Complex trauma lecture series. Lecture 2 Overview of the role of dissociation and attachment in complex trauma

1. Lecture 2 Understanding the Role of
Dissociation and Attachment.
Module: Complex Case Work
Kevin Standish

3. Learning outcomes
 To explore and understand dissociation.
 To describe Attachment theory and attachment
disorders.
 Assess the neuropsychological impact of
trauma.
 Explore the case studies in relation to
dissociation and attachment.

4. 1.
2.
3.
4.
5.
6.
7.
8.
Defining dissociation
The spectrum of dissociation
Continuum of dissociation
Clinical dissociation
Structural association
High functioning dissociation
The range of dissociative disorders
Working with dissociation
1. DISSOCIATION.

5. 1. Defining dissociation
 Is a defense against trauma that helps persons
remove themselves from trauma as it occurs &
delays the working through of the trauma
 Patients have lost sense of having ones
consciousness
 Dissociation is an adaptive survival mechanism
in the presence of overwhelming externally
threatening experiences from which the victim
cannot escape physically, but may escape
psychologically by splitting off from the
experience and associated sensations, feelings,
thoughts and memories.

6. 1. Defining dissociation
“It’s as if your mind is not
in your body; as if you
are looking at yourself
from a distance; like
looking at a stranger”.

7. 1. Defining dissociation
 Dissociation is a normal response to
trauma. Survivors inhabit their head and
lose contact with their body
 Frequent detachment from bodily
experiences results in loss of reality, and
uncertainty about whether the
experience actually happened
 Dissociation is a form of emotional
anaesthetic to aid survival.

8. 2. The spectrum of dissociation
 A degree of dissociation is normal and adaptive.
Getting lost in a book, being immersed in a film
are examples.
 Children's absorption in play fantasy and
imagination is a healthy adaptive form of
dissociation
 Some children continue to dissociate when there
is a need to escape their environment. Escape
into dissociative imagination with imaginary
companions.

9. 3. Continuum of dissociation
 Dissociation is a continuum across a range from
normal to severe dissociative identity disorder
 Within the normal range there is an experience
of related states of alertness and detachment. It
is normal to move through multiple experiential
states with the continuous sense of core
identity.

10. 3. Continuum of dissociation
 Clinical dissociation: the degree of detachment
becomes increasingly severe as a person is
immersed in their internal world, losing contact
with reality, their body and sense of self for
periods of time.
 The range of dissociation goes from distraction,
to depersonalisation, dissociative/psychogenic
amnesia, dissociative/ psychogenic fugue, to
finally dissociative identity disorder

12. 3. Continuum of dissociation
There are five types of dissociation:
1. Amnesia
This is when you can’t remember incidents or experiences that happened at a
particular time, or when you can’t remember important personal information.
2. Depersonalisation
A feeling that your body is unreal, changing or dissolving. It also includes outof-body experiences, such as seeing yourself as if watching a movie.
3. Derealisation
The world around you seems unreal. You may see objects changing in
shape, size or colour, or you may feel that other people are robots.
4. Identity confusion
Feeling uncertain about who you are. You may feel as if there is a struggle
within to define yourself.
5. Identity alteration
This is when there is a shift in your role or identity that changes your behaviour
in ways that others could notice. For instance, you may be very different at
work from when you are at home.

13. 4. Clinical dissociation
 Three types of dissociation of associated with
trauma order which aid survival
 Primary dissociation occurs in the face of
overwhelming trauma preventing the individual
from integrating what is happening to the extent
that experience remains fragmented
 Secondary or peritraumatic Association is
activated during trauma winning is no escape
and represents a psychological flight when a
physical flight is not possible. Accompanied by
after body experiences and sense of leaving the
body

14. 4. Clinical dissociation
 Tertiary dissociation is associated with severe
childhood abuse and complex trauma, in which
distinct ego states emerged to contain
traumatic experiences, which can result in
dissociative identity disorder

15. 4. Clinical dissociation
 Dissociation is mediated through the release of
endorphins. Children are particularly
vulnerable, and can result in traumatic
experience becoming locked into the right brain
preventing access to left brain processing and
analysis
 Whilst initially adaptive, dissociation becomes
maladaptive in becoming a learned response to
all feelings and sensations even positive ones.
This leads to impaired emotional processing,
impaired thinking and cognitive processing
resulting in cognitive distortions and
dichotomous thinking.

