15 Aug Dissociation, Dissociative Disorders & The Therapeutic Relationship
Trauma can be conceptualized as stemming from a failure of the natural physiological activation and hormonal secretions to organize an effective response to threat. Rather than producing a successful fight or flight response the organism becomes immobilized. Probably the best animal model for this phenomenon is that of ‘inescapable shock,” in which creatures are tortured without being unable to do anything to affect the outcome of events. The resulting failure to fight or flight, that is, the physical immobilization (the freeze response), becomes a conditioned behavioral response.
In his book, Affect Regulation and the Origin of the Self, Allen Schore has outlined in exquisite detail the psychobiology of early childhood development involving maturation of orbitofrontal and limbic structures based on reciprocal experiences with the caregiver. Dysfunctional associations in this dyadic relationship result in permanent physicochemical and anatomical changes, which have implications for personality development as well as for a wide variety of clinical manifestations. An intimate relationship may exist, with negative child/care giver interaction leading to a state of persisting hypertonicity of the sympathetic and parasympathetic systems that may profoundly affect the arousal state of the developing child. Sustained hyperarousal in these children may markedly affect behavioral and characterological development.
Many traumatized children and adults, confronted with chronically overwhelming emotions, lose their capacity to use emotions as guides for effective action. They often do not recognize what they are feeling and fail to mount an appropriate response. This phenomenon is called alexithymia, an inability to identify the meaning of physical sensations and muscle activation. Failure to recognize what is going on causes them to be out of touch with their needs, and, as a consequence, they are unable to take care of them. This inability to correctly identify sensations, emotions, and physical states often extends itself to having difficulty appreciating the emotional states and needs of those around them. Unable to gauge and modulate their own internal states they habitually collapse in the face of threat, or lash out in response to minor irritations. Dissociation and/or Futility become the hallmark of daily life.
“We use our minds not to discover facts but to hide them. One of things the screen hides most effectively is the body, our own body, by which I mean, the ins and outs of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day. The elusiveness of emotions and feelings is probably . . . an indication of how we cover to the presentation of our bodies, how much mental imagery masks the reality of the body” – Damasio
Effective treatment needs to involve (1) learning to tolerate feelings and sensations by increasing the capacity for interoception, (2) learning to modulate arousal, and (3) learning that after confrontation with physical helplessness it is essential to engage in taking effective action. Introception is the process of embodied mindfulness, and in neuroscientific terms it is becoming aware of visceral afferent information (bodily sensations)
Being traumatized is continuing to organize your life as if the trauma was still going on unchanged and every new encounter or event is contaminated by the past. After trauma the world is experienced with a different nervous system, a survivor’s energy now becomes about suppressing inner chaos at the expense of spontaneous involvement in life. These attempts to maintain control of these unbearable physiological reactions can result in a whole a range of physical symptoms such as autoimmune diseases, this is why it is important in trauma treatment to engage the entire organism, body, mind and brain. Deactivation of the left hemisphere of the brain has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. Without sequencing we cannot identify cause and effect, grasp the long-term effects of our actions or create coherent plans for the future.
When something reminds traumatized people of the past, their right brain reacts as if the trauma were happening in the present but because their left brain may not be working very well, they may not be aware that they are re-experiencing and reenacting the past, they are just furious, terrified, enraged, shamed or frozen. After the emotional storm passes, they may look for something or somebody to blame for it, for their behaviour, they may say,
“I acted this way because you looked at me like that or because you were late”. This is called being stuck in fight or flight.
In trauma recovery where the left hemisphere is activated through speaking of the traumatic past and making sense of what happened within a safe environment, the left brain can talk the right brain out of reacting by saying that was then and this is now. This can only happen when safety is establish through attunement with a therapist where the amygdala is down regulated, this can often take some time for traumatized people as the amygdala tends to stay in a heightened state of arousal ready for fight or flight even years after then traumatic event or experience. Even the slightest detection of a threat can cause extreme arousal of this system. Minor stimuli will illicit major responses.
This is why it is important to engage the left and right-brain in trauma recovery, whilst body based interventions are absolutely imperative and ofcourse right brain to right brain affect reglation is critical for rewiring the nervous system contributing to long term character change and critical for trauma recovery, these interventions may be undermined should they exclude left-brain based activities. Body based interventions such as dance; massage and yoga are a fantastic adjunct to psychodynamic psychotherapy. Lazar’s study lends support to the notion that treatment of traumatic stress may need to include becoming mindful: that is, learning to become a careful observer of the ebb and flow of internal experience, and noticing whatever thoughts, feelings, body sensations, and impulses emerge. In order to deal with the past, it is helpful for traumatized people to learn to activate their capacity for introspection and develop a deep curiosity about their internal experience. This is necessary in order to identify their physical sensations and to translate their emotions and sensations into communicable language—understandable, most of all, to themselves.
