Trauma & Art

‘Trauma therapy requires being grounded in trauma theory and many creative therapeutic approaches’ (Ross &Halpern, 2011)

Trauma Model Therapy: A Treatment Approach for Trauma Dissociation and Complex Comorbidity by Colin A. Ross and Naomi Halpern (2011-10-24 – Kindle Edition)

I don’t think Trauma Model Therapy: A Treatment Approach for Trauma Dissociation and Complex Comorbidity by Ross and Halpern is available in Greek, but would be worth buying and reading if one can read English, especially as an introduction to trauma and treatment since it is comprehensible, organized in relatively short chapters and covers so many aspects of trauma and treatment, from diagnostic tools and issues to issues of spirituality. Furthermore, it includes many vignettes which clarify the topics presented, it is not theory oriented and the focus is on treatment as the title itself suggests. The authors provide very helpful and practical material and suggestions and normalize trauma symptomatology. Therefore, the book is suitable for survivors of trauma and people in therapy, as well as, psychology students and therapists. What would perhaps be desirable is a little further discussion of PTSD, Complex PTSD and the psychotherapeutic utility of new neurobiological findings and perhaps the inclusion of sensorimotor approaches or techniques that address the somatic and physiological aspects of trauma. Pat Ogden and others claim that survivors have dysregulated nervous systems and unresolved animal responses and that dissociation is both psychological and physical. Trauma elicits an instinctual, bottom up response and our frontal lobes shut down, therefore, it is suggested that physiology should be addressed and trauma should be worked through the body as well. However, as the authors clarify the book is not theory oriented so one would not expect a thorough discussion of such topics. Also, the book was written in 2011 and the new DSM-V had not been published yet (PTSD is now put into a newly created group of trauma and stressor related disorders).

In the introduction of this book it is stated that it is a treatment manual, written for therapists and clinicians, but as mentioned above, I think survivors could also benefit from reading the book because it is written in a style that does not include a lot of jargon or theory and it covers a great variety of issues. It is organized in clear, short chapters, which further facilitates reading and understanding. The book includes techniques and interventions, photocopiable screening and diagnostic tools with instructions on how to use them and extracts from therapy vignettes. There is emphasis on dissociation because like many other people in the field, they believe that dissociation is ‘a core component of the trauma response’. Actually, the book begins with an overview of dissociation, which is understood on a continuum. It provides examples and explains the difference between dissociation and repression and briefly presents four basic meanings of dissociation as: a) a general systems meaning; b) an operationalized meaning; c) a technical term in cognitive psychology, and finally, d) an adaptive, intrapsychic defense mechanism. Ross and Halpern write ‘sometimes dissociation is a good thing, other times it interferes with function. Sometimes it is done consciously, other times it happens automatically. You couldn’t get through the day without healthy, normal dissociation. On the other hand, if you put everything on the back burner for life, or were always and only in your head, it wouldn’t be possible to live a balanced, healthy life. It’s all a matter of balance and degree. The ability to dissociate is a skill. Normal dissociation includes common experiences such as zoning out and missing part of a conversation or movie. We all dissociate a little bit. As you move right on the continuum, the dissociative experiences become more frequent, more severe, and increasingly interfere with function. If you zone out for 45 minutes during an exam and then fail, this is obviously not a good thing. If this zoning out happens during most tests, then it can be a serious problem and may require treatment’. Thirdly, they briefly discuss dissociation as a technical term in experimental cognitive psychology, ‘where dissociation refers to a disconnection within memory. Memory is not one thing. Rather, it is an overall system composed of two major subsystems. These are called procedural memory and declarative memory. Procedural memory corresponds to unconscious or implicit memory, while declarative memory corresponds to conscious or explicit memory. Dissociation between procedural and declarative memory is one of the most rigorously proven phenomena in cognitive psychology. It means that the normal human mind can store an accurate memory of a real event in procedural memory, while there is complete amnesia for this information in declarative memory. Not only is the memory there in the unconscious mind; it affects behaviour and speech in a measurable fashion’. Finally, in its fourth meaning, dissociation is an intrapsychic defense mechanism (other classical defense mechanisms include projection, acting out, denial, identification with the aggressor, and rationalization, used by all of us to one degree or another in different contexts). The authors go on to explain the adaptive, survival oriented benefits of dissociation through examples. They suggest that ‘dissociation is normal, healthy and built-into (all mammals) through evolution.  It is not a deficit or a disability, if used in a flexible, healthy fashion’. The claim that dissociation is simply a matter of degree and it can become maladaptive ‘if it is overused or used in the wrong context’. Ross and Halpern write that therapy is necessary only when dissociative symptoms interfere with one’s healthy functioning, life and safety and that ‘the goal of treatment is not to eliminate the person’s skill at dissociation but to help the individual learn more fluid, flexible, adaptive, coping  survival strategies’. Furthermore, the book includes a brief, clear history of dissociation and references to the different categories of dissociative disorders in the diagnostic statistic manuals (from 1980 when dissociative disorders first appeared up until DSM-IV (not DSM-V). It defines Dissociative Identity Disorder (DID) as ‘a set of behaviours and a psychological structure, designed to help the person cope with life’, which ‘has been full of abuse, trauma, neglect, misfortune and misery’ and refers to common misconceptions about it, briefly discusses diagnosis and diagnostic criteria and distinguishes criteria from theories of etiology. Like many others authors, clinicians and therapists Ross and Halpern believe that PTSD, Acute Stress Disorder, DID and DDNOS belong to the same section of the DSM (for instance, 80% of people diagnosed with DID meet criteria for PTSD). ((Since the 1990s Judith Herman (1992) proposed that her new definition of Complex PTSD would include somatization disorder (reclassified in DSM-V as somatic symptoms disorder), BPD and DID)). There is also a part in the book that covers epidemiology of dissociation based on studies conducted on the general population in Canada, the US, China and Turkey; studies of clinical populations in seven countries and findings concerning dissociative disorders in chemical dependency populations. Screening and diagnostic tools are also discussed and tools like the Dissociative Experience Scale (DES), which focuses more on the cognitive aspects of dissociation or the Somatoform Dissociative Questionnaire (SDQ), which addresses the somatic aspects of dissociation, (can be copied without permission and used without training) are also included in the appendices with instructions on how to use and score them. The Dissociative Disorders Interview Schedule (DDIS) and the Multidimensional Inventory of Dissociation (MID), a computer scored self- report measure, are also presented and included in the Appendix. SCID-D (Marlene Steinberg, 1995) is also briefly discussed although not included since it cannot be copied or used without permission (training).

