Kronos Abuses His Son: A Case Study of Severe Interpersonal Trauma, Dissociation, and Survival in Adolescence

Trauma and Dissociation in Posttraumatic Stress Disorder

The traumatizing events associated with posttraumatic stress disorder (PTSD) may be a single trauma such as an accident or may range all the way to the severe early developmental traumatization of a helpless child. Needless to say, not all severe and impactful developmental trauma are contained within the definition of PTSD. Nonetheless, childhood traumatization interferes with the child’s development of a cohesive and coherent personality structure. According to Main and Morgan (as cited in Van der Hart, Nijenhuis, & Steele, 2005), chronic childhood abuse can compromise the integrative capacity and the development of secure attachment and caretaker abuse may lead to the development of disorganized attachment in the child. This type of attachment is strongly linked to dissociation (e.g., Carlson; Ogawa, Sroufe, Weinfeld, Carlson, & Egeland, as cited in Van der Hart et al., 2005).

As trauma therapists, we may think of dissociation as a way of reacting to and organizing information occurring at the time of the trauma. From this perspective, dissociation can be viewed as an adaptive response to physical and/or sexual abuse because it may decrease the overwhelming distress created by trauma and by the conflicting and demanding environment in which the child is living (Knipe, 2014). However, even though dissociation may help children survive and cope with trauma, it can be considered maladaptive because it inhibits appropriate learning and healthy attachment and tends to persist over time. More specifically, TSDP views trauma-generated dissociation of the personality primarily as an integrative failure—a “falling apart.” Subsequently, it may have some limited adaptive value in that one (or more) part, emotional part of the personality (EP), keeps the traumatic memories, and one (or more) part, apparently normal part of the personality (ANP), is able to function, to some degree, in daily life (Van der Hart et al., 2006). If dissociation of the personality continues into adulthood, when the original danger no longer exists, it will most likely continue to be maladaptive (International Society for the Study of Trauma and Dissociation [ISSTD], 2016).

Treatment of Trauma and Dissociation in Posttraumatic Stress Disorder

The ISSTD Task Force for Children and Adolescents has developed guidelines for the assessment and treatment of dissociative symptoms in traumatized children and adolescents. To foster the coherence of self and promote healthy adaptation according to the child or adolescent’s ability to enter a relationship and feel safe again in the present (Van der Hart, Groenendijk, Gonzalez, Mosquera, & Solomon, 2014), the guidelines recommend proceeding slowly by titrating therapeutic interventions while maintaining safety, building trust, and using a phased approach (ISSTD, 2004). The three treatment phases of Pierre Janet (as cited in Van der Hart et al., 2005) are History, Assessment, Stabilization, Symptom Reduction, and Skills Building (Phase I); Treatment of Traumatic Memories (Phase II); and Personality Reintegration and Rehabilitation (Phase III). The more complex the trauma is, the less likely that these phases will be applied in order. Backtracking to Phase I is necessary in order that safety and trust are promoted in the client–therapist relationship (Van der Hart et al., 2014).

The Adaptive Information Processing Model and EMDR Therapy

EMDR therapy is an empirically valid treatment for PTSD, based on numerous randomized controlled trials and several meta-analyses (e.g., Chen, Zhang, Hu, & Liang, 2015). There is also preliminary evidence from several controlled trials and published case reports for EMDR’s effectiveness with other presenting problems, such as depression (e.g., Gauhar, 2016) and anxiety disorders (e.g., Faretta, 2013), following difficult life events. EMDR is one of two psychotherapies recommended by the World Health Organization (2013) for children, adolescents, and adults with PTSD.