17. 5. Structural association
 A vertical split in consciousness as a way of
shielding oneself from overwhelming fear of
annihilation and cognitive knowledge of
traumatic events
 A separation of mental and experiential contents
that would normally be connected
 This lack of integration and disowning of
conceptual experiences, prevents the integration
of self states in young children, or the
fragmentation of integrated systems and
decoupling of self states in adults

18. 5. Structural association
 Structural dissociation is a split between
"apparently normal personality" (ANP) and the
"emotional personality" (EP).
 ANP detaches and avoid any contact with
trauma related alternatives and is highly
functional in managing daily life in a
emotionally and physically numb manner
 Ep: remains embedded in the trauma, reliving
the trauma through post-traumatic symptoms
such as flashbacks, hyper arousal,
disorientation

20. ANP VS EP

21. 6. High functioning dissociation
 Some survivors extremely high functioning with
successful careers but have great difficulties in
close personal relationships
 There is a split in the attachment style where
the ANP is avoidant and dismissive of
attachment needs, while the EP is insecurely
dependent upon and preoccupied with
attachment needs.
 By separating the two States survivors get on
with daily life without being overwhelmed by
the internal stresses caused by the trauma

22. 6. High functioning dissociation
 The survivors developed a phobia of inner
experience. Emotions are rarely "felt" and
commonly of as "thought emotions" in which
the right emotion is cognitively identified
rather than experience.
 It is crucial that survivors become aware of in
experience and learn to tolerate and regulate
it, in order to facilitate change
 Survivors will often create a fantasy world
which is beautiful, benign and harmonious in
order to escape the real world of despair
trauma and abuse.

23. 6. High functioning dissociation
 When clients dissociate into the fantasy world
they create significant barriers in the
therapeutic relationship through
 mis-atunement,
 defensive reactions,
 projection
 and negative transference

24. 7. The range of dissociative
disorders
 Depersonalisation - de
realisation disorder
 Dissociative amnesia
 Dissociative identity
disorder (DID)
 Dissociative disorder
not elsewhere
classified (DDNEC)

25. 7. The range of dissociative
disorders

26. 8. Working with dissociation
 Avoidance of in experience and dissociation is
highly correlated with some personality
disorders in particular borderline personality
disorder
 The role of dissociation is to split off a range
of feelings and thoughts such as vulnerability,
dependency, hurt, anger and rage
 The most common self states seen in survivors
of complex trauma can be described in Young's
terms as abuse child, the angry child, the
punitive parent and the detached protector .
From schema therapy

27. 8. Working with dissociation
 Not all survivors are aware of the role of
dissociation and how it impacts on them
 This important familiarise yourself with the
hallmark signs of dissociation to assess the
degree of dissociation in a client
 If you suspect a client suffers from chronic
dissociation make use of an assessment scale:
dissociative experiences scale (DES);
Somatoform dissociation questionnaire (SDQ 5),
or SDQ 20

29. Dissociative experiences scales
 file:///C:/Users/Owner/Downloads/des.pdf
 http://counsellingresource.com/lib/quizzes/m
isc-tests/des/

31. Useful reading
 Treating dissociation: Courtis & Ford (2009)
chapter 7 Treating Dissociation by Steele & Van
der Hart

32. 1. The function of attachment
2. Attachment styles
3. Complex trauma and attachment
2. ATTACHMENT THEORY AND
ATTACHMENT DISORDERS.