There is a chapter dedicated to Borderline Personality Disorder (BPD) and the relationship and similarities between BPD and dissociative disorders. Ross and Halpern write ‘the basic epidemiological facts tell us that DID / DDNOS and borderline personality disorder are not neat, distinct categories’. Similarly to DID, people with BPD have also experiences of childhood abuse, neglect, violence, family chaos, and loss of primary caretakers and about two thirds have a dissociative disorder. Also, about two thirds of people with DID have borderline personality disorder and DID and BPD have similar patterns of extensive comorbidity on Axis I and II in the DSM. In terms of treatment Colin and Halpern view BPD as an adaptation to trauma and believe that in terms of actually doing the work of therapy, ‘borderline personality’ can be worked with in the same way as any dissociative disorder. Moreover, they claim that everyone displays some borderline characteristics, especially when stressed out, and believe that borderline traits are again a matter of degree, not something one has or does not have, and therefore, it should be viewed on a continuum. Additionally, the authors’ more integrated view of treating Obsessive Compulsive Disorder (OCD), is much more effective and can accelerate recovery, because treating OCD with antidepressants or CBT alone may wall off the obsessions and compulsions for a certain time, but they are not gone; therefore, ‘the underlying conflicts should be resolved; the disavowed impulses, thoughts, and feelings acknowledged and owned; and the psyche integrated’. The authors write (and I totally agree) that in standard OCD literature, one never asks about the location or source of the intrusions. However, ‘viewing OCD as originating in a disowned, disavowed, disconnected—that is, a dissociated—part of the psyche facilitates effective treatment’.  Ross and Halpern claim ‘there cannot be intrusion without structural dissociation. This is generally true, whether the intrusions are compulsions like in OCD, flashbacks in PTSD, or similar phenomena in DID’. They continue ‘the inverse of intrusion is withdrawal’ which ‘corresponds to numbing in PTSD, symptoms such as thought withdrawal, hallucinations, conversion symptoms such as motor paralysis in DID, and so on. In this class of symptoms, affect, memory, information, motor function, identity, or other psychic components are withdrawn from the executive self by an active psychological process. ‘The symptoms are not simply absent; they have been withdrawn, are stored elsewhere, and can be recovered’.