The EMDR Therapy Standard Protocol has eight specific phases. Each phase has a purpose and procedure. The phases are as follows: Phase 1, History taking and building the therapeutic alliance. This phase provides an opportunity to identify salient issues (past, present, and future). AIP is used for case conceptualization and a three-pronged treatment plan. Not all clients are able to give a clear history at onset of therapy. This phase is also useful for assessing client appropriateness for EMDR therapy. Phase 2, Client stabilization and preparation. During this phase, general assessment for a sense of self-control and attachment issues continues while the therapist psychoeducates the client to the particular therapy. Phase 3, Assessment activation of traumatic memory network. The therapist elicits the image, negative cognition, currently desired positive cognition, current emotion, physical sensation, and baseline pertaining to particular target. Phase 4, Desensitization of traumatic memory with the use of bilateral stimulation up to adaptive resolution while monitoring distress on the level of Subjective Units of Disturbance (SUD) scale, where 0 = no disturbance and 10 = worst possible. In this phase, the client focuses on aspects of the targeted memory, while engaging in dual attention (DA). This allows the client to be in the present while mentally accessing a traumatic event from the past. In some ways, DA helps the client to modulate self between past and present without losing self in-the-past trauma (Gonzalez & Mosquera, 2012). It is desirable to process past, present, future targets and associated channels: image, cognitions, emotions, and somatic sensations. There is a use of cognitive interweaves when processed blocking occurs. Phase 5, Installation allows an increase of connections and generalizations to positive cognitive networks. The therapist and client identify the most appropriate positive cognition and reinforce validity of positive belief. The validity of the positive cognition should be a 6 or 7 on the Validity of Cognition (VOC) scale, where 1 = completely false and 7 = totally true. Phase 6, Body scanning is used to monitor and clear any residual disturbing feelings in the body. A neutral body response is the goal; otherwise, desensitization will continue. Phase 7, Closure ensures client stability at the end of an EMDR session and between incomplete sessions. There is possible use of self-help techniques and self-observation between sessions. Phase 8, Reevaluation takes place at the beginning of the next session, and it assesses treatment effects. Therapist and client explore what has emerged since last session and access memory and its current level of disturbance.

EMDR therapy is guided by the AIP model which seeks to explain pathology, predict clinical outcomes, and guide case conceptualization and treatment procedures in EMDR therapy (F. Shapiro, 2001; F. Shapiro & Solomon, 2008). It is posited that when the natural AIP system is disrupted, unresolved experiences can leave behind a residue in state specific form (F. Shapiro, 2007). Earlier adverse life experiences are understood to create a template for later psychological problems. The AIP model posits that for every problem there are past, present, and future aspects: Past distressing memories, present-day triggers that usually bring the client in for help, and future challenges where the client may be concerned about what may occur or go wrong. EMDR reprocessing is thought to bring about adaptive resolution by removing blocks and allowing the reintegration of memory to a more holistic adaptive resolution of perceptions, attitudes, emotions, and body sensations. EMDR therapy appears to restimulate the AIP self-healing system.

Similarly to ISSTD’s recommendations, Shapiro also advises practitioners to be flexible when providing EMDR to clients who have difficulties in attaining affect tolerance, modulation, and self-regulation. She recommends that clinicians be aware of possible dissociation and show clinical judgment concerning the timing of traumatic memory reprocessing during treatment (F. Shapiro, 2001).

Theory of Structural Dissociation of the Personality

The TSDP provides useful concepts to explain the impact of trauma on the personality of an abuse survivor. One principle of TSDP is that each human being has an integrative capacity to deal with experiences. The integrative capacity entails two major mental actions, namely, synthesis and realization. Synthesis can be thought of as the way one perceives, compares, differentiates, and/or categorizes internal and external experiences in the present and over time. Realization involves higher level mental actions that entail awareness of reality, accepting it, and adapting to it: It entails (a) personification, that is, knowing “this is what happened to me” and knowing my feelings and thoughts about it and (b) presentification, that is, being grounded in the present while able to integrate the past, the present, and the expected future (Van der Hart et al., 2006).