Traumatized individuals need to learn that it is safe to have feelings and sensations. If they learn to attend to inner experience they will become aware that bodily experience never remains static. Unlike at the moment of a trauma, when everything seems to freeze in time, physical sensations and emotions are in a constant state of flux. They need to learn to tell the difference between a sensation and an emotion (How do you know you are angry/afraid? Where do you feel that in your body? Do you notice any impulses in your body to move in some way right now?). Once they realize that their internal sensations continuously shift and change, particularly if they learn to develop a certain degree of control over their physiological states by breathing, and movement, they will viscerally discover that remembering the past does not inevitably result in overwhelming emotions.
After having been traumatized people often lose the effective use of fight or flight defenses and respond to perceived threat with immobilization. Attention to inner experience can help them to reorient themselves to the present by learning to attend to non-traumatic stimuli. This can open them up to attending to new, non-traumatic experiences and learning from them, rather than reliving the past over and over again, without modification by subsequent information. Once they learn to reorient themselves to the present they can experiment with reactivating their lost capacities to physically defend and protect themselves.
Trauma and the Nervous System
Exposure to extreme threat, particularly early in life, combined with a lack of adequate caregiving responses significantly affect the long-term capacity of the human organism to modulate the response of the sympathetic and parasympathetic nervous systems in response to subsequent stress. The sympathetic nervous system (SNS) is primarily geared to mobilization by preparing the body for action by increasing cardiac output, stimulating sweat glands, and by inhibiting the gastrointestinal tract. Since the SNS has long been associated with emotion, a great deal of work on the role of the SNS has been collected to identify autonomic “signatures” of specific affective states. Overall, increased adrenergic activity is found in about two-thirds of traumatized children and adults. The parasympathetic branch of the ANS not only influences HR independently of the sympathetic branch, but makes a greater contribution to HR, including resting HR. Vagal fibers originating in the brainstem affect emotional and behavioral responses to stress by inhibiting sympathetic influence to the sinoatrial node and promoting rapid decreases in metabolic output that enable almost instantaneous shifts in behavioral state. The parasympathetic system consists of two branches: the ventral vagal complex (VVC) and the dorsal vagal complex (DVC) systems. The DVC is primarily associated with digestive, taste, and hypoxic responses in mammals. The DVC contributes to pathophysiological conditions including the formation of ulcers via excess gastric secretion and colitis. In contrast, the VVC has the primary control of supradiaphragmatic visceral organs including the larynx, pharynx, bronchi, esophagus, and heart. The VVC inhibits the mobilization of the SNS, enabling rapid engagement and disengagement in the environment.
The Dorsal Vagal State and manifestation of autoimmune disorders
People who are in the dorsal vagal state a lot which is the state when the amygdala is activated due to a detection of a slight threat in the environment consciously or unconsciously through neuroception and the traumatized person goes into a state of learned helplessness or what is called dissociation or freeze response which is an unconscious conditioned fear response, the body’s reflex to an internal or external stimuli from a cue of an original trauma. This will activate all the viscera, your heart, your lungs, your colon, your stomach, all of these are run unconsciously by the dorsal vagal nucleus and if you have syndromes where you are in the freeze response a lot, the dorsal vagal nucleus will be hyperactive and you will get syndromes of hyperactivity within the viscera and that can be characterized by Irritable bowel disease, colitis and other autoimmune diseases.
These are cyclical diseases which means they oscillate between sympathetic and parasympathetic nervous system meaning the symptoms come and go which is why the medical profession very often can not diagnose the problem or refer to it as psychosomatic meaning it is a condition of the mind when in fact it is actually emotionally driven physiological conditions of the gut and the brain. Problems with the gut are common with people who have had trauma, it is the physiology of trauma that drives these conditions and so if you heal the trauma you can heal the disease. These conditions are also referred to as neurosomatic, which means they are brain based conditions, physical conditions caused by abnormal function of the brain.
