Treating Trauma-Related Dissociation: A Practical, Integrative Approach

601 Pages·2016·4.11 MB·English

by  Kathy Steele

A NORTON PROFESSIONAL BOOK
Treating
Trauma-Related Dissociation
A Practical, Integrative Approach
KATHY STEELE
SUZETTE BOON
ONNO VAN DER HART
W. W. NORTON & COMPANY
Independent Publishers Since 1923
New York • London
To all patients and therapists around the world who choose this challenging
journey, who are willing to risk and persevere together in an imperfect but
wholly “good enough” psychotherapy. To each of you, an abundance of
compassion, courage, and clarity.
CONTENTS
Preface
Acknowledgments
Introduction
1. Dissociation as Non-Realization
PART I
The Therapeutic Relationship
2. The Good Enough Therapist
3. The Therapeutic Relationship: Safety, Threat, and Conflict
4. Beyond Attachment: A Collaborative Therapeutic Relationship
PART II
Assessment, Case Formulation, and Treatment Planning
5. Assessment of Dissociative Disorders
6. Beyond Diagnosis: Further Assessment, Prognosis, and Case Formulation
7. Treatment Planning
8. Principles of Treatment
9. Phase-Oriented Treatment: An Overview
PART III
Phase 1 Treatment and Beyond
10. Working With Dissociative Parts: An Integrative Systems Perspective
11. Resistance as Phobic Avoidance: An Introduction
12. Resistance as Phobic Avoidance: Practical Approaches
13. Dependency in Therapy: Always, Sometimes, Never?
14. Working With Child Parts of the Patient
15. Integrative Approaches to Shame
16. Working With Angry and Hostile Parts of the Patient
17. Working With Perpetrator-Imitating Parts of the Patient
18. Resolving Unsafe Behaviors
19. Selected Issues
PART IV
Phase 2 Treatment
20. Treatment of Traumatic Memory: An Overview
21. Treatment of Traumatic Memory: Guidelines and Techniques
PART V
Phase 3 Treatment
22. Integration of Dissociative Parts Into a Cohesive Personality
23. Phase 3 and Beyond
Appendices
References
Index
PREFACE
T
his book was born not only out of countless hours of treating patients with
dissociative disorders, but also out of the crucible of supervision and
consultation, where therapists bring their most urgent questions, needs, and
vulnerabilities. For many years we have heard therapists around the world ask
similar questions and struggle with similar challenges with dissociative patients.
In addition to an overview of phase-oriented treatment, it is this set of issues we
have tried to bring to this volume: what to focus on first in a complex therapy,
and how to do it; how to establish safety for a patient engaging in unsafe
behaviors without rescuing; how to work with dissociative parts in ways that
facilitate integration rather than further dissociation; how to set and maintain
helpful boundaries; how to deal compassionately and effectively with
dependency on the therapist; how to help patients integrate traumatic memories;
what to do when the patient is enraged, chronically ashamed, avoidant, or unable
to experience the therapist as having any good intentions; and how to
compassionately understand and work with resistances. Most importantly, we
have focused not only on how to conceptualize and treat dissociation but on how
to be with patients who experience themselves as many instead of one.
Doing Versus Being
Most therapists who are just becoming familiar with working with dissociative
patients are seeking techniques. When one is faced with complexity and
unfamiliar territory, it is the most natural thing in the world to seek out what to
do. These therapists will find that treatment of patients with dissociative
disorders includes some very practical techniques that support gradual
integration. Nevertheless, relational ways of being with the patient are the
backbone of treatment, and are themselves essentialtherapeutic interventions.
The task of every good therapist is to seamlessly interweave a coherent
combination of cognitive, emotional, and somatic interventions (things to do)
with the relational experience in the moment between two human beings in a
two-person psychology (ways to be). In fact, there is nothing more practical and
integrative than making the therapeutic relationship an integral part of working
with patients who have been so wounded by others. The findings of
interpersonal neurobiology point more and more to the centrality and
transforming power of implicit relational interactions in therapy (e.g., Cozolino,
2010; Schore, 2012; Siegel, 2010b, 2015). The effect size of the impact of the
therapeutic relationship is even greater in patients with dissociative disorders
than in many other clinical populations (Cronin, Brand, & Mattanah, 2014), so
relational processes with these patients deserve extra attention and care. Yet,
despite recommendations by experts to the contrary, therapists generally
underutilize the relationship as a therapeutic process (Brand et al., 2013). Thus,
we have set out to embed in a relational context a practical and integrative
