Incest cont.  More severe symptoms occur with:  early childhood onset,  longer duration,  violence and coercion,  penetration,  blaming the child by the parent, and  observed or reported incest that continues Treating DID  Goal: Fusion, final fusion/unification, cooperation  17-33% achieve final fusion  The longer the treatment the fewer the symptoms  Three Phase Model 1. Safety, stabilization, and symptom reduction 2. Integrating traumatic memories 3. Identity integration and rehabilitation 1. Establish Safety, Stabilization, and Symptom Reduction  Safety self-mgmt and agreements (Seeking Safety- Najavits)  Emotion Regulation skill building (TF-CBT, SkTrnAfIntRe)  grounding (awareness through senses)  mindfulness breathing and/or  progressive muscle relaxation  mindfulness  cognitive interventions Phase I cont  present-ness and self-reflective  trust  therapeutic alliance  Polyvagal Theory (Stephen Porges)  But, no improvement without direct work with alters and amnesia Working with Alters prior to Memory Work  Client must accept, value, and be able to access their alters  Practice- Daily inward focus, awareness, and listening to parts  Denial of parts prolongs symptoms and DID  Practice- Daily talking to parts, writing to parts, inner meetings  Encourage negotiation between the alters to resolve differences  Establish commitments by all identities for safety from self-harm and/or suicidal behaviors.  Practice- Create safe, calm place in client’s mind and  in external world for client Preparation for Trauma Memory Work  Determine:  Which procedures will be used to contain traumatic memories (e.g., put some alters to sleep or safe place)  Which memories will be focal,  Which alternate identities will participate,  What steps will be taken to maintain safety  At what level of intensity they will be processed,  Is client stable enough to begin memory work? 2. Working Through, & Integrating Traumatic Memories  Repeated re-accessing integrates fragmented/dissociated parts of traumatic memories into a linear, coherent narrative  Abreaction: release of strong emotions connected to trauma  Working with alters that hold the traumatic memories  Controlled and paced process:  Fractionated Abreaction Technique (small % at a time)  Behavior, Affect, Sensory, Knowledge (BASK)  EMDR  Integrate memories, events, associated sensory experiences 3. Identity Integration  Include fusion rituals:  imagine all parts working together, for example, seated around a conference table discussion and issue.  May suggest that the emergent alter “go in” and talk with other parts about an issue  Gradually fade therapist direct work with alters and encourage alters to discuss issues  Process distorted beliefs about self and others  Expand support system and generalize skill application Ethical Issues  Reenactments of boundary violations by abuser  Setting boundaries  length and time of sessions,  conﬁdentiality and its limits,  therapist availability between sessions,  the respective roles and responsibilities of the patient and therapist,  management of inter-session crises,  procedures if hospitalization is necessary,  physical contact between the therapist and patient, and  involvement of the patient’s family or signiﬁcant others in the treatment, among other topic

Complex Trauma and Complex Dissociative Disorders Part 3

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