As stated a great part of the book is about therapy and treatment and some chapters could well serve the purpose of psychoeducation or assigned readings for survivors or people in therapy. Therapy is not viewed as a linear process, but as ‘a progression through the levels of a spiral, with each new level bringing the client back to the same issue but at a different place’. Validation and normalization are fundamental to the Trauma Model (Ross, 2007) and the person is assumed to be exhibiting ‘a normal reaction to the trauma, abuse, neglect, and tragedy to which he has been exposed’. Therefore, within this model the therapist works on normalizing and validating defenses; reframing defenses in different ways, including psychoeducation; modeling flexible thinking; pointing out the dysfunctional aspects of defenses; examining the cost-benefit of various defenses in their current forms or in the present; and working on recovering from unhealthy or inflexible defenses. Resistance is explored as a survival defense which can become inflexible and rigid. Short dialogues are provided to demonstrate brief psychoeducation on defenses, such as, denial and dissociation. The following is an example of normalizing defenses from the book: ‘the whole purpose of DID is to have resistance. Creating parts was your mind’s way of pushing all the terror, grief, and guilt away, so you could function and survive. If you hadn’t resisted, what would have happened?’ The authors adopt a more holistic approach and believe that ‘therapy is about learning how to deal with what is being defended against, not about the defenses as such. They write ‘the mental health field is currently structured according to supposedly separate categories of defense— substance abuse, eating disorders, personality disorders, etc.—each category with its set of journals, section of the DSM, experts, conferences, and therapy methods’. According to the Trauma Model (Ross, 2007), ‘the distinctions between these categories are mostly artificial and of limited relevance to the goals, tasks, and strategies of therapy’. Moreover, the need to take into account the survivor’s attachment to the perpetrator and the need to resolve the conflict of this attachment is highlighted and is considered a core aspect of therapy because these early destructive patterns of relating and the defenses employed, which served survival initially, set the stage for future patterns of relating both with the self and others As part of this treatment model it is suggested that attachment styles should be explored in order to help clients deal with blaming the self and accepting disavowed feelings. There is also reference to pervasive cognitive distortions (e.g. I am unworthy; I deserved it, etc) among survivors of childhood abuse, which they explain ‘compensates for feelings of powerlessness and loss of control and also facilitates avoidance of overwhelming feelings of pain, grief and anger’. Consistent to those of the trauma field the authors here also suggest 3 stages of recovery that are not linear but overlap (they use the terms initial, middle and late stage). The part in the book on the rationale for orienting parts to the body and the present during the early stages of therapy is very helpful because by orienting the terror-alert parts of the self to the body and the present, and helping them understand that they are much safer now, they de-escalate automatically, hyperarousal drops. This is also important anytime there is programming or programmed parts, because self parts are probably not oriented to the body and the present. Treatment potential goals are discussed and distinguished into universal goals and tasks. They clarify that for them ‘memory work’ is not a treatment goal because remembering the trauma is not an end in and of itself. The task is to construct a coherent life narrative that has meaning, order and purpose, ‘a middle path of intense recollection that leads to healing’. Boundaries within the therapeutic relationship are also discussed quite extensively and other issues like therapeutic neutrality are also explored. Boundaries are discussed in relation to dissociation because due to the fact that the structure of dissociation is internal separateness and dividedness maintained by amnesic barriers people with DID have many issues with trust, boundaries and safety. This internal disconnection and conflicts are mirrored in external relationships. Furthermore, the Victim-Rescuer-Perpetrator triangle, the dynamic that operates within the person’s internal world, external relationships and within the therapeutic relationship is discussed because according to the authors identifying these dynamics operating in one’s external world facilitates understanding relationship dynamics and identifying and addressing the internal V-R-P dynamic, which in turn is the key to deep and lasting change in one’s relationship to self and others.

Within this systemic therapeutic model, symptoms, addictions, thoughts, and behaviours all have a function, a meaning, and a context and they are part of one’s life story, which is situated into a particular socio-cultural context. The function of symptoms, addictions, thoughts, and behaviours is emotional regulation and coping. Coping behaviours can range from bulimia and anorexia, to drug use or abuse, to dissociation and amnesia and can include depression, auditory hallucinations, compulsions, anxiety and everything else encountered in treatment. Within this systemic therapeutic model all symptoms, addictions, unhealthy behaviours, and diagnoses are treated as avoidance strategies, and therefore, a broad addictions model is applied to everything. They view ‘the so-called “addict” as a traumatized person who was never taught or modeled healthy coping strategies, and who has much more conflict and painful feelings to deal with than the average person. The addiction is driven not by a core biological defect in the individual, but by a mixture of too few healthy coping strategies and too much pain’. This model of addictions is taught to the client as part of the work.