Thus, integration at the level of realization can be thought of as staying in the present while describing a past whole life narrative and owning experience. The person can express and feel his or her painful experience and memories without avoiding them. This causes a shift in his or her view of self and the internal phobias once experienced because of the trauma and/or memories. According to TSDP, the failure to integrate traumatic experiences basically yields a structural dissociation of the personality into two or more mental systems, labeled as dissociative parts of the personality (Van der Hart et al., 2006). There are moments when the individual appears to relive the trauma and other occasions when the individual presents with a lack of personification or a sense of “not me” regarding one’s own body sensations and feelings. There also appears to be a sense of “not real” as opposed to knowing one’s story and seeing options for a future while having a stable sense of self and what has occurred in the past.

This structural dissociation of the personality involves a division between at least one EP that is essentially associated with reexperiencing the trauma and at least one ANP that has failed to integrate the traumatic experience and the involved EP and that engages in matters of daily life. These “structural” parts are not static, they are dynamic interrelated parts which are not fully aware of each other and often not in cooperation with each other. The more intense the traumatization, the earlier it starts in life and the longer it lasts, probably the more complex the dissociation of the personality becomes (Van der Hart et al., 2006).

Procedures

The current project entails a case study of a 14-year-old boy, with a diagnosis of PTSD who endured emotional, physical, and sexual abuse by his father, and who presented with severe emotional and behavioral problems and dissociative symptoms. Two clinicians provided EMDR therapy, guided by the AIP model and the TSDP. Treatment was provided over a 7-month period, while the boy was an inpatient in a secure university hospital psychiatric unit for children and adolescents. Applying a single-case AB design, several instruments and measures were employed to assess changes in the youth’s subjective emotional states over time. In addition, objective behavior change was also recorded over time on the hospital unit where he resided. Goals of EMDR treatment were to help this adolescent regain a sense of time and a coherent sense of self; establish and maintain a more adaptive resolution of perceptions, emotions, attitudes and behaviors; and integrate the traumatic memories into a life narrative.

Treatment

Assessment

A battery of assessment tools was administered by the EMDR therapists throughout treatment to obtain objective measures of the youth’s progress over time. With the exception of the O’Neill Functional Assessment Form and the drawings, the assessment tools were administered on the following dates: Time 1 = baseline; Time 2 = 2 months later; Time 3 = 4.5 months later; Time 4 = 6 months later; and Time 5 = 7 months later. Time 1 was considered baseline because this assessment was completed prior to the beginning of treatment.

Patient History

Stephanos was a 14-year-old adolescent admitted and hospitalized in a University Child and Adolescent Psychiatry Department in Greece, because of his aggressive acting out behavior in the therapeutic residential setting where he lived. Based on his history, which was obtained from the file on record at the hospital, he had been abandoned by his mother at birth and raised by his father and paternal grandmother. Although the recorded history was very minimal with large informational gaps related to frequent discontinuation of service, it indicated that he had been neglected and severely beaten by his father from the age 5 years or younger. His father was a substance abuser involved in criminal behavior.

The file mentioned that Stephanos had first entered a state institution at age 3 years. He was in and out of institutions until he was finally taken away from his father at the age of 8 years and placed into state custody. Stephanos had endured severe beatings by his father. During one such incident, Stephanos lost one testicle after being beaten and left on the roof in a rain storm tied to an antenna to die.

Stephanos was frequently moved from one institution to the next, after getting involved in arguments and physical altercations with the staff and other residents. He had noticeable scars on one leg, which he described as the result of being attacked and stabbed in one of these institutions.

Presenting Problems and Diagnosis

Mental health professionals had given Stephanos several different diagnoses over the years ranging from psychosis, intellectual and developmental disorder, bipolar disorder, attention-deficit/hyperactivity disorder, and oppositional defiant disorder. When Stephanos was first admitted to the University Department, he was on three antipsychotic agents, an antiparkinsonian drug, and a benzodiazepine. At that time, his diagnosis was changed to PTSD by the child psychiatrist working on the inpatient unit team.

