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ADVANCES IN UNDERSTANDING T R AU M A A N D D I S S O C I AT I O N :
PERSONAL LIFE, SOCIAL PROCESS, AND PUBLIC HEALTH

ConferenCe SChedule
MONDAY, NOVEMBER 17
6:45 am - 8:00 am ddPtP Meeting
Wolf Point Pre-Function

7:00 am - 8:15 am iSStd Committee Meetings


Any available room

7:30 am - 5:30 pm Conference registration and information desk open 9:00 am - 5:30 pm exhibits, Survivor's art exhibit and Bookstore open
LaSalle on the 15th Floor and 14th Floor Lobby

8:30 am - 10:00 am
PAPer SeSSion 11

manifested by Vietnamese veterans were extremely different than those manifested by U.S. veterans of the same war. In 2005, I was part of a 4 month global investigation project that went into 10 developing countries. My primary purpose was to observe and analyze specific social responses of individuals with varying degrees of HIV/AIDS and trauma. Remarkable differences in behaviors and responses to similar traumas were identified, and these will be shared in this presentation. These variances appeared to be a result of community values, ideals and beliefs. This presentation offers the opportunity for an interchange of ideas regarding the specific clinical findings of the probability that people react to trauma and dissociation differently, depending on their unique experiences and to the cultural values of their specific communities. did in a refugee Population: implications for the Possibility of late onset dissociative disorders Anna Gerge, MSc Findings in a refugee population who were referred to a special unit for trauma treatment for Complex PTSD (severe psychosomatic conditions and PTSD) indicate the possibility of severe dissociative disorders arising after traumatization later in life than previously assumed. Our findings suggests that the onset of traumatization leading to the diagnosis of DID might be as late as late latency or adolescence. In females who had suffered war trauma before age 20, DES and SDQ 5 were administered at start of treatment. Trauma history for each individual was taken, and included home abuse for some. Mean scores were: DES= 43.5, n=46, DES-T=40.5, n=47, SDQ 5=13,1 n=38. Through single case presentations it will be demonstrated that various trauma-related disorders occur in this particular population. DID appears to develop later than previously

assumed in this extremely traumatized population. The patients with DID presented in the study were diagnosed with the SCID-D. Based on the individuals integrative capacity as indicated by age, maturation of CNS, and severity as well as type of trauma at onset, a preliminary theoretical framework on how to conceptualize DID as occurring after the age of 8 will be described. Threats to the integrative capacity of the individual from abuse might be worse during wartime and during stressful living conditions in a society in havoc. Abusive incidents in themselves will be harmful for a growing individual, compounded by the impact of the wartime events and conditions on parents and other caretaking functions of society. Implications for treatment of this population with its resources and obstacles, will be discussed. understanding ritual trauma: a Comparison of findings from three online Surveys Wanda Karriker, PhD In 1989, Richard Kluft, MD addressed the polarization in the dissociative disorders field over the subject of ritual abuse. Even though he appreciated the ethical and practical impossibilities of such research, he recommended serious study of the phenomenon. The ethical issues in trauma research were studied by Cromer, Freyd, et al. (2006) who concluded that anonymous surveys of trauma survivors (either paper and pencil or online) can be classified as minimal risk. With the advent of the Internet, the practical impossibilities of conducting research with ritual abuse survivors and their caregivers have been overcome. In 2007, more than 2,000 persons representing at least 40 countries and 31 primary languages participated in three jonline surveys developed by ISSTD members Thorsten Becker and Bettina Overkamp (Germany), and Wanda Karriker (US), and by researcher and survivor advocate, Carol Rutz (US).

MONDAY NOVEMBER17

Social, Cultural, and religious factors in dissociation


Lake House

Elizabeth Bowman, MD, Chair understanding differences in expressions of traumatization and dissociation Based on Community Values, ideals and Beliefs Craig Abrahamson, PhD This presentation examines the possibility that people who suffer from trauma and dissociation react and cope in accordance to the values of their community. Through over 30 years of providing clinical services to trauma victims of similar experiences within different global communities, I have concluded through anecdotal observations that victims of similar traumas manifest different behaviors and symptoms. In 1991, I participated in a research project in which 50 Vietnamese combat veterans were interviewed through an interpreter. We found that the PTSD symptoms

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serve as points of entry for clinical intervention in survivors of both direct and indirect psychological abuse.
PAPer SeSSion 12

ANNIVERSARY
A N N UA L C O N F E R E N C E

ISSTD

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Offered in English and German, the first survey was for adult survivors of extreme abuse including, but not limited to, ritual abuse and mind control. The second survey was for professionals who work with adult survivors; and the third survey was for caregivers of child survivors of ritual abuse and mind control. This presenter will discuss findings from these surveys that help advance our understanding of extreme trauma. attachment as a Mediator between abuse in Childhhod and later Psychopathology Kristin Gragtmans; Robert Muller, PhD This study examined the mediating role of attachment in the relationship between both psychological abuse and witnessing psychological abuse in childhood, and later psychopathology. Young adults completed a series of questionnaires inquiring about past abuse experiences and current levels of attachment and psychopathology. Attachment was measured in terms of model of self and model of other, as measured by the Relationship Questionnaire and the Relationship Scales Questionnaire. Maltreatment was measured using the Record of Maltreatment Experiences. Results indicated a robust mediational effect. Namely, attachment fully mediated the relationship between both direct and indirect experiences of childhood psychological abuse and psychopathology. The mediation occurred across all three measures of psychopathology; that is, total PTSD symptomatology as measured by the Trauma Symptom Checklist-40 and externalizing and internalizing behaviors as measured by the Young Adult Self-Report. Identification of mediators leading to psychopathology helps to clarify the mechanisms by which the effects of maltreatment are carried from childhood to adulthood, and how they may influence a person later in life. These results suggest that attachment models of self and other may

and morbidity of the depersonalization syndrome initiated by substance use, as well as the uniform phenotype of the syndrome regardless of antecedent. an update on Suicidality and dissociation Brad Foote, MD; Scot McNary, PhD; Jane Park, BA; Noam Fast, MD; Karie Nguyen, MD Historically, systematic data on the association between dissociative disorders and suicidality and self-harm has been sparse. In 2008, Foote et al reported that in a population of psychiatric outpatients, a dissociative disorder diagnosis was the strongest predictor of repeated suicide attempts. Currently, we are engaged in research to replicate and expand on these findings, including an attempt to identify psychological, historical, and diagnostic variables which may mediate this relationship. The relevant literature is summarized, and interim research results are reported. the dissociative Brain: feature or ruled by fantasy? Simone Reinders, PhD Despite the recognition of dissociative identity disorder (DID) in the DSM IV, there is no general agreement about the origin and biological foundations. The traumagenic view states that DID constitutes a severe form of post-traumatic stress disorder while the iatrogenic view asserts that DID originates from suggestion or role-playing, facilitated by a high level of fantasy proneness. A brain imaging study was performed applying a symptom provocation paradigm in a three (DID patients, high and low fantasy prone (FP) DID-simulating controls)-bytwo (ANP/EP)-by-two (neutral/traumarelated memory script) factorial design. Three psycho-biological parameters were tested: subjective ratings, cardiovascular responses (reported in another contribu-

research
Sauganash east

Paul Dell, PhD, Chair is depersonalization disorder initiated by drug use any different? a Survey of 394 adults Daphne Simeon, MD; David Kozin, BA; Karina Segal, BSc; Brenna Lerch, BA Previous studies have documented that in a substantial minority of individuals with depersonalization disorder, onset is first triggered by drug ingestion. The goal of this study was to systematically compare a large sample of drug (D) versus non-drug (ND) initiated chronic depersonalization. We conducted an internet survey of 394 adults endorsing depersonalization and / or derealization as defined in the DSM-IV-TR. Sixty-four questions inquired about demographic and clinical characteristics, illness course, substance use histories, and treatment response. The Cambridge Depersonalization Scale (CDS) was administered. Compared to ND group (N = 198), the D group (N = 196) comprised of more male and younger individuals. The two most common precipitating drugs were cannabis and hallucinogens, followed by ecstasy, then ketamine. Comparison of the D and ND groups revealed similar illness course, impairment, suicidality, and limited treatment efficacy. The D group showed greater spontaneous improvement over time, statistically significant but not clinically robust. The groups did not differ in total CDS score or on the four subscale scores of unreality of self, perceptual alterations, unreality of surroundings, and temporal disintegration. Numbing was greater in the ND group only prior to controlling for age and gender. The study documents the chronicity

