Restoring the Shattered Self: Restoring the Shattered Self: Complex Traumatic Stress

Disorder (CTSD) and Missionaries

Mental Health and MissionsMental Health and Missions, , 20132013

Heather Davediuk Gingrich, Ph.D.Denver Seminary

heather.gingrich@denverseminary.edu

www.heathergingrich.com

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

www.heathergingrich.com

Trauma Field 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)

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)

Trauma Psychology, Division 56, APA

Posttraumatic Stress Disorder:DSM-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

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 one’s own mind or body

– derealization• experiences in which the world seems unreal, dreamlike or

distorted. http://pro.psychcentral.com

DSM-5 PTSD Dissociative Subtype

chosen when PTSD is seen with prominent dissociative symptoms– depersonalization

• experiences of feeling detached from one’s own mind or body

– derealization• experiences in which the world seems unreal,

dreamlike or distorted.

http://pro.psychcentral.com

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

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

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

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

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

DSM-5-Definition of Dissociation

Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motorcontrol, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience

Normal versus Pathological Dissociation

CONTINUUM OF DISSOCIATION

  

NORMALDISSOCIA-

TIVEEPISODE

ACUTE STRESS

DISORDER(up to 4 wks.)

POSTTRAUMATIC

STRESSDISORDER(4 weeks +)

DISSOCIA-TIVE

DISORDER

DISSOCIA-TIVE

DISORDERNOT

OTHERWISESPECIFIED

DISSOCIA-TIVE

IDENTITYDISORDER

• 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)

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

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)

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 one’s self, e.g., a sense of looking at one’s self as if one is an outsider

Derealization: A feeling that one’s surroundings are strange or unreal.

Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict about one’s identity

Identity alteration: Objective behavior indicating the assumption of different identities or ego states, much more distinct than different roles

Steinberg (1994).

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)

BASK MODEL OF DISSOCIATION

BehaviorAffect (emotions)Sensation (physical)Knowledge

Full, integrated memory includes all four re-associated components.

Braun, 1988

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”

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

BASK - AFFECT

Affect is dissociated from other aspects of memory

Example: feeling of fear for no apparent reason

BASK – AFFECT(continued)

There are no feelings attached to the cognitive knowledge of the memory

-flat affect-matter-of-fact tone of voicee.g., can talk about being raped as

though discussing the heat of the coming summer

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

BASK ModelBASK Model

Gingrich, H. D., 2013, p. 107

Three-Phase Treatment Process

Premature trauma processing can lead to destabilization

– Hospitalization– Inability to function in job– Difficulty parenting– Basic coping capacities can be overwhelmed

Rationale for Phase-Oriented Model

Phase I – Safety and Stabilization Phase II – Processing of Traumatic

Memories Phase III – Consolidation and Restoration

Three Phases

Phase 1: Safety and Stabilization

Where most missionary counselors/member care workers can be helpful

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

Safety within the Therapeutic Relationship

Helping individuals find physical safety

Identifying healthy vs. unhealthy relationships

Looking for signs of spiritual abuse

Safety from Others

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

Safety from Self and Symptoms

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

Phase II - Processing of Traumatic Memories

BASK ModelBASK Model

Gingrich, H. D., 2013, p. 107

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

Phase II - Processing of Traumatic Memories (cont’d)

Levels of Integration of SelfLevels of Integration of Self

No Integration Partial Integration Full Integration

Gingrich, H. D., 2013, p. 121

 

Integration of Self and ExperienceIntegration of Self and Experience

Gingrich, H. D., 2013, p. 122

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

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

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)

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

Phase III – Consolidation and Resolution

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

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

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

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

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 clinician’s 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.

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 counselor’s 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.

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.