Self-injury and suicidality are also discussed in terms of their source and purpose and in relation to contracting and self-assessing self injurious behaviour, Moreover, the importance of internal communication between parts of the system, concerning the function and the impact of self-injury, is explored because success in this task provides an empowering experience of containment and managing crisis situations. Suggestions for functional alternative behaviours, like drawing or writing about the pain; using relaxation or distancing techniques; exercising; expressing anger in safe ways; dialoguing about the conflict, etc, are suggested as ways of creating emotional space so that the client can work through unresolved conflicts and issues. Actually, the authors claim that dialoguing between parts of the self is ‘one of the cornerstones of trauma therapy’ because communication and support among parts of the self is central to integrating traumas, and therefore, dissociated parts of the psyche. Integration is viewed as ‘a by-product of healing’ and Colin and Halpern consider that the ‘sharing of knowledge, experiences, feelings, and skills among parts of the internal system strengthens the whole person; develops resilience and the capacity to manage and express the broad spectrum of human emotions’. This model of treatment acknowledges, like most people in the field, that one of the most challenging aspects of trauma therapy is safely connecting with, processing, and expressing feelings while bearing in mind that many survivors ‘may never have experienced a sense of safety, either within themselves or with others’. The need to work with feelings is inherently linked with trauma memory work, for ‘memories will surface when feelings are approached and feelings will surface when memories are approached’. Systematic desensitization of unresolved overwhelming feelings and conflicts is used within this trauma therapeutic approach, not flooding but desensitization in small steps for as long as it takes, keeping a focus on containment and pacing, stabilization and daily functioning, because ‘developing tolerance to intense feelings is a skill and capacity requiring time, patience, and courage’ (Ross & Halpern).  Desensitization involves both affect management (emotional regulation) and skills building. Strategies and techniques of pacing, containment, affect management, grounding, and skills building, for working with feelings are included in the book. The authors write that ‘the power of the experiential therapies is that the avoided feelings—grief, rage, fear, emptiness—are mobilized and felt, intensely’; however, once the feelings are activated the person needs to be able to ‘back out of them, de-escalate and re-stabilize’, which in turn results in further desensitization. Additional techniques for desensitization, such as, developing internal safe places, focusing on adaptation in the present, various experiential approaches, etc, are also included in various chapters. In addition, the book discusses the various difficult feelings survivors will need to face and process like negative shame (vs positive shame) that does not belong to them but their perpetrators, grief, fear, pain, anger, rage, hate, loss.etc. For instance, they discuss the need to normalize and de-pathologise anger, and also the need to understand the differences between anger, violence, assertion, and aggression. They write ‘a vital part of trauma therapy is tapping into the healing and restorative power of anger. Anger is rocket fuel for life. Anger is energy. Mobilized and channeled in a healthy fashion, anger fosters assertiveness. It improves posture and muscle tone and it has a powerful antidepressant effect. Getting in touch with, learning to tolerate, and then learning to use one’s anger is a major component of healing and recovery. This involves working with anger at cognitive, physical, emotional, and spiritual or philosophical levels’.