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ADVANCES IN UNDERSTANDING T R AU M A A N D D I S S O C I AT I O N :
PERSONAL LIFE, SOCIAL PROCESS, AND PUBLIC HEALTH

ConferenCe SChedule
tion), and regional cerebral blood flow (rCBF) as measured with positron emission tomography. Genuine and simulated identity states showed significant different rCBF patterns between DID patients and the FPhigh/FPlow DID-simulating controls, as did the processing of the trauma-related text. Conjunction analysis did not show any overlap in brain activation between DID patients and the FPhigh/FPlow group. Directly compared with patients, neither high nor low FP DID-simulating controls are able to (fully) mimic dissociative identity states that are observed in DID patients. More specifically, our results do not support an iatrogenic origin of DID. evaluating dissociation and Posttrauma by Means of the rorschach test Gadi Maoz, PhD Notwithstanding the practical and theoretical importance of diagnosing dissociative states, there is still a lack of direct psychological diagnostic tools for the assessment of dissociation.The described research attempted to define parameters based on Rorschach responses for identifying dissociative conditions among post-traumatic patients. The research analyzed and compared the Rorschach test protocols of 187 subjects who underwent psychodiagnostic and psychiatric evaluation after past exposure to traumatic events, at an evaluation center. The subjects were divided into two groups: those with post-traumatic disorders (PTSD) and those with other mental disorders (Non PTSD). The findings of previous studies on the assessment of trauma and dissociation were used for a elaborating a series of parameters Dissociation (DIS%); Reintegration attempts (INT%); and Trauma (TRA%) based on the narrative responses to the Rorschach ink blots indicating dissociative and posttraumatic conditions. The 187 protocols of Rorschach tests were analyzed by researchers, unaware of which group ('with PTSD'

or 'Non PTSD') the patients belonged to. The comparison between the narrative responses of the two groups showed that the above three parameters, enabled to distinguish between them. The researchers conclude that the judicious use of these parameters, or combinations thereof, may prove helpful in the diagnosis and treatment of trauma and dissociation.
SymPoSium 10

attachment, Mentalization and the role of reflective function: Working with Complex Structural dissociation Michael Dadson, MA; Marion Fallding, MA; Becky Stewart, MA This case presentation will include an overview of the application of attachment theory, mentalization and reflective functioning from the perspective of the primary therapist. These therapeutic models have guided treatment and presenters will discuss how these apply to clinical practice in this specific case (Allen, Fonagy & Bateman, 2008). Working in partnership with a government mental heath agency, psychiatric services, and private practice therapists, the care team has used an attachment-based approach with a focus on providing a secure base from which to build mentalization and the reflective function. This is designed to build an awareness of alter personalities followed by an integration of alters. For example, while the various facets of mentalization have been applied to clinical treatment of individuals with Axis II diagnoses (Bateman & Fonagy, 2004), there is little written or available in terms of how to incorporate mentalization in therapy with clients who present with DID. the Successes, Struggles and Surprises that emerge when applying theory and therapeutic interventions to a Complex did Case Study Becky Stewart, MA; Michael Dadson, MA; Marion Fallding, MA This presentation will elucidate how a treatment team (mental health case manager, primary therapist and support worker) have applied theoretical and clinical techniques, and how these applications have unfolded in the course of treatment. Specific examples of intervention strategies and their application to this case will

MONDAY NOVEMBER17

the application of attachment theory, Mentalization and reflective function in Complex Structural dissociation: a Case Study
Bulls Head

Becky Stewart, MA, Chair


SkiLL LeveL: intermediAte

The purpose of the symposium is to present a complex case study of therapeutic approaches with a woman who has been diagnosed with dissociative identity disorder (DID) and has a history of extreme emotional deprivation and sexual abuse combined with physical and sexual torture throughout her early childhood development. Profound developmental trauma: a Case history Marion Fallding, MA; Michael Dadson, MA; Becky Stewart, MA This presentation explores the presenting problems and relevant history of a woman with a severe trauma history, including commentary around the profound impact of both neglect and abuse and their relation to structural dissociation. This middle aged woman was adopted at 9 months of age by a spiritually, emotionally and physically abusive family who left her vulnerable to various sexual perpetrators starting at the age of 3. As part of the care team, her mental health case manager will outline the current presenting problems, relevant history, therapeutic goals and current life situation.

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mentalizing ability, and a clinical map of directed mindfulness that orients attention and enhances reflective functioning. 8:30 am - 12:00 pm
invited HALF dAy WorkSHoP 14 HALF dAy WorkSHoP 15

ANNIVERSARY
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be discussed. These include strategies in working with child alters, perpetrator/ protector introjects and increasing stability and co-consciousness within the system as a whole. Finally, the care team will invite the audience to add their perspectives to this challenging but rewarding study of human resiliency.
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When Caring hurts: Medical trauma and dissociation in Children


American House

Na'ama Yehuda, MSc; Frances Waters, LCSW; Bradley Stolbach, PhD


SkiLL LeveL: intermediAte

Mentalizing, Mindfulness, and the Body: restoring the felt Sense in traumatized Patients
Sauganash West

ethical issues and dilemmas in treating Complex trauma and dissociative disorders1
Western Stage

Christine Courtois, PhD; Philip Kinsler, PhD


SkiLL LeveL: ALL
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Pat Ogden, PhD; Clare Pain, MD


SkiLL LeveL: intermediAte

3 CE Ethics Credits are available

Mentalizingthe process by which we make sense of the contents of our own mind and that of othersis problematic for patients with trauma-related disorders. Requiring an optimal level of arousal as well as a nurturing and safe attachment relationship to develop, mentalizing is conspicuously impaired and even frightening for patients who have suffered attachment trauma. Such patients typically experience a variety of symptoms that cannot be understood, with susceptibility to dysregulated arousal stemming from often unrecognized internal and environmental triggers that remind them of past trauma, and distressing, inaccurate inferences about other peoples intentions, emotions, and actions. They often find it difficult to predict the emotions and behavior of others as well as their own. The process of mentalizing often occurs automatically, without thought or deliberation, and is influenced by many factors, including the posture, sensation, and movement of the body. This workshop will define mentalizing, describe the difference between explicit and implicit mentalizing, and explore how to address failures in mentalizing in traumatized populations. The presenters will explore the bodys role in mentalizing, and demonstrate non-verbal, somatic interventions useful in improving patients

Professional ethics have as their concern the welfare of the client/patient. Many complex ethical issues and dilemmas arise in the treatment individuals who have suffered complex trauma and have resultant posttraumatic and dissociative disorders in addition to other Axis I, II, & III co-morbidities. The primary principle of treatment is: First, do no more harm. In this workshop, the presenters will review some of the most common ethical issues and questions and make general recommendations for their management, taking into consideration some of the most current writings on professional ethics. The term ethical dilemmas suggests that there is no one-size-fits-all response and that therapists must use their most mature clinical judgment (along with professional consultation and clinical supervision) in making determinations for different situations. Self-care is an ethical obligation for all psychotherapists, but particularly those who work with the traumatized. Major strategies for self-care will also be reviewed in this workshop.

Painful and frightening medical procedures are necessary for survival. However, they can be overwhelming and traumatic, especially to children. Premature babies experiencing separation and invasive procedures, children with cerebral palsy requiring repeated corrective surgery for malformations, burn and accident victims, pediatric cancer patients; these and others may experience overwhelm and intolerable pain that one is helpless to stop. When one considers how caretakers often take part in medical care or do not stop the pain from happening, dissociation becomes an understandable response to medical trauma. However, it is one that is often minimized in view of the medical necessity and underlying care of those interventions. The complicated issue of medical trauma and dissociative behaviors will be explored through pediatric case studies with varying medical histories and dissociative presentations. Issues of attachment, fear, helplessness, anger, conflict, and confusion in the child, (as well as caregivers) will be discussed. Developmental vulnerability in premature babies and newborns will be considered, as will the perceptions and subjective realities of young children undergoing repeated painful procedures. The reality and possible causes of adult dissociation in reaction to medical trauma will be addressed as well. Suggestions for minimizing initial dissociation and intervention approaches in cases of medical trauma will be shared.