33. 1. The function of attachment
 Attachment is an innate psychobiological
imperative that aids physical and psychological
survival.
 Attachment bonding shapes the baby's brain to
ensure healthy psychological development and
provides a secure base in which physical and
emotional needs are met. Gerhardt (2004) why
those matters: how affection shapes a baby's
brain.
 Primary purpose of early attachment is to support
experience dependent maturation of the
developing brain before autonomy and affect
regulation develop

34. 1. The function of attachment
 The external caregiver acts as an affect
regulating system to facilitate the child's own
regulation of arousal and emotional inner
psychological mental states
 It is through consistent appropriate caregiving
responses that the infant learns internal states
can be soothed and regulated. The bonding
process releases critical hormones such as
oxytocin which mediate the sense of comfort
pleasure and delight in close relationships

35. 1. The function of attachment
 Bowlby’s concept of inner working models, of
what can and cannot be expected in
relationships and how others respond to needs,
formulate attachment bonds.
 In complex trauma children are not able to
achieve self integration, or develop healthy
internal working models necessary to feel safe
around others. This leads to disruption in the
attachment system giving rise to insecure
attachments

36. 1. The function of attachment
 Secure attachment: associated with a history of
warm, responsive and consistent relationships
both in childhood and adulthood. They have a
positive view of self, others and relationships.
Find it easy to be emotionally close to others
and being comfortable depending on others and
having others depend on them.
 Insecure attachment: survivors of complex
trauma experience relationships as dangerous
and terrifying rather than as a source of
pleasure.

38. 2. Attachment styles




Anxious preoccupied attachment
Dismissive avoidant attachment
Fearful avoidant attachment
Disorganised/disorientated/ dissociated
attachment

40. 2. Attachment styles

43. Childhood to adulthood
attachment

44. Disorganised/disorientated/
dissociated attachment
 Most commonly associated with emotional or sexual
violence and abuse
 Characterised by dissociation, trancelike states,
freezing, hypervigilance, hyperactivity, hyper arousal,
were stress tolerance, attention deficit and cognitive
deficits, lack of empathy and failure to thrive
 The individual is put into irreconcilable paradox of
approach and avoidance as this significant other is both a
safe haven and a source of terror. This leads to "fear
without solution".
 The child cannot form a coherent sense of self or any
organised attachment resulting in extremely chaotic
attachments in which they isolate between seeking
comfort and defending against what they are seeking

45. 3. Complex trauma and
attachment
 Traumatic bonding
 Traumatic loneliness

46. Traumatic bonding
 "Strong emotional ties that developed between
two persons where one person intermittently
harasses, beats, threatens, abuses or
intimidates the other".
 It is most likely to occur in the presence of
inescapable life-threatening trauma which
evokes fearful dependency and denial of rage
and the victim
 The core feature of traumatic bonding is that
the abuser is both the source of preserving life
and destroying life. Therefore any anger or
rage by the victim must be denied

47. Traumatic bonding
 For traumatic bonding to occur certain
dynamics need to be present: 1. An imbalance
of power. 2. Abuse is sporadic and intermittent
alternating with highly positive and caring
behaviour.
 To survive, reality has to be distorted and the
true nature of the abusive relationship has to
be seen as normal. This allows abuse to be
masked and a high tolerance for abuse to be
created

48. Traumatic bonding
 The alternation between abuse and loving
behaviour becomes "super glue that bonds" the
relationship. Any attempts to threaten the bond
will be resisted. Survivors adopt the abuser's
belief system and come to identify with the
aggressor. These cognitive distortions are a
central feature that survivors have about self,
others and relationships.
 Otherwise known as the Stockholm syndrome

50. Traumatic loneliness
 Survivors of complex trauma learn that they
are safer when they are alone
 The sense of relief and security experienced
when alone can become conditioned in the
presence of stressful experiences
 Rather than reach out for the help survivors
likely to withdraw and become invisible.

51. Traumatic loneliness

52. THE NEUROPSYCHOLOGICAL
IMPACT OF TRAUMA

53. BIOLOGICAL FACTORS
There is growing evidence of
the role of trauma on
intricate neurobiological and
neuroanatomical structures
in dissociative disorders.
Early childhood
trauma, witnessing or
exposure to traumatic or
violent incidents, apparently
has the potential to produce
enduring alterations on
brain
chemistry, neuroendocrine
processes, and memory.

54. The neuropsychological impact
of trauma.
 Psychological traumas are developmentally
adverse if they disrupt normal development in
acquiring the necessary foundations:
 1. Attention and learning.
 2. Working memory, narrative memory,.
 3. Emotion regulation.
 4. Personality formation and integration.
 5. Relationships and attachment.