According to the authors, this trauma treatment model is an integration of psychoeducation, cognitive-behavioural, systems, emotional processing, and experiential work and is influenced by psychodynamic principles, as well. They state that experiential therapies and emotional processing, which are structured procedures and tasks designed to desensitize a person to phobically avoided feelings and conflicts, are at the core of Trauma Model Therapy; however, exposure is combined with cognitive processing and restructuring because ‘the cerebral cortex and the limbic system have to be on the dance floor at the same time. Multiple parts of the brain have to talk to each other—the amygdala talks to the prefrontal cortex, the hippocampus talks to the temporal-parietal cortex, the visual cortex talks to the anterior cingulate, and the reticular activating system needs to be on for therapy to work. Parts of the mind and parts of the brain need to learn new patterns of communication, information sharing, and problem-solving. The problems to be solved are simultaneously emotional, intellectual, social, cultural, and biological in nature. The work of integration involves parts of the brain learning how to talk to each other’. In terms of therapeutic approaches the book also presents several creative approaches like art therapy work (structured art activities are described); music therapy (for relaxation or de-escalation from more intense therapy work, or the use of inspirational recovery songs, etc); ROPES courses are also suggested because they ‘can be very useful in the treatment of DID and other dissociative disorders). Moreover, this treatment model focuses on all three dimensions of time: past, present, and future since ‘much of the motivation for recovery comes from the hope of imagining and then building a better future’. However, stabilization and safety in the present allows one to deal with the past and then dealing with the past frees one to move on. As the authors write ‘in order to live better in the present, one must deal with the past; on the other hand, in order to face the past, one must focus on improving life in the present’. Improving one’s current circumstances, increasing one’s safety in the ‘here and now’ and experiences of success and mastery can provide an antidote to hopelessness, which in turn facilitates or/ and accelerates recovery and healing. In addition, the book contains a separate chapter on long-term consequences of sexual abuse, particularly on the impact of abuse on sexuality and sex. They believe that ‘the survivor of sexual abuse is dealt a more complex hand to play in what is already a complex aspect of the human condition’. Their discussion on flashbacks here increases clarity and is useful both to therapists and survivors working with these issues. Another important area explored in the book is spirituality in the context of cultural and socio-economic factors, gender, sexuality and trauma dynamics. The authors’ treatment model focuses on ‘assisting clients to reconcile spiritual conflicts and philosophical constructs and to draw on their spirituality as a profound resource in healing and well-being’. Spirituality is defined as a search for meaning and connection with something greater or other than the self and may or may not involve an organized religion. They recognise that survivors struggle with concepts of good and evil, the role of God or the universe and search for meaning, and also that this process is inherent in healing from trauma. Practical guidance applicable to both religious and secular ideologies are presented to assist therapists to enter into a spiritual dialogue with clients, to explore how trauma impacts spirituality, and also the role of spirituality in healing. An approach that embraces  all religions and belief systems, and does not condone harm towards others or self, is adopted, and clients’ search for meaning making of their experience is viewed within their socio-political-cultural-racial and ethnic context, and the interaction of factors like gender, sexuality, age and type of trauma are also taken into consideration. Spirituality further needs to be addressed if someone has been victimized in religious contexts or criminal contexts where ritual abuse has taken place. Colin and Halpern write that abuse committed by spiritual leaders inevitably adds an additional layer to the trauma experience and it is easy to understand that an interpersonal trauma, which involves issues of betrayal and failed humanity further impact one’s experience and may be experienced differently at a spiritual level than impersonal trauma, like an accident or a natural disaster. They further mention that especially survivors reporting ritual abuse or those who have been abused within religious or organised crime contexts, who have been terrorized, subjected to various forms of mind manipulation resulting in distorted perceptions and tricked into believing certain events have occurred, may need a very long time to sift through the layers and levels of their experience before coming to a place of deeper understanding. The book includes spirituality exercises designed to facilitate the exploration of spirituality, the impact trauma has had on an individual’s spirituality and the role spirituality plays in the healing process, which can be done in therapy sessions or as homework assignments.

Finally, the authors also provide an interesting discussion on medication, polypharmacy and the limitations of psychiatric medication. Halpern and Ross discuss the lack of facts and scientific evidence concerning the chemical imbalance theory of mental disorders. They claim that ‘actually, there are numerous studies that show there is no consistent chemical imbalance of any kind in mental illnesses’.  Chapter 36 briefly covers inpatient treatment based on acuity criteria and clients’ inability to maintain basic safety and function, and structured group therapy on a Ross Institute Trauma Program (Colin Ross has been treating dissociative disorders on an inpatient basis since 1979, and in a dedicated specialty program since 1991). Life after trauma and challenges encountered, which may range from developing healthier and safer relationships, to creating financial security and developing new skills and interests, is discussed at the end of the book, along with therapists’ need to take care of the self and deal with vicarious traumatization, which often occurs when exposed to trauma survivors’ histories. ‘Research by Laurie Anne Pearlman and others, has identified that therapists with a history of trauma not only experience vicarious traumatization as a consequence of exposure to their clients’ material, but they may also experience a reactivation of their own stories. This additional risk factor increases the potential for counter-transference reactions going unchecked and of the therapist stepping onto the Victim–Rescuer–Perpetrator triangle’ (cited in Ross & Halpern, 2011).

(Tonya Kyriazis-Alexandri – June, 2014)