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ADVANCES IN UNDERSTANDING T R AU M A A N D D I S S O C I AT I O N :
PERSONAL LIFE, SOCIAL PROCESS, AND PUBLIC HEALTH

ConferenCe SChedule
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Parent education to Prevent dissociative disorders


edgewater

Alison Miller, PhD


SkiLL LeveL: BASic

Parent education can increase or decrease the probability of dissociative conditions in children. Programs which focus only on behavior management can increase dissociation and lead to further problems, especially if children are traumatized. An effective prevention program focusing on parents must include certain important components: understanding child development and individual differences, focusing on empathy rather than obedience, learning to relinquish control, using natural rather than artificial consequences, promoting attachment and healthy positive communication, and secure boundaries in the family.
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structural developmental repair . Personal Mythology techniques allow individuals to experience deep explorations and transformations of the belief systems of ego states and can bring about profound and permanent changes They also bridge the gap between external history and interior self-perceptions; The profound transformations they produce are utilized to help patients form healing commitments to new belief systems that can accelerate integration. Patients are also helped to create a path for ongoing work with conflicting belief systems. This workshop will consist of lecture, demonstration, and practica.
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MONDAY NOVEMBER17

imitations and/or false-Positive diagnoses of Complex dissociative disorders: Patients at risk, therapists at risk
Steamboat Hotel

Suzette Boon, PhD


SkiLL LeveL: intermediAte

the diagnostic landscape: differential diagnosis of Complex trauma disorders


Wolf Point Ballroom

Bridging two Worlds: the Power that Personal Mythology approaches Bring to ego State therapy
Shakespeare House

Ruth Lanius, MD, PhD; Eric Vermetten, MD; David Spiegel, MD; Bethany Brand, PhD; Richard Cheftez, MD; Richard Kluft, MD; Richard Loewenstein, MD
SkiLL LeveL: intermediAte

Claire Frederick, MD
SkiLL LeveL: intermediAte

ASCH credits available (see page 8 for more information)


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Ego State Therapy has been shown to be helpful with the resolution of complex post-traumatic and dissociative conditions. Developments in this field have helped therapists work successfully with both malevolent and non-verbal ego states, address attachment issues, and help patients repair other cognitive, affective, and object relations developmental deficiencies. Ego State Therapy can be integrated with many other therapeutic modalities. In this workshop Ego State Therapy will be integrated with the social reconstruction therapy, Personal Mythology, for the resolution of trauma, the healing of attachment problems, and

The goal of this workshop is to assist both clinicians and researchers in optimizing their skills in diagnosing patients with complex trauma-related disorders. It has been well established that complex trauma disorders often present with symptoms that mimic or overlap with dissociative disorders, personality disorders, bipolar disorder, psychotic disorders and temporal lobe epilepsy. Clinicians and researchers are therefore often faced with the challenge of making an accurate diagnosis. The present workshop will carefully examine the complexities of complex trauma disorders using case examples. In addition, a variety of assessment tools to help in differential diagnosis will be discussed. Neurobiological studies which may help to elucidate the diagnostic complexity will also be examined where appropriate.

A majority of the patients suffering from complex dissociative disorders (DID and DDNOS) hide or dissimulate dissociative and other posttraumatic symptoms and are at risk for a false negative diagnosis of the disorder. Another group of patients mostly with a personality disorder as their primary diagnosis- are particularly at risk for a false positive dissociative disorder diagnosis. Complex dissociative disorders can be imitated due to contagion, to iatrogenesis, or a combination of both. The core dynamics behind imitative symptom production of complex dissociative disorders seem to be: 1) the avoidance of responsibility (or feelings like shame) for negative behaviors; or 2) the compensation for an overwhelming feeling of being unseen. The main part of this workshop will cover diagnostic issues based on many years of systematic research with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (Boon & Draijer, 1991,1993, Draijer & Boon 1999) and a new diagnostic instrument, the Interview for Dissociative Disorders and Traumarelated Symptoms (IDDTS, Boon, Draijer, & Matthess, 2006). Several groups of patients will be distinguished: 1) patients with genuine DID or DDNOS 2) patients with genuine DID/DDNOS and a coexistent (histrionic) personality disorder; 3) patients with a personality disorder; 4) patients with imitated DID borderline type; 5) patients with imitated DID histrionic type; 6) patients with other Axis I disorders mistakenly diagnosed as having a complex dissociative disorder. Case examples will be presented.

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10:30 am - 12:00 pm
PAPer SeSSion 13

ANNIVERSARY
A N N UA L C O N F E R E N C E

ISSTD
HALF dAy WorkSHoP 20

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Complex trauma and Vexing Medical Complaints Carol Low, PsyD


SkiLL LeveL: BASic

family environment in trauma and dissociation


Sauganash east

Complex trauma represents the combined effects of negative life experiences and trauma, past and present. This includes impaired attachment, abandonment issues in childhood, and overt child abuse superimposed upon by adult trauma such as, but not restricted to, medical trauma; devastating, unnatural loss; and adult physical and sexual abuse. This process leads to progressive dysregulation of emotional and cognitive functions and of autonomic, endocrine and immune systems; essentially a process of dissociation of the mind and body from internal regulatory mechanisms. The result is a variety of psychological disorders and a host of poorly understood medical conditions that reflect disordered neuroregulation and procedural memory. These include chronic fatigue syndrome, various visceral disorders (IBS, GERDS, mitral valve prolapse, interstitial cystitis), tics and movement disorders, chronic pain syndromes (fibromyalgia, CRPS-1), autoimmune disorders, and syndromes of neurosensitization. Understanding such disorders as adaptations to trauma has significant implications for medical and psychological treatment of these medical enigmas, importantly clarifying the essential role of such psychological techniques as hypnosis in their treatment. 10:00 am - 10:30 am refreshment Break

George Rhoades, PhD, Chair family environment, depression, and alexithymia in adult Survivors of Childhood Sexual abuse Yenys Castillo, MS; Jessie Morrow, BA; Matthew Mascitelli, BA; Steven Gold, PhD Alexithymia involves difficulties defining physiological states or emotions with words. Limited research has suggested a relationship between alexithymia, depression, and family environment. We explored whether family environment predicted alexithymia and depression in childhood sexual abuse (CSA) survivors. Participants were 88 adult survivors of CSA receiving psychotherapy in a private South Florida university clinic. They were mostly female (81.8%), with a mean age of 38.72 years (SD = 10.27) and ranging from 21-63 years. The Toronto Alexithymia Scale (TAS-20), the Family Environment Scale (FES), and the Beck Depression Inventory (BDI-II) were administered to all participants. There was a significant relationship between alexithymia and the Family Control dimension of the FES (F [9, 71] = 2.059, p = .045). There was a trend in the relationship between alexithymia and Family Cohesion that approached significance (F [9, 71] = 1.984, p = .054). There was not a significant relationship between family environment and depression. Preliminary findings suggest that for CSA survivors, alexithymia may be related to how much set rules and procedures are used to run family life, and to the degree of commitment, help, and support that family members provide for one another.

Parental Stress as a Mediator between emotion regulation and Posttraumatic Stress Symptomatology in traumaexposed Children Angela Vascotto; Julie Margulis, MA; Robert Muller, PhD This study examined parental stress as a potential mediator between emotion regulation and child posttraumatic stress symptomatology (PTSS). Parental stress was hypothesized to function as a mediator between both subtypes of emotion regulation, (a) lability/negativity (i.e., mood lability, dysregulated negative affect, and inflexibility) and (b) emotion regulation (i.e., difficulties in displays of emotion, self-awareness, and empathy), and PTSS. As PTSS is strongly associated with both internalizing and externalizing problems, both behavior problems were included in the investigation as outcome variables to increase our understanding of the mediational processes between emotion regulation and PTSS. A clinical sample of 52 children (7-12 years old) were obtained from the Healthy Coping Program (Muller, 2008) prior to receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for histories of trauma. Caregivers were administered the Parental Stress Index (PSI), Emotion Regulation Checklist (ERC), Trauma Symptom Checklist for Young Children (TSCYC), and the Child Behavior Checklist (CBCL). Results indicated a partial mediational effect. Namely, increases in parental stress directly impacted the relationship between the emotion regulation subtype and all levels of symptomatology. Parental stress also functioned as a mediator between lability/negativity and externalizing problems. Theoretical and clinical implications are discussed.