Stephanos’s specific presenting symptoms were reported by hospital staff as aggressive bursts of anger and rage, fighting with support staff (yelling, hitting, and destroying materials), highly aroused and fearful behavior, with disorganized thinking in moments of high arousal and possible dissociative states which were observed by the child psychiatrist in charge. These dissociative states were characterized by fear, shame, rage, and chaotic emotional states with regressed behaviors (shying away in a corner and being afraid to look at therapist). As explained in the “Conceptualization” section, understanding these states as EPs with evident regressed behavior triggered in the present was helpful in understanding Stephanos’s present condition.

Treatment Goals

The EMDR approach used for working with this adolescent was two pronged. The first goal was stabilization, helping Stephanos to manage and improve his maladaptive behavior and to reduce his difficult and unmanageable behaviors on his unit. Therapeutic goals included decreasing his arousal while simultaneously increasing his grounding in the present, his safety, and his ability to build trust and learn more daily living skills and skills for dealing with interpersonal conflict and internal arousal. To achieve these goals, it was essential for the therapists to understand and identify Stephanos’s optimal level of arousal and affect tolerance.

The second goal was to provide trauma therapy for the multiple abuses he had suffered. The therapists were there to understand what had happened to Stephanos and to treat his PTSD with EMDR therapy. The adolescent’s life situation was seen through the prism of trauma informed EMDR therapy (i.e., AIP model and the concepts of TSDP). Perhaps, the most important questions that the therapists needed to answer were “What has happened to Stephanos? How did Stephanos survive these events? How did these methods of survival become his coping strategies today?”

Case Conceptualization

This case entailed early interpersonal trauma and institutional retraumatization. It was seen through the prism of trauma-informed EMDR therapy, using the AIP model and the TSDP (Farrell, 2015) with the past, present, and future orientation and its repetitive traumatic reenactment (Figure 1).

FIGURE 1.

Case conceptualization. Hx = history; ACE = adverse childhood experiences; ANP = apparently normal part of the personality; EP = emotional part of the personality; TM = traumatic memory; TSDP = theory of structural dissociation of the personality.

(Modified from Farrell, D. [2015]. EMDR HAP training manual and case conceptualization. Watsonville, CA: EMDR Institute.)

Stephanos’s current behaviors appeared clearly linked to his traumatic history, and his present-day reactions were understood as behaviors he had acquired to survive his early severe physical and emotional abuse. Thus, it appeared that some memories were held by dissociated EPs and these memories were conceptualized as intrusions from an EP into an ANP. For example, when it rained, he would be triggered into an overwhelming physiological panic reaction because he had been beaten and tied on the roof and left to die. Whenever he would see a male that resembled his father on the hospital grounds, he would react with terror. Many times, when staff requested or demanded something from him, he reacted impulsively with a fight response.

It was clear that the dysfunctionally stored memories from early life had been disorganized and disconnected. Stephanos exhibited qualities such as joking, laughter, horseplay initially when we would try to touch on any of his traumatizing life events. Therefore, it seemed that he exhibited positive affect that served the purpose of avoiding prior life trauma. Alternately, he also lowered his head, closed his eyes, and went silent when EPs appeared and the therapists brought them to his attention.

According to Knipe (2014), the extreme avoidance or phobia of the traumatic memories is invested with high levels of dysfunctional positive affect to keep the EPs separate and out of awareness of the ANP and to keep the traumatic memories at bay. There was no doubt that his mental efficiency was weak and disorganized and he had minimal social support in his life, which led him to cling to the few positive relationships in his life (psychiatrists, psychologists, nurses, and one candidate foster mother). Separations from these individuals were very difficult for Stephanos and triggered issues of abandonment and betrayal.

When viewing Stephanos’s presentation through the prism of personality dissociation, he had one ANP that was charming, lovable, effective, able to do things, and “look normal” while being oriented to the present for the most part. Nevertheless, Stephanos learned to survive by investing much of his energy in avoiding his traumatic experiences, and this ANP exhibited many defenses. Stephanos overidealized himself as a super strong hero and others as his saviors (physicians, nurses, interns, prospective foster parent). He also exhibited overarousal that originated from EPs that appeared to be reliving trauma in the present. Early in treatment, there were many times where he would be overaroused or disconnected. At times, he tended to be hypergregarious, and at other times, foggy and dissociated.

