing
    process
  • In highly dissociative clients, some parts of
    self may have a relationship with Christ, while
    others may not
  • E.g., internal Bible study

40
Dealing with Spiritual Issues (2)
  • Distinguish between parts of self and demonic
  • Ultimately gift of discernment necessary
  • Potentially VERY destructive to attempt
    deliverance ministry
  • If any kind of deliverance/exorcism ritual is
    decided upon make sure that the following factors
    are incorporated (Bull, Ellason, Ross, 1998)
  • Permission of the individual
  • Noncoercion
  • Active participation by the individual
  • Understanding of DID dynamics by those in charge
  • Implementation of the procedure within the
    context of psychotherapy
  • See my article Not all voices are demonic
    (Gingrich, 2005b)

41
Phase III Consolidation and Resolution
  • Consolidating changes
  • Development of new coping strategies
  • Learning to live as an integrated whole
  • Navigating changing relationships
  • Marriage and parenting
  • Friendships
  • Relationship to God and church congregations
  • Community
  • Family of origin
  • Employment
  • Confronting the perpetrator
  • Forgiveness

42
How the Church/Member Care Organization Can Help
1
  • Educating about CTSD
  • Process of healing for the missionary
  • How they can be of help
  • Length of commitment
  • Setting of appropriate boundaries
  • Self-care for helpers

43
How the Church/Member Care Organization Can Help
2
  • Providing emotional and spiritual support
  • Formal care
  • Groups
  • Lay counseling
  • Mentoring, spiritual direction and life coaching
  • Assigned helpers
  • Informal care

44
How the Church/Member Care Organization Can Help
3
  • Availability in times of crisis
  • Phone, email, Skype, prayer chains
  • Churches, member care organizations and Christian
    mental health professionals in partnership
  • Therapist should have one key contact person
    (e.g., pastor, elder, designated lay helper) who
    then communicates with other support people

45
What Can I Do with This Info?
  • Counselor
  • Be informed
  • Get training on how to work with CTSD
  • Pastor/Member Care Provider
  • Understand the process of healing
  • Be more empathic
  • Know what to look for in making a counselor
    referral
  • Help gather other resources
  • Use some grounding techniques

46
References
  • American Psychiatric Association (2000).
    Diagnostic and statistical manual of mental
    disorders (text revision). Washington, DC
    Author.
  • American Psychiatric Association (2013).
    Diagnostic and statistical manual of mental
    disorders, (5th ed). Washington, DC Author.
  • Braun (1988). The BASK model of dissociation
    Clinical applications. Dissociation, 1(2), 16-23.
  • Bull, D., Ellason, J., Ross, C. (1998).
    Exorcism revisited Some positive outcomes with
    dissociative identity disorder. Journal of
    Psychology and Theology, 26, 188-196.
  • Carlson, E. (1997). Trauma assessments A
    clinicians guide. New York, NY Guilford Press.
  • Gingrich, H. D. (2002). Stalked by Death
    Cross-cultural Trauma Work with a Tribal
    Missionary. Journal of Psychology and
    Christianity, 21(3), 262-265.

47
  • Gingrich, H. D. (2005a). Trauma and dissociation
    in the Philippines. In G. F. Rhoades, Jr. and V.
    Sar (2005), Trauma and dissociation in a
    cross-cultural perspective Not just a North
    American phenomenon. New York, NY Haworth Press.
  • Gingrich, H. (2005b). Not all voices are demonic.
    Phronesis, (Asian Theological Seminary/Alliance
    Graduate School, Philippines)12, 81-104.
  • Gingrich, H. D. (2013). Restoring the shattered
    self A Christian counselors guide to complex
    trauma. Downers Grove, IL InterVarsity Press
  • McFarlane, A. Girolamo, G. (1996). The nature
    of traumatic stressors and the epidemiology of
    posttraumatic reactions. In B. A. van der Kolk,
    A. C. McFarlane, L. Weisaeth (Eds.), Traumatic
    stress The effects of overwhelming experience on
    mind, body, and society. New York, NY Guilford
    Press.
  • Nijenhuis, E. R. S. (1999). Somatoform
    dissociation Phenomena, measurement, and
    theoretical issues. Assen, The Netherlands Van
    Gorcum.

48
  • Putnam, F. W. (1997). Dissociation in children
    and adolescents A developmental perspective. New
    York, NY Guilford Press.
  • Steinberg, M. (1993). Structured Clinical
    Interview for DSM-IV Dissociative Disorders
    (SCID-D). Washington, DC American Psychiatric
    Press.
  • van der Kolk, B. A., Weisaeth, L., van der
    Hart, O. (1996). History of trauma in psychiatry.
    In B. A. vander Kolk, A. C. McFarlane, L.
    Weisaeth (Eds.), Traumatic stress The effects of
    overwhelming experience on mind, body, and
    society. New York Guilford Press.
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