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ADVANCES IN UNDERSTANDING T R AU M A A N D D I S S O C I AT I O N :
PERSONAL LIFE, SOCIAL PROCESS, AND PUBLIC HEALTH

ConferenCe SChedule
dissociation and domestic Violence Clients Kevin Connors, MS, MFT This paper seeks to address the question: Are clients presenting in domestic violence treatment programs dissociative? Clients at three domestic violence treatment programs and two private practice settings were given the Dissociative Experiences Scale (DES) (n = 95). Results indicate approximately 33% endorsed scores suggesting dissociative behaviors. When assessed using the DES Taxon scoring protocol, approximately 18% endorsed scores suggesting pathological dissociation. Using the Conflict Tactic Scale (CTS), the Controlling and Abusive Tactics Scale (CAT) and a brief history and background questionnaire, preliminary results indicate DES scores are significantly related to the frequency of engagement in negative relationship behaviors by both partners in violent couples. Interestingly, increases in the victims engaging in dysfunctional and controlling behaviors, as measured by average frequency scores on the CAT, correlated to increased DES scores. These relationships are significant at p<.05. Recognizing that the percentage of domestic violence clients who use dissociation to defend against painful material and that the content and context of DV treatment is highly stressful; this paper suggests therapists and DV staff will be more effective if they learn to recognize and respond to dissociative defenses within their client population.

Memory disturbances due to Childhood abuse: examining Betrayal trauma theory Victoria Lishak, BA; Susan O'Rinn, BA; Catherine Classen, PhD; Robert Muller, PhD This presentation examines Betrayal Trauma Theory (Freyd, 1996) by exploring the relationship between victim-perpetrator relationship and associated feelings of betrayal and memory disturbances (clarity and quality of memory for abuse experiences, changes in memory for abuse experiences and dissociation). We also extend Betrayal Trauma Theory to examine the relationship between feelings of betrayal in relation to the non-abusing caregiver and memory disturbances. A sample of 160 treatment seeking women abused in childhood were given The Child Maltreatment Interview Schedule (Briere, 1992; adapted), the Dissociative Experiences Scale (Bernstein & Putnam, 1986), and an adapted Memory Questionnaire (Butler, 2000; unpublished) to assess betrayal and memory disturbances. We found those abused by a parent felt more betrayed at the time of the abuse and had more changes in memory than those abused by an other. Further, feelings of betrayal were positively correlated with dissociation. Similar relationships were found when examining current feelings of betrayal by the non-abusing parent. Contrary to our hypothesis, feelings of betrayal were positively correlated with clarity of memory. We argue that these contradictory findings can be explained by the design of this study, rather than challenging Betrayal Trauma Theory. These results provide partial support for Betrayal Trauma Theory.

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MONDAY NOVEMBER17

existential issues in trauma and dissociation


Bulls Head

Joanne Twombly, LCSW, Chair trauma is not enough Oliver French, MD Several studies have suggested that dissociative disorder is the result of psychological factors such as disrupted attachment, rather than trauma. This presentation will focus on five psychological factors that seem to be omnipresent in the history of children and adults suffering from dissociative disorders even when no trauma can be demonstrated. These factors are: confusion, disrupted attachment, isolation, pain and fear of death. Each of these factors will be discussed in detail. They relate to a childs perception of, and reaction to, a dysfunctional environment, rather than any actual trauma. This model of dissociative disorder is different from a trauma model or a sociocognitive model. Narrow definitions of trauma used to link trauma to dissociative disorders are likely to fail. Consequently dissociative disorder must be viewed and taught as a condition distinct from PTSD, though the two conditions often coexist. Other consequences of this shift in focus will be discussed. E22 "Where Were You God?:" how trauma Survivors Gain (or regain) their Spiritual/religious faith Sharon Phelps, PhD Chronic trauma significantly impacts the spiritual/religious development of sexual abuse survivors. These patients often ask, "Where was God when I was abused?" and "If I can't trust those who were supposed to protect me, how can I trust God?" Issues of shame and guilt, resulting from sexual abuse, frequently lead survivors to feel undeserving of God's love. If a therapist provides a safe, non-judgmental set-

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the dissociated State Known as ecstasy Sharon Farber, PhD There is a hunger today for ecstatic experience, yet little attention has been paid to understanding the altered state of consciousness known as ecstasy. A theory of ecstasy as a dissociated state will be formulated. Ecstasy is about radically altering ones consciousness. Ecstatic experience that arises spontaneously can be about the life force, or when it is actively sought is often about excess, frenzy, and violence, even death. Todays ecstasy seekers push to and beyond their physical and mental limits, to the darkest side of human experience, crossing the borders between health and illness, life and death, with little regard to what is on the other side. Many in the throes of ecstasy have remained there, to live in chronic severe dissociated or psychotic states. Although the ways of attaining ecstasy may differ-religion, sex, self-mutilation, the most violent bulimic purging, drugs, music, even epilepsy, the essential experience is the same. In ecstatic frenzies, human beings have committed the most inhuman of acts, including war, the Holocaust, terrorism, rape, murder, cannibalism, and suicide bombings. This presentation will explore just what ecstasy is, how and why so many are looking for it, the subjective experience of ecstasy, and the relationship of severe trauma to the quest for ecstasy.
SymPoSium 11

ANNIVERSARY
A N N UA L C O N F E R E N C E

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ting, survivors are often eager to discuss and process how their abuse histories affected their spiritual/religious views. This paper uses case examples to illustrate how trauma survivors may gain or regain their spiritual connections and successfully develop their religious faith. orts, Scraps and fragments: an anatomy of Virginia Woolfs Suicide Theresa Albini, LCSW Self-injury and suicidal ideations are ubiquitous among DID patients, and studies report 1 - 2.1% of DID patients completed suicide. Yet few case reports examine the dynamics leading to this fatal act. Virginia Woolf, a literary genius, drowned herself at age 59. Her suicide letters clearly stated that she felt certain she was going mad againIt was just as it was the first timeand that she feared she had gone too farto come back again. Although veiled in diverse fiction, her semiautobiographical novels parallel her developmental preoccupations. Woolfs so-called experimental method seemed to have been spawned from an incessant desire to capture the essence of her dissociative mind and discover the riddle of her subjective reality. Throughout her life she wrote to maintain a sense of cohesiveness and order. But there were other times, especially upon completion or proofing of her novels, when she was suicidal. This paper provides a hypothesized psychological dissection of Woolfs suicide. Innumerable disentangled threads will be pulled from her last years letters, memoir, diary and posthumously published fiction to highlight the salient factors leading to her suicide.

highlight their conceptual perspectives on the processes underlying dissociation. Their brief presentations provide a context for the subsequent discussion among attendees and presenters. dissociation Viewed from an evolutionary-developmental Perspective Kenneth Beattie, PhD Basing their conceptualizations on both developmental and evolutionary perspectives, Putnam (1997), Schore (2003), and Liotti (2006) have made significant theoretical contributions to our understanding of dissociation while proponents of the attachment theory perspective in particular (see reviews by Kraemer et al, 2005; Harari, et al 2007) have drawn on work from many fields in psychology to focus attention on the influences of early interpersonal and traumatic experiences on developing affect-regulation capacities and later cognitive, social bonding, and attachment patterns. While the aforementioned shed light on dissociation seen through the lens of psychopathology, it can be argued that other concepts and models drawn from an evolutionarydevelopmental perspective (e.g., Werner, 1957; Piaget 1970; Porges, 2006) can help us place dissociation in the broader context of adaptive phylogenetic and ontogenetic development. Those concepts/models include: Piagetian views of self-regulating systems; Werners orthogenetic principle predicting forms of structural development; and Porges polyvagal theory and neuroperception characterizing reciprocal inhibition and enervation of systems at different levels within a hierarchic structure. The Mushroom Theory (Beattie, 2007) extends this evolutionary- developmental perspective to clearly differentiate between mundane and trauma-induced dissociation and relate them to the dynamics of transactions between organism and environment structural characteristics.