There were several different EPs. One EP imitated his abusing father’s street wise behavior, especially in his living quarters on the hospital ward. Another EP was an aggressor which protected him as well as other young children, and which he called “DOPI” (a name found in Internet avatar characters). There was an EP that felt betrayed and another that carried the beatings, the fear, and terror. He introduced another EP named “RAVA” (another name found in Internet avatar characters) which was most interested in revenge and the punishment of his perpetrator and others around him. These dissociative parts (ANP and its defenses and multiple EPs) appeared to be somewhat separated and unaware of each other. Stephanos’s personality had a unique structure that had developed as an adaptation to his childhood environment, even though threats were no longer present in his current situation (Knipe, 2014).

EMDR Treatment Progress

Outcome and Results of Assessment Battery and Drawings

Overall, the results of the assessment battery are summarized in Figures 2 and 3, which depict the changes in Stephanos’s scores (i.e., UCLA PTSD-RI, SDQ-HEL, SCARED-SF, S-anxiety Inventory, IES-R, DES-II, OSS-3) or frequency of behavior (i.e., O’Neill’s Checklist) on each of the assessment tools from baseline to the end of treatment.

FIGURE 2.

Stephanos’s scores on the UCLA PTSD Reaction Index (UCLA PTSD-RI), Strengths and Difficulties Questionnaire—HEL (SDQ-HEL), Screen for Childhood Anxiety Related Emotional Disorders-Short Form (SCARED-SF), and State Anxiety (S-anxiety) Inventory at baseline and at the end of treatment.

FIGURE 3.

Stephanos’s scores on the Impact of Event Scale-Revised (IES-R), Dissociative Experiences Scale II (DES-II), Oslo 3-Item Social Support Scale (OSS-3), and frequency of behavior on O’Neill’s Checklist at baseline and at the end of treatment.

Drawings

The drawings (Figure 4) were introduced to Stephanos after he had started exhibiting signs of stabilization and being present in the sessions, and it should be noted that it took several months to get Stephanos to cooperate. The first drawing can be considered a baseline drawing. The second drawing was later in therapy. The third drawing was a mandala at the closure of therapy. The fourth drawing was at posttreatment to evaluate if Stephanos maintained his progress at treatment closure approximately a year later.

FIGURE 4.

1: First self-image during treatment. 2: Second self-image, more integrated. 3: Mandala- closure of treatment. 4: Follow-up one year.

All four of his drawings showed a significant emotional shift. In the first drawing, he described himself as “a jerk, a bad kid without feelings; I hit, I kick, and I kill.” In the second drawing, he drew himself with a big red heart and the depiction of his body is clearly more integrated than the previous drawing. The third was a mandala that was created by both therapists and Stephanos over a period of 2 weeks. The reason the mandala was initiated was to express how he was feeling in the present and what his dreams were of the future and to gain closure for the treatment in general. It was a way of saying goodbye. The mandala was laminated and given as a gift during the last session. The fourth drawing was created a year later at treatment follow-up where his drawing was again integrated, and clearly emotionally positive about his experiences with the two therapists. He wrote on the drawing that he was “happy” to see both therapists and welcomed their support.

Psychopharmacological Changes

When Stephanos was first admitted to the University Department, he was on three antipsychotic agents, and antiparkinsonian drug and benzodiazepine, which were gradually decreased. When discharged from the University Department, he was on one antidepressant and a small dose of antipsychotic medication.

Follow-Up

After being moved to two different residential placements around the country, Stephanos finally settled again in another group home. The two EMDR therapists met with him 11 months later. He communicated quite lucidly, explaining that he was pleased and happy to see them. He remembered a lot of the work he had learned during the therapy together and mentioned that he tried to use it. He lucidly talked about his life and his current living environment and what had happened in his life since he last saw the therapists. He reported positive experiences with staff and coresidents in his group home. In addition to this, his child psychiatrist and his judicial case handler both reported to the therapists that his behavior was well adjusted.