The Amygdala is the agent of fear conditioning, it stores emotionally based memory positive and negative, it is also the gate keeper for responding to threat by activating the fight or flight response, when the fight or flight response is not successful, such as you can not escape the traumatic event, the body goes into a freeze response. The freeze response is predicated by the effects of early childhood experiences, the freeze response is also called dissociation. When dissociation happens you are dysregulated, Dissociation is based a lot on what happened in childhood that allowed you to develop the brain in a way to prevent that from happening too easy. This has to do with Allan Schore’s work on attunement, the part of the brain that controls this regulation of autonomic nervous system and emotional system, which is the orbital frontal cortex. This develops in a healthy attuned infant and shrinks in a neglected infant. We need a developed orbital frontal cortex to regulate us over our lifetime and prevent us from going into freeze states and dysregulation. Helplessness is the essential ingredient for the freeze response.
The freeze response is a motor action, which perpetuates the escape behaviour in a way that erases all the procedural (Implicit) memory of that trauma. If you have a threat and don’t discharge the freeze response, you are conditioned thereafter to any body cues related to that traumatic event.
Interoceptive, body-oriented therapies can directly confront a core clinical issue in PTSD: traumatized individuals are prone to experience the present with physical sensations and emotions associated with the past. This, in turn, informs how they react to events in the present. For therapy to be effective it might be useful to focus on the patient’s physical self-experience and increase their self- awareness, rather than focusing exclusively on the meaning that people make of their experience—their narrative of the past. If past experience is embodied in current physiological states and action tendencies and the trauma is reenacted in breath, gestures, sensory perceptions, movement, emotion and thought, therapy may be most effective if it facilitates self-awareness and self-regulation. Once patients become aware of their sensations and action tendencies they can set about discovering new ways of orienting themselves to their surroundings and exploring novel ways of engaging with potential sources of mastery and pleasure.
Working with traumatized individuals entails several major obstacles. One is that, while human contact and attunement are cardinal elements of physiological self-regulation, interpersonal trauma often results in a fear of intimacy. The promise of closeness and attunement for many traumatized individuals automatically evokes implicit memories of hurt, betrayal, and abandonment. As a result, feeling seen and understood, which ordinarily helps people to feel a greater sense of calm and in control, may precipitate a reliving of the trauma in individuals who have been victimized in intimate relationships. This means that, as trust is established it is critical to help create a physical sense of control by working on the establishment of physical boundaries, exploring ways of regulating physiological arousal, in which using breath and body movement can be extremely useful, and focusing on regaining a physical sense of being able to defend and protect oneself. It is particularly useful to explore previous experiences of safety and competency and to activate memories of what it feels like to experience pleasure, enjoyment, focus, power, and effectiveness, before activating trauma-related sensations and emotions. Working with trauma is as much about remembering how one survived as it is about what is broken.
Working with Trauma & Dissociation through right brain affect regulation at Trauma Recovery Institute
Trauma Recovery Institute offers unparalleled services and treatment approach through unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP).
At Trauma Recovery Institute we address three of the core Attachment Styles, their origin’s the way they reveal themselves in relationships, and methods for transforming attachment hurt into healing. We use the latest discoveries in Neuroscience which enhances our capacity for deepening intimacy. The foundation for establishing healthy relationships relies on developing secure attachment skills, thus increasing your sensitivity for contingency and relational attunement. According to Allan Schore, the regulatory function of the brain is experience-dependent and he says that, as an infant, our Mother is our whole environment. In our relational trauma recovery approach you will learn to understand how the early patterns of implicit memory – which is pre-verbal, sub-psychological, and non-conceptual – build pathways in our brain that affect our attachment styles. Clinically, we can shift such ingrained associative patterns in our established neural network by bringing in new and different “lived” experiences in the Here and Now.
The Role of the Therapist in transforming attachment trauma: Healing into wholeness takes the active participation of at least one other brain, mind, and body to repair past injuries – and that can be accomplished through a one-to-one therapeutic relationship, a therapeutic group relationship or one that is intimate and loving. In exploring the “age and stage” development of the right hemisphere and prefrontal cortex in childhood, we discover how the presence of a loving caregiver can stimulate certain hormones, which will help support our growing capacity for social engagement and pleasure in all of our relationships. Brain integration leads to connection and love throughout our entire life span. At trauma recovery institute we bring a deep focus to the role of Neuroscience in restoring the brain’s natural attunement to Secure Attachment. Our brain is a social brain – it is primed for connection, not isolation, and its innate quality of plasticity gives it the ability to re-establish, reveal and expand one’s intrinsic healthy attachment system.
Dynamic Psychosocialsomatic Psychotherapy (DPP) at Trauma Recovery Institute Dublin
Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.
Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.
“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as clients and therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking and behaviour.”