Placing dissociation in the Mainstream of Current Psychological thinking


Sauganash West

Kenneth Beattie, PhD, Chair


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What is Dissociation? This theoryfocused symposium involves neither content with accepted definitions nor symptom descriptions of dissociation, but instead invites presenters from four different domains within psychology to

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normative dissociative Processes Lisa Butler, PhD Most dissociation research has focused on pathological dissociative states and assumed that dissociation represents a self-protective psychological adaptation specific to overwhelming traumatic experience. The present paper will argue instead that nonpathological dissociative experiences are ubiquitous in daily life, instantiated in intense absorption, daydreaming, fantasy, and flow states, and that such experiences represent the normative dissociative foundation from which pathological dissociative states may arise. Research on the frequency of such experiences and their potential adaptive functions will be briefly described. Hypothesized links between these nonpathological processes and their stress-related perturbations will also be presented. By understanding the pervasiveness, mechanisms, and utility of the dissociations of everyday life, we may gain a fresh vantage point to appreciate and consider anew the extensive clinical and empirical knowledge that has accrued in the study of the dissociative disorders. Phenomenological and discourse analyses of dissociation Kymbra Clayton, PhD candidate The unstated and largely unexamined assumptions underlying conceptions of dissociation held by different groups and individuals are revealed by discourse analysis. When compared to the discourse of phenomenological accounts by those identifying themselves as having dissociative identities, the discourse of both lay people and professionals assumed a particular notion of self: that a person has one consistent, stable, unitary self, and that anything else is seen as deviant from the norm, abnormal, and as such, dysfunctional. These comparisons also reveal that lay people and professionals de-contextualize dissociation. Even

clinicians often ignore the roles of social context, the dissociative persons internal psychological context, and the affects of the social and the internal contexts on each other. By contrast, the on-going experience of persons with dissociative identities within a social or interpersonal context is a central component of their phenomenological accounts. The comparative discourse analyses also reveal dramatic divergence of views on the functionality of dissociative identities functionality was very much in the eye of the beholderwith outsiders often subscribing to many of the dominant discourses pertaining to the (dis)functionality of dissociative identities. In conclusion, some implications of these findings are presented. the Cognitive approach to Studying dissociation Martin Dorahy, PhD The cognitive approach to studying dissociation is not a unified church with a single endeavour. Rather, researchers and theorists interested in the relationship between cognitive functions and dissociation have been motivated by different questions. Studies focussed on memory processes have been largely motivated by clinical reports of amnesia between dissociative identities in DID and the degree to which different types of cognitive information are pervious and impervious to transfer. The theorised function of dissociation as a threat management and defence strategy has fostered research into the cognitive processes (e.g., divided attention) that may explain this capacity. This work has focussed on attentional processes at the early stages of the information processing stream. Other work has not started from the position of trying to determine the cognitive processes associated with the symptoms or proposed defensive function of dissociation. Rather, this work has taken a bottom-up approach to examining the cognitive un-

derpinnings of dissociation. Work examining attentional and working memory processes, such as cognitive inhibition and working memory span, would fall into this category. Future work needs to examine the degree to which pathological and high non-pathological dissociators look similar cognitively and whether different dissociative symptoms share the same cognitive underpinnings.
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therapeutically founded and Selforganized networks as additional Components of Multi-Modal trauma Psychotherapy
Lake House

Ralf Vogt, PhD, Chair


SkiLL LeveL: BASic

In this symposium a diverse range of interdisciplinary network structures for treating complex traumatized children and adults will be discussed. Aspects such as cooperation between outpatient and inpatient centers and the necessity to reform traditional treatment concepts will be discussed. An outpatient stepwise treatment concept will be introduced, beginning with a therapeutic premise that encourages the autonomous self-organization of clients. introducing an analytical actionoriented Model for Complex traumatized adults Ralf Vogt, PhD; Irina Vogt, DP A psychoanalytic action-oriented treatment concept for complex traumatized patient groups will be presented. The main focus will be on the continuous combination of outpatient individual and group psychotherapy by permanent practitioners. Through gradual learning tasks, groups are therapeutically trained and encouraged to become self-reliant and self-organizing networks, in which both analytical symbolization work and structured behavioral support are effec-

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Case Study of the interdisciplinary Medical and Psychotherapy treatment of a five-Year-old Girl Franziska Schlensog-Schuster, MD; Ralf Vogt, PhD The treatment of chronic adult and childrens medical diseases typically include potentially traumatizing medical interventions, which increase the risk of developing post-traumatic stress disorder. This presentation will describe the advantages of interdisciplinary cooperation between the Pediatric Ward and the Childrens Psychiatry Ward at the University Of Leipzig in Germany to improve the quality of life of a five-year-old girl with terminal renal insufficiency prior to her kidney transplant. This case study aims to show the effective integration of trauma therapy (inpatient followed by outpatient) and somatic treatment. In this particular case, the girl displayed aggressive behavior, hyperactivity, and dissociation resulting from a post-traumatic stress disorder caused by multiple invasive medical treatments (e.g., cardiopulmonary resuscitation, insertion of a central venous catheter, surgery, and skin, liver and kidney biopsies) since her seventh month of life. The five-year-old girls resources were improved by trauma psychotherapy, which included the creation of an inner safe place for further medical interventions, imaginative inner helpers, as well as reorientation exercises during dissociative phases. It was possible to conclude that interdisciplinary approaches of medical and psychotherapy treatment contribute to improved quality of life in complex traumatized patients and their families. Changes in the traditional Physician-Patient relationship in treating Complex traumatized Patients Sebastian Schuster, MD; Franziska Schlensog-Schuster, MD The results of a study conducted at the University of Leipzig in Germany concerning the influence of the personal traits and values of pediatricians and surgeons on their preferred type of physician-patient relationship will be presented. In the case of complex traumatized patients the need for treatment based on mutual consent and decision-making is shown to be of particular import in order to stabilize the physician-patient relationship and build trust. This presentation will therefore focus on the inherent problems of such relationship issues of power, intimacy, trust, helplessness, lack of control and knowledge - which are especially pressing for complex traumatized patients. This presentation will suggest ways of improving the quality of medical treatment of complex traumatized patients.
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tively arranged. Clients are familiarized with methods of self-diagnostics and external diagnostics for problematic regulative states. They work out group rules which contribute to creating a constructive and low-tension group atmosphere. Social development tasks such as therapeutically justified home visits by mutual consent for finding unconscious potential triggers and other self-help tasks are essential components of this newly created phase-oriented treatment concept, which is well-researched and usable for various groups with DESNOS and DDNOS patients. This method requires a specially trained (and outpatient) team of therapists and patients who are able to commit to a minimum treatment period of three years. the foundation of a Social network: a Case Study from an adult Course of therapy Irina Vogt, DP; Ralf Vogt, PhD This contribution will explain the foundation and growth of a network comprised of 80 patients at an outpatient psychotherapy practice. A case study of a patient with dissociative identity disorder will be presented in order to demonstrate the useful interaction between individual and group therapy followed up with a self-help group setting. Clients in one such particular network developed a range of group-based ideas, which served as the basis for the development of a trauma center. The mission of this center has been to provide preventative work within the general population, in particular with parents-to-be.

