This chapter describes maneuvers to access the internal system of the patient as well as means to accelerate or decelerate the work in that process of accessing the self-system. Eye movement desensitization and reprocessing (EMDR), ego state therapy, and somatic therapy fit together like hand and glove. An extended preparation phase is often necessary before trauma processing in complex traumatic stress presentations and attachment-related syndromes, particularly when dealing with the sequelae of chronic early trauma. Clinical practice suggests that the adjunctive use of body therapy and ego state interventions can be useful, during stabilization and later on in increasing the treatment response to EMDR. Traditional treatment of complex posttraumatic stress disorder (PTSD) and dissociative disorders has usually included hypnoanalytic interventions, during which abreaction is considered an important part of treatment.
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This chapter focuses on identifying and working with dissociative symptoms and dissociative disorders in a therapeutic context, providing a road map to assist with the pacing and planning of clinical interventions. Rapid eye movement (REM) sleep can be conceptualized as a household strength processor that can accommodate the usual processing requirements of daily life. Posttraumatic stress disorder (PTSD) has been historically defined as requiring a trauma that is outside the range of normal human experience. Hypoarousal and parasympathetic activation that are an intrinsic part of dissociative symptoms are much more difficult to assess. The original painful memories live on in flashbacks and nightmares as well as in reenactments of the unconscious dynamics captured from the family of origin’s enactments of perpetration, victimization, rescuing, and neglect. Excessive sympathetic nervous system activation is easily construed to be an indicator of psychopathology.
This chapter reviews a range of tools and approaches for the stabilization of traumatized patients and the containment of eruptions of traumatic material until they can be effectively addressed in a later phase of treatment. The International Society for the Study of Trauma and Dissociation (ISSTD) Treatment Guidelines describe the consensus model in three phases, to include stabilization, trauma metabolization, and integration phases of treatment. Many patients experience continuous swings from one extreme of arousal to the other or have lives characterized by chronic shutdown, punctuated with occasional explosions of high arousal. Consistent with the theory of optimal arousal level, the patient must have the capacity to tolerate somatic sensation and affective awareness in order to process through any channels of information that comprise traumatic memory. Therapy will often need to help establish resources for traumatized patients through basic psychoeducation, an essential feature of preparation for poststabilization trauma reduction work.
- Go to chapter: Alexithymia, Affective Dysregulation, and the Imaginal: Resetting the Subcortical Affective Circuits
Alexithymia, Affective Dysregulation, and the Imaginal: Resetting the Subcortical Affective Circuits
This chapter focuses on the strategies that use neocortical resources of imagery to increase affective mentalization as well as, possibly reset them to allow increased adaptive, relational, and intersubjectivity capacity. Brain organization reflects self-organization; and human emotions constitute the fundamental basis the brain uses to organize its functioning where parent-child communication with regard to emotions directly affects the child's ability to organize his- or herself. Alexithymia and affective dysregulation play a significant role in that they constitute profound barriers for the effective treatment of traumatic stress syndromes and dissociative disorders by directly interfering with emotional processing as well as contributing to emotional destabilization. Traumatic stress and early childhood trauma has been associated with alexithymia, affective dysregulation, and deficits with regard to affective mentalization. Mentalization has been described as the ability to read the mental states of others through the brain’s mirror system.
This chapter addresses crises precipitated by problems in the relationships among the patient's internal states. It focuses on increasing awareness of different parts of the self and ultimately creating a more stable sense of self. The chapter describes interventions into instability or crises related to an internal locus of disturbance. An important early-stage approach to increasing patient stability involves the application of ego state therapy's conceptual framework and tools in an effort to reduce conflict among parts of self. A beneficial strategy in the treatment of shame involves approaching the damaged sense of self using object awareness, rather than ego awareness to evoke a tolerably remote, quasi-objective stance. When the locus of an ongoing or acute disturbance in a patient's life is centered in relationships among his or her states, systematically addressing that internal conflict can greatly increase stability.
This chapter describes different approaches to fractionating and titrating trauma processing to facilitate efficient information processing. Fractionation in the treatment of dissociative disorders specifically refers to the direction of attention to aspects of traumatic experience to attenuate the intensity of abreaction. In eye movement desensitization and reprocessing (EMDR) parlance, refers to setting up a "target" for trauma processing specifying the image, cognitions, affect/emotions, and sensations associated with the traumatic memory. A strategy in somatic work involves oscillation between the traumatic state and the resourced state. Bottom-up processing is characterized by an absence of higher level direction in sensory processing, whereas top-down processing reflects higher level neocortical processes such as cognitions. TOTEMSPOTS uses channels as described in the approaches noted earlier to fractionate an intense traumatic memory, to make it more manageable. Somatosensory processing is bottom-up, as it is suggested that sensation is foundational to the experience of emotion.
This chapter describes an approach to fractionation and titration of traumatic material, specifically the use of the time domain. The approach is informed by our understanding of neural development and the integration of mental experience using developmental time sequence. The chapter explains the early trauma (ET) approach of complex cases, specifically dissociative disorders. Maladaptive lessons learned at very early ages will effect decisions for a lifetime and form the basis for certain Axis I and Axis II symptom configurations. Temporal integrationism is the term established by Paulsen to describe the approach to resolving very ET and attachment injury, including neglect in the absence of declarative or explicit memories. For eye movement desensitization and reprocessing (EMDR) practitioners, it is challenging to obtain subjective units of disturbance (SUD) levels and usually impossible to derive cognitions or narratives for very ET and neglect.
This chapter suggests neurobiological mechanisms to account for dissociative symptoms in general and structural dissociation in particular. Peritraumatic dissociation (PD) is associated with the release of endogenous opioids and other anesthetic neurochemicals that alter communication between lower and higher brain structures. MacLean's triune brain model provides a structure for the understanding of emotional functioning and dissociation. The integration of brain functioning both horizontally and vertically at different levels of the brain is at the core of information processing. The thalamus also plays a role in cortical oscillations, a phenomenon that has been related to cognitive-temporal binding and information processing, thus affecting cortical connectivity. The corpus callosum is the largest connective pathway in the human brain, constituted of nerve fibers that connect the left and right hemispheres, thus facilitating interhemispheric communication. Disruption of thalamocortical communication is a key component of anesthetic-induced unconsciousness.
This chapter focuses on how to effectively integrate somatic interventions during the different stages of trauma treatment, such as stabilization, trauma processing, and reconnection, and how to integrate their use to maximize the effectiveness of eye movement desensitization and reprocessing (EMDR). Ventral vagal connectedness between and within people is the name of the game to enhance association and integration. The EMDR standard protocol integrates cognitive, emotional, and sensory information. Information processing breaks down, likely due to significant peritraumatic dissociation (PD) that co occurs with the apparent hyperarousal. Social engagement reflects a ventral vagal response that results in increased self-regulation and calming, thereby decreasing the likelihood of a dorsal vagal response. To facilitate both dual focus and body mindfulness, both exteroceptive and interoceptive awareness are required. Olfactory pathways travel directly to the limbic system and amygdala, and from there olfactory information is likely conveyed to lower brain structures.