approach with as many and as varied techniques as possible for what often is a
challenging and complex therapy.
When faced with urgency, crisis, and confusion, it is especially hard to follow
the wise adage Don’t just do something; stand there. Words may fail or are
misinterpreted in therapy; interventions fall flat or are rejected out of hand; good
intentions fall short; and issues emerge that are beyond any directive action to
change or fix. Interventions then become invisible, transmuting into nonverbal,
implicit, unconscious, intersubjective ways of being. Thus, we offer a slight
twist on that old truism: Don’t just do something; be there. Such relational
interchanges are the hardest for therapists to recognize and participate in
effectively. But they are so very important. We have tried to include ways for the
therapist to communicate what is not communicable with words. This is essential
for highly traumatized patients who are often living in an overwhelming inner
world in which words have lost their meaning and language is not possible. To
this end, we have also tried to include somatic interventions that are helpful
when words fail or are not sufficient.
The common factors theory of psychotherapy suggests that particular
theoretical approaches play little overall role in whether patients improve or not.
Common factors that do make a significant contribution to the patient’s
improvement include collaboration on shared goals, therapeutic alliance,
empathy of the therapist, positive regard and affirmation, congruence and
genuineness of the therapist, and other therapist factors (Laska, Gurman, &
Wampold, 2014; Wampold, 2001). These findings do not imply that therapists
should abandon theory and technique in the treatment of patients with
dissociative disorders—or any other disorder, for that matter. We believe an
organized and thoughtful approach to treatment—regardless of what it is—is
necessary for common factors to be effective. Even with sound relational
approaches that include a solid treatment frame and boundaries, therapists still
need special techniques to work with dissociative parts, at least in patients who
have severe dissociative disorders. Such techniques are central to the effective
treatment of these patients (e.g., Boon, Steele, & Van der Hart, 2011; Brand et
al., 2011; Kluft, 1991, 1993a, 1995; Van der Hart, Nijenhuis, & Steele, 2006).
The Humbling Experience of Treating Patients With Dissociative
Disorders
We offer the contents of this book with a large dose of humility, realizing that no
single clinician has all the right or best answers. Even though the three of us
have over 120 years of experience in treating patients with dissociative disorders
between us, we are nevertheless acutely aware of so much that we do not know,
that we cannot know, that others know so much more clearly than we do; and of
the mistakes we so often make. However, we offer you what we do know, and
what we are reasonably certain will add to your skills in treating patients with
dissociative disorders.
We also acknowledge that evidence-based treatment of patients with
dissociative disorders is still in its infancy, so the approaches in this book are
based primarily on clinical wisdom and experience (a legitimate form of
evidence), not randomized controlled research. Fortunately, there is a healthy
and burgeoning body of empirical literature on the effectiveness of these time-
honored, anecdotal approaches to working with dissociative patients (Brand,
Classen, Lanius, et al., 2009; Brand & Loewenstein, 2014; Brand, Loewenstein,
& Spiegel, 2014; Myrick, Chasson, Lanius, Leventhal, & Brand, 2015). What we
—and others—have found successful in clinical practice is finally being
validated by research. But we caution readers to stay abreast of current research
and treatment recommendations.
In some ways we may seem to be trying to impose linear order on what is a
very complex and messy process in the therapy room. We are perhaps guilty of
making it seem easier than it is. However, we truly know from our own
experiences that there is perhaps no other therapy that challenges the therapist’s
sense of competence so profoundly as work with chronically traumatized
individuals. The humbling reality for all of us is that therapy can be uneven and
uncertain, challenging and confusing. We, like other therapists, find ourselves
sometimes lost for a moment, not knowing what to do or how to be, making
unintentional mistakes, missing important cues, caught by transference and
countertransference. Some of the lessons we share in this book evolved not only
from our successes but also from our failures and mistakes. We hope you, the
reader, will benefit from our mishaps as much as from our triumphs. We also
hope that you can embrace your own mistakes and learn from them, knowing
that you are not required to be perfect for this work, and every therapist would
do best to eventually shed the heavy and unrealistic burden of perfection.