Building Connections: Working toward Co-Consciousness in adult and Children Clients


Wolf Point Pre-Function

Sandra Baita, MA; Anabel Gonzales Vazquez


SkiLL LeveL: BASic

An important step in the treatment of dissociative identity disorders patients is coconsciousness. The term was coined by Morton Prince (1906) as a state of awareness in which one personality is able to directly experience the thoughts, feelings and actions of another alter (Kluft, 1984). Co-consciousness can be referred to as the internal awareness of the existence and experiences of other self aspects (Turkus & Kahler, 2006). Co-consciousness supports internal cooperation such that the whole dissociative system is

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committed to decrease internal conflict and its impact in the daily functioning of the patient. Once the dissociative system is acknowledged, and safety and stabilization issues have been addressed, the clinician must begin working toward coconsciousness. Increasing coconsciousness is a longitudinal process during the course of therapy. This is an important target in the treatment of both adult and children patients (Phillips, 1995; Putnam, 1989). This workshop will offer diverse ways (e.g., homework, exercises, art techniques) to reach co-consciousness in dissociative patients with diverse presentations, both adult and children, These techniques will be illustrated through clinical vignettes.

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imitations and/or false-Positive diagnoses of Complex dissociative disorders: Patients at risk, therapists at risk
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Complex trauma and Vexing Medical Complaints 12:00 pm - 1:20 pm Student focus Group: how Can iSStd Benefit You?
Wolf Point Ballroom

HAlf DAY WORksHOps, CONtiNuED


remain in the same room

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ethical issues and dilemmas in treating Complex trauma and dissociative disorders
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Steven Gold, PhD, Moderator ISSTD is seeking to strengthen its Student Committee and to encourage greater participation by people in training. We are eager to serve students with a particular interest in trauma and dissociation. Whether you are an undergraduate student, graduate student, intern or resident, ISSTD invites you to attend this special session to help us find out more about how we can better meet you needs. Lunch will be provided and each participant will receive a free copy of Understanding Dissociation, a video of experts disscussing the concept of dissociation. 12:00 pm - 1:20 pm lunch (on your own) 12:20 pm - 1:20 pm Student training exihibit
Wolf Point Pre-Function

The Adverse Childhood Experiences (ACE) study demonstrates the relationship of childhood abuse, neglect, domestic violence and related experiences to health throughout the lifespan. The findings are consistent with recent discoveries about the neurobiology of stress and the effect of stress on the developing central nervous system. Unlike other studies, the ACE study assessed a wide array of traumatic childhood experiences as well as many health and social problems from adolescence to late adulthood.The number of ACEs has a graded relationship to many common medical and public health problems. An overview of these concepts and findings from the study will be presented. Objectives Participants will be able to: 1. Summarize the basic biology of the effects of childhood trauma on neurodevelopment. 2. Show that Adverse Childhood Experiences are common and highly interrelated. 3. Give examples of how the number of Adverse Childhood Experiences has a strong, graded, dose-response relationship to many health and social problems, consistent with the impact of cumulative stress on childhood neurodevelopment. 2:30 pm 2:45 pm refreshment Break 2:45 pm - 3:45 pm

MONDAY NOVEMBER17

When Caring hurts: Medical trauma and dissociation in Children


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Parent education to Prevent dissociative disorders


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Bridging two Worlds: the Power that Personal Mythology approaches Bring to ego State therapy
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1:30 pm - 2:30 pm
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the diagnostic landscape: differential diagnosis of Complex trauma disorders

the Wide ranging health and Social impact of adverse Childhood experiences
Sauganash Ballroom

President's address a duality Model of dissociative Mind: Protection, Crisis, and harmony
Sauganash Ballroom

Vedat Sar, MD Catherine Classen, PhD, Chair


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Robert F. Anda, MD Kathy Steele, MN, CS, Chair


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Naturalistic observations on the psychotherapy of dissociative patients across

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is co-opted by the sociological self, while the opportunity to return to its original place in the psychological self remains a possibility. This duality model assumes establishment of harmony between sociological and psychological selves as the main goal of the psychotherapy of dissociative disorders. This cannot be achieved directly, but rather through adapting the functions of alter personalities and by resolving resistances of the traumatic self. Oscillations of the traumatic self between two domains of the larger self are represented in abrupt clinical changes in dissociative patients. The model proposed here aims to provide theoretical tools for clinical interventions both in dealing with crises and in delivery of long-term integrative treatment, while facilitating the active participation of patients. We hope that this approach may shorten the average duration of treatment for dissociative patients while encouraging integration, preventing development of treatment resistance, and liberating patients motivations for progress. Objectives Participants will be able to: 1. Illustrate a new theory regarding the operations of the dissociative mind. 2. Formulate new and effective psychotherapeutic interventions for dissociative disorders. 3. Describe the non-iatrogenic sociocognitive origin of dissociative disorders. 3:45 pm 4:00 pm refreshment Break 4:00 pm - 5:30 pm
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changing contexts (e.g. working with rotating psychiatry residents in training, different cultural origins of patients, clinical crisis situations requiring immediate solutions, resolving impasses from previous therapies) inspire new models of the dissociative mind to explain these clinical occurrences. This is true in diverse psychiatric settings such as emergency psychiatric wards, inpatient and outpatient units, and private practice settings. Such events include abrupt positive or negative changes in the clinical presentation of patients, strong correlations between treatment outcome and the individual qualities of therapists, and struggles with persistent resistances to treatment. The variability of treatment outcome from patient to patient is not merely a challenge for clinicians but it also depends on diverse factors that offer potential opportunities for discoveries which can be better identified by a model of mind that fits with this empirical heterogeneity. The model proposed here assumes duality of the larger self composed of a preserving (sociological self) and a preserved (psychological self) domain. The sociological self has the mission of preserving the psychological self. It becomes hypertrophied as a result of overfunctioning due to the chronic need to buffer from developmental traumas and to subsequent detachment from the psychological self. The psychological self is preserved in a frozen condition in dissociative patients but is ready to be activated with therapeutic interventions. Thus, the proposed model considers dissociation as primarily manifested in the disharmony between these two aspects of the larger self. Alter personalities are regarded as mental structures related to the sociological self rather than being dissociated parts of the overall personality. Two additional mental agents are proposed to complete this two-domain system: the traumatic self (the special trauma-related portion of the psychological self) and the moderator (a regulator for emotions). In dissociative disorders, the traumatic self

retrospective lessons
Lake House

Bethany Brand, PhD, Chair dissociative disorders Patients Perspectives of the helpful and harmful aspects of their treatment Lorien Baker; Gabrielle Gill; Micayla Weissburg; Dorothy Brumfeld, MA; Rachel Rock There has been minimal research on the treatment outcome of individuals with dissociative disorders (DD). In addition, qualitative measures and surveys of patient satisfaction are noticeably absent. Some authors express concern that trauma focused therapy, in particular therapy for dissociative patients, is regressive and harmful (Lilienfeld & Lambert, 2007; Piper & Merskey, 2004). The goal of the Treatment of Patients with Dissociative Disorders (TOP DD) Study was to learn more about DD treatment outcomes by surveying an international sample of outpatients and their therapists regarding their treatment progress. This paper will present the preliminary results of the qualitative responses of the TOP DD patients regarding the aspects of treatment that they found helpful and harmful. Spontaneous integration: Possible reality or Wishful thinking? Heather Gingrich, PhD Numbers of research studies have examined the prevalence of dissociative experiences or dissociative disorders in the general population of various countries or in specific non-clinical samples. Few, if any studies, however, have looked at whether individuals in a non-clinical population,