55. Impact of psychological trauma of early
childhood development: the survival brain
 With trauma there is a shift from the brain
focused on learning to brain focused on
survival
 The learning brain is engaged in exploration
reinforced by searching for balance between
novelty and familiarity
 Survival brain seeks to anticipate prevent
and protect against damage caused by
potential dangers, reinforced by search to
identify threats and to mobilise bodily
resources in defence

56. Impact of psychological trauma of early
childhood development: the survival brain
 This available brain relies on rapid automatic
processes that involve the more primitive parts
of the brain bypassing areas in the more
complex cognitive components of the brain
 The survival response is the stress response
system operating automatically to maintain
homoeostasis
 stress response system overrides the
functionality of the brain systems for learning,
reward seeking, stress management, planning
and judgment. The executive functions of the
brain development are impaired

57. the survival brain

58. Read Hudon-Allez, G (2009)
 Read Hudon-Allez, G (2009) Infant Losses; Adult
Searches: a neural and developmental
perspective of psychopathology and sexual
offending. Chapter 1 and chapter 2.

59. Two defining characteristics of
post-traumatic survival brain
1. Emotional dysregulation: when abuse
prolongs, exacerbates or prevents the learning
of ways behaviourally and biologically to
modulate fear of the unfamiliar, novelty they
become a source of unmanageable distress. This
is because the the child failed to learn how to
regulate the body when experiencing fear of
the unfamiliar

60. Two defining characteristics of
post-traumatic survival brain
2. Dysregulated information processing:
exposure to traumatic stresses in early childhood
reduce the brain's ability to create neural
networks to support reflective self awareness
because the neural networks are prepared for
survival of danger rather than learning. Without
the capacity to observe one's own thought
processes, it is not possible to create a new
knowledge. It results in reactiveness to
experiences with automatic, chaotic and fixed
perceptions, thoughts and actions

61. Neurocircuitry System
 There is strong clinical
evidence that indicates that
the amygdala is a central
structure in the brain
neurocircuitry and plays a
pivotal role in conditioned or
(learned) fear responding.
 Dysregulation of the amygdala
or the hippocampus, or
both, results in poor
contextual stimulus
discrimination
(misinterpretation) and leads
to overgeneralization of fear
responding cues.

62. Neurocircuitry System
 Because the limbic system is where memories are
processed, early trauma experiences will remain
unassimilated to the degree the stress of detachment
affected the limbic system.
 Significant early traumatic experiences and the lack of
attachment have also been demonstrated to have longterm effects on neurotransmitters, especially
serotonin, which has been identified as a primary
neurotransmitter involved in the regulation of affect.
 Clients with dissociative disorder often present with a
multitude of somatic complaints. The somatic
complaints may be representative of a memory laid
down along primitive neurological pathways that is
being stimulated by something in the current
environment.

63. Neurocircuitry System
 Prolonged sleep deprivation, fever, and
hyperventilation can present with symptoms of
amnesia, depersonalization, or identity disturbance.
 Clients with head injuries, seizure disorders, or brain
lesions can present with symptoms of dissociation.
 In the nineteenth century, Charcot and others
attributed dissociative processes to various forms of
epilepsy involving the temporal lobe.
 Research on stress and trauma has also demonstrated
altered limbic system function in response to chronic
stress, with concurrent suppression of hypothalamic
activity and dysregulation of the neurocircuitry
systems.

64. 1. Sanderson (2013)
chapter 3 understanding the role of the dissociation and
dissociative disorders.
Chapter 4 understanding the role of attachment
2. Courtois & Ford (2009)
Chap 2: Ford, J. Neurobiological and Developmental
Research: Clinical Implications.
Chap 6 Assessment of Attachment and Abuse History, and Adult
Attachment Style, Daniel Brown & Treating Dissociation, Kathy
Steele and Onno van der Hart
8. Cultural Competence, Laura S. Brow
3. Courtois & Ford (2013) chapter 8 into the breach: Voids,
absences, and the post-traumatic/dissociative relational field
READINGS