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with diagnosable dissociative disorders, can experience significant integration of dissociated aspects of self without the benefit of psychotherapy. In this presentation, four cases of apparently spontaneous integration will be examined. These individuals were participants in a twoyear follow-up study of non-clinical Filipino college students who met diagnostic criteria for a dissociative disorder as freshmen (Gingrich, 2008). Discussion will include an assessment of whether or not actual integration took place, as well as the factors contributing to each outcome. The possible influence of the cultural context will also be examined. Implications of the study for a better understanding of developmental processes with regard to dissociative symptoms, and the potential benefits of participating in research studies on trauma and dissociation will be discussed. lessons from the natural Course of Posttraumatic disorders Andreas Laddis, MD Research shows that post-traumatic disorders in their natural course (with little or no treatment) eventually show reduction of symptoms similar to that of long-term psychotherapy from various schools, but much more slowly. The reduction is particularly notable for symptoms of negative affects and dysfunctional beliefs. However, measurements of fulfillment, intimacy and self-actualization generally showed little progress for both conditions, i.e., for the natural course and for long term psychotherapy. There are reports of individuals exceptions, with a leap to fulfillment, but those, too, come from both conditions. Lorna Benjamin and Marcia Linehan debated the state of outcome research and agreed that proof of psychotherapys efficacy should eventually become the clients well-being, not merely distress tolerance. They proposed a program for psychotherapy based on identifying the core dysfunction of

the disorder, which seems to be specific to intimacy and trust and, then, find interventions that lessen this dysfunction during engagement in intimacy. A study by Laddis investigated a crisis intervention according to the principles proposed by Benjamin and Linehan. Evidence was found that supported the hypothesis for a particular core dysfunction, and will be presented in this paper. 25 Years of Presenting at iSStd Colin Ross, MD The author has presented one or more papers at the ISSTD Annual Conference every year for 25 years. In this paper he reviews the history of the ISSTD from his personal perspective and the fluctating crises and challenges faced by the field, including during his Presidency year at the height of the false memory wars. This will include painful lessons learned from the false memory wars and conflict within the ISSTD over these issues. The presenter will then formulate what he considers to be the most important tasks to be accomplished by the dissociative disorders field over the next ten years. These are: 1) publishing more prospective treatment outcome studies 2) more work on dissociative disorders in children, and 3) more research in a wide variety of languages, cultures and countries. The presenter will not talk about organizational problems of the ISSTD itself, but instead will focus on clinical and research issues within the field.
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Extensive clinical experience suggests that clients with histories of childhood abuse often comply with what they perceive as the expectations of the clinician unbeknownst to that clinician. Although compliance with an abusers wishes is assumed to be an intentional, if not always conscious, decision made by a child or adult facing the threat of harm, this may not be the case. An evolutionary perspective on the issue of compliance behavior suggests that automatic compliance to authority figures (whether the prairie dog sentry or alpha wolf in a pack) may be evoked by state changes associated with heightened levels of arousal. This has significant implications for clinicians working with those manifesting trauma-induced dissociation. Because traumatized persons often respond to heightened arousal by dissociating from their affect and presenting as calm, clinicians not attuned to compliance issues can unwittingly be mistaking client compliance with authority for client progress. After making some observations on the adaptive role of automatic compliance among herd, pack, and troop animals, a case study will be presented of a DID client with an extensive history of inpatient and outpatient treatment compliance but little progress until her compliance was addressed. Shame as etiology for dissociation Benjamin Keyes, PhD Shame has been an underpinning for cognitive distortions of many, if not most, survivors of sexual abuse ( Ross, 1989; Putnam 1989). Recent studies (Ross, Keyes, et al 2008) suggest that shame may be a powerful enough emotion to factor as etiology for dissociation and significantly strong enough to cause Dissociative Identity Disorder. This workshop will examine case studies and the trauma literature to examine shame/loss of face in a multicultural context and its impact on those subjected to it. Loss of face often

MONDAY NOVEMBER17

evolution and etiology in dissociation


Western Stage

Suzette Boon, PhD, Chair antelope and Baboons: an evolutionary View of the Compliance Problem in Work with dissociative Clients Kenneth Beattie, PhD

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times the circuitry was activated. If infancy is secure and the child is traumatized later, s/he will have a more strongly developed core self, and will experience emotion-based ego states rather than alter personalities.
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causes an individual to be incapacitated or confused. Ones identity is attacked and the result is often shock followed by shame and embarrassment (Folge, Poole and Stutman, 2001). This feeling can be accompanied by a host of symptoms reflecting social distress to include blushing, sweating, blinking, stuttering, and general nervousness (Sharkey 1988). These symptoms can also rise to the level of flashbacks, memory intrusion, startle response and are consistent with symptoms for Post Traumatic Stress Disorder and dissociation. Can shame cause the personality fragmentation found in Dissociative Identity Disorder? This writer believes this to be true and has a number of cases to support the hypothesis. the nature and development of ego States and alter Personalities Alison Miller, PhD Pica (1999) proposes that alter personalities evolve out of childhood imaginary companions that merge with dissociative states of consciousness before individuating into distinct personality states during adolescence. I propose an alternate model based on Greenbergs Emotionally Focused Therapy. When an infant undergoes an overwhelming experience, the brain circuit containing that experience becomes overloaded and is therefore disconnected from other circuitry. Separate circuits may be split off for each aspect of a trauma, such as bodily pain, hopelessness, or rage. A single brief trauma results in circuits which remain disconnected from the brain circuitry used in everyday life. If the child experiences further trauma eliciting the same emotions or bodily sensations, the circuits which have previously recorded these experiences are activated and gain more content. With repeated similar trauma, these develop into alter personalities, which generally have a characteristic emotion and/or bodily sensation, and acquire more or less content and complexity depending on how many

turning Ghosts into ancestors: assessing and treating adolescents with intellectual disability (id) and trauma
American House

Lynne Sinclair, PhD, Chair


SkiLL LeveL: intermediAte

of trauma will be understood as such and receive appropriate treatment. In the context of an interdisciplinary diagnostic workup, the trauma history that the adolescent may not be able to put into words is understood as finding expression in symptoms that at first glance may not make sense. Armed with a diagnostic formulation, the therapist can help the adolescent work through her traumatic history by engaging her in therapeutic tasks that take into account her special communication difficulties, her developmental level and her trauma history. Psychiatrys role on the interdisciplinary team assessing intellectual disability (id) and trauma in adolescents Elspeth Bradley, PhD The steps needed to complete a diagnostic formulation of an adolescent with ID and trauma history will be described. Diagnosis is regarded as an appropriate goal as it establishes an implicit comparison between the identified patient and others with similar configuration of symptoms; as such it guides treatment. Formulation is seen as crucial because it captures the uniqueness of the patient and her complaints and seeks to establish the etiology of the complaint. The diagnostic formulation is a working hypothesis to be refuted or embraced as further assessment and initial interventions are offered. For this reason, the interdisciplinary team may need to be available to the therapist throughout the course of therapy. Jane, 17 years, presented with sudden onset of delirium-like episodes during which she lost adaptive functioning to the point that she could not feed herself or even move. During interdisciplinary workup, the differential diagnosis included seizure and ID-syndrome related episodes, major depression and stress related anxiety. A history of severe early trauma involving being born apparently unwanted into a toilet, to parents with ID and low

This presentation will outline a model for conceptualizing and treating trauma in adolescents with ID. Until now, there has been no model for psychotherapy with such adolescents. Psychotherapy of the traumatized adolescent is more effective when it is informed by interdisciplinary assessment. A case example will illustrate treatment approach. intensive Psychotherapy of adolescents With intellectual disability (id) and trauma Lynne Sinclair, PhD The PRISM-R model of therapy was adapted from Wexlers model for group therapy with highly symptomatic inpatient adolescents to be used for outpatient adolescents with ID in individual therapy. For adolescents with ID who are highly symptomatic and have a trauma history, the PRISM-R model provides a medium for self-expression that may have been lacking. In therapy, the adolescent explicates feelings, clarifies distorted perceptions and receives comfort for experiences that were overwhelming when borne alone. The manner in which the PRISM-R functions in the mental life of an adolescent with ID and severe early trauma is examined. Adolescents with ID have unique communication difficulties, making it less likely that the symptoms

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SES was described. Jane had been placed in care and was subsequently adopted by a loving middle class family. No further episodes occurred after starting therapy with a therapist experienced in trauma and ID. Psychologys role on the interdisciplinary team assessing intellectual disability (id) and trauma in adolescents Rachel Greenbaum, PhD A psychologist is deemed an integral part of the proposed interdisciplinary approach. The psychologists unique role is outlined herein, particularly in relation to the case of Jane. The psychologist serves the dual function of (1) evaluating whether cognitive factors may adversely be impacting functioning (2) exploring particular intrapsychic features of the individual. Previous psychological assessments are reviewed to help determine whether features of the patients cognitive profile may contribute to the presenting picture and speculate whether these or specific intrapsychic factors might complicate therapy. The psychologist gauges whether updated formal psychological assessment is needed. Cognitive issues per se did not appear to be of primary concern for Jane. However, certain aspects of her intrapsychic profile were highlighted. More specifically, Janes perception of herself and others tended to be distorted by her high need to achieve. This information would prove critical to her therapy; the therapist could anticipate that Jane may resist processing information about herself that she deemed as casting her in an unfavorable light. This distorting tendency amounted to a dissociation of negative thoughts and feelings about herself that essentially overwhelmed her, contributing to the severe debilitating episodes that brought her to clinical attention.
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Getting out the Word: twenty-five Years and Beyond on local education on dissociation
Shakespeare House

Su Baker, MEd; Janet Migdow, MA; Dennis Pilon, LCSW; Jocelyn Laverinto, MA
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Though much has been accomplished in education on dissociative disorders, at the local levels the majority of mental health professionals still lack or have limited knowledge in the field. As the ISSTD celebrates its twenty-fifth anniversary, we look back at the initiatives of local groups and individuals in providing education, networking and support to professionals on dissociation and the dissociative disorders. We will discuss various experiences in professional education and outreach in our geographic areas. Each of the forum members will present some history of her/his local component group, and plans for the future of their groups. Together the presenters will facilitate a conversation with participants as to how they might best reach out to resource and educate their local professional communities to provide a setting in which professionals could meet for further education and networking. In addition, ideas on how to sustain current interest in local groups will be explored.
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important, dissociation based in double binds and chronic relational trauma may account for the instability of identity, affect, behavior and relationships. Acute, episodic impairment in reality testing may result from dissociative symptoms such as illusions, disorientation and flashbacks. A more pervasive and essential form of impairment of reality testing seen in BPD is based on partially or fully dissociated, polarized perceptions of self and others. Dissociated, i.e. split, mental representations of the good and bad aspects of the self in relationship to caregiver cannot be integrated into whole self and object representations, impairing the ability to interpret peoples appearance, intentions and behavior. Attachment relationships with caregivers who are dissociative, psychotic or sociopathic involve thousands of frightening, doublebinding interactions that may impair the development of reality testing in a more pervasive and insidious manner than discrete traumatic events. Case examples will illustrate treatment of persons with BPD, pervasive instability, impaired reality testing, and delusions of grandeur and persecution.
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MONDAY NOVEMBER17

Contextual approach to integrating Compartmentalized Self-States: the Political is Personal


edgewater

Borderline Psychosis, double Binds and Chronic relational trauma in Borderline Personality disorder
Sauganash east

Steven Gold, PhD


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Ruth Blizard, PhD


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The essence of BPD is the instability of relationships, self-image and affect, accompanied by transient dissociative or psychotic-like symptoms. Trauma-based dissociative processes may underlie many of the symptoms of BPD, including the apparently psychotic symptoms. More

Recognizing the impact of social and political forces on identity development can be crucial to successful treatment of compartmentalized self states. A detailed case presentation will be used to illustrate this conceptual and intervention approach. A homosexual male physician in his early thirties diagnosed at various times as suffering from anxiety, depression and bipolar disorder entered therapy after a long course of psychopharmacological treatment. He described discrete periods

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cus on facilitating emotional change in interpersonally traumatized patients by recognizing and changing two insecure attachment-based regulation strategies: de-activating and hyper-activating regulation strategies. These insecure attachment-based regulation strategies promote and maintain insecure attachment representations. Generally, this results in a vicious circle of insecure cognitive-emotional information processing which activates insecure attachment self-regulation strategies. Moreover, when confronted with potentially dysregulating internal of external (adverse) events, poorly regulated individuals are unable to experience a sense of personal efficacy, resilience, and optimism. Using didactics and active participation, assessment and treatment techniques will be demonstrated.
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ANNIVERSARY
A N N UA L C O N F E R E N C E

ISSTD

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of dysphoric mood lasting days or weeks that could not be neatly classified as anxiety, depression or mania. These periods were characterized by an affective, cognitive and perceptual set that differed markedly enough from the clients usual selfexperience to comprise an alternate sense of self. By the clients report this self state existed as far back as he could remember and seemed to have developed parallel to his primary sense of identity. It gradually emerged that his dysphoric self was constellated chiefly around internalized negative societal attitudes about homosexuality. In contrast, his primary sense of self was confident and self-accepting. Course of therapy will be reviewed and panelists will discuss how recognition of sociopolitical influences on identity formation can be crucial to successful treatment for dissociated self states.
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However, many individuals may be managing trauma or non-optimal attachment histories outside the clinical context. This workshop will use the adult attachment perspective to link research on trauma and dissociation to non-clinical populations. This will be accomplished using emerging theory and research on the relationships between trauma, dissociation, and attachment in performing artists and athletes. Discussion will include how the adult attachment interview evidences dissociative features and disorganized states of mind regarding trauma and loss. Cross-cultural data from a South African sample will be presented.
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Whos in Charge here? Patterns of dysfunctional Control in Severely traumatized Clients


Bulls Head

the Clinical assessment and treatment of trauma-related Self and affect dysregulation
Sauganash West

forgiveness: the use and Misuse in the treatment of trauma and dissociation
Wolf Point Ballroom

Kevin Connors, MS, MFT


SkiLL LeveL: intermediAte

George Rhoades, PhD


SkiLL LeveL: BASic

Annemiek van Dijke, MSc


SkiLL LeveL: intermediAte

In this workshop a multi-disciplinary method of diagnosis and therapeutic interventions for patients suffering from early interpersonal trauma-related dysregulation will be presented. Clinically, these patients present with a variety of symptoms. In order to ensure the use of appropriate interventions, it is crucial to not only diagnose descriptive pathology (DSM axis I and II disorders) but to also consider structural pathology (e.g. personality organization, attachment styles, affect dysregulation styles, somatoform and psychoform dissociation, mentalizing capacities). Illustrated by patient vignettes, therapy interventions and outcome measures will be discussed for use by psychotherapists, creative therapists (music and art), milieu-therapists, and dance therapists. This workshop will fo-

Forgiveness is seen as the power to not hold to account or to close doors on the past. The use and power of forgiveness is shown in research and clinical examples. The misuse of forgiveness, often leading to guilt and even the re-abuse of patients is demonstrated in writings and clinical examples. The practical application of giving and receiving forgiveness in a therapeutic context is given in five stages.
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researching trauma, dissociation, and attachment in non-Clinical Populations


Steamboat north

Kelly Forrest, PhD, JD; Paula Thomson, PsyD


SkiLL LeveL: AdvAnced

Much of the research on trauma and dissociation focuses on clinical populations.

For the trauma survivor, issues of control, responsibility, power and shame are a tangle of confusing and conflicting paradigms and paradoxes that serves to maintain chaos in the survivors life leading to repetitive re-victimization. For the clinician treating survivors of profound abuse, these same dysfunctional patterns of control complicate and confound the therapeutic process. This workshop examines how externalized locus of control is defined through abusive childhood experiences and reinforced via disorganized attachment patterns. This paradigm is subsequently sustained through dysfunctional adult patterns of relating. Further, the paradoxical double-bind of responsibility without authority, played out repeatedly in the abusive family, creates a sense of self that both powerless and thus steeped in shame. These dysfunctional attitudes keep the client trapped, alternating between dependence and dominance. Dissociation, in childhood, while protecting the infant from psychic

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f i na l c o n f e r e n c e p ro g r a m a n d p ro c e e d i n g s

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ADVANCES IN UNDERSTANDING T R AU M A A N D D I S S O C I AT I O N :
PERSONAL LIFE, SOCIAL PROCESS, AND PUBLIC HEALTH

ConferenCe SChedule
pain, interrupts the development of mastery, integration, affect modulation and the development of genuine interpersonal power and the sharing of control and vulnerability that are hallmarks of healthy adult relationships. Dissociation in adulthood maintains the intrapsychic prison. This workshop describes these paradigms and paradoxes of dysfunctional control issues inherent to the treatment of trauma survivors, discusses the dynamics thereof and delineates treatment strategies accordingly.
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a process of moving from an insecure to a more secure internalized environment via more effective intrapersonal careseeking and care-giving. Participants will have the opportunity to apply the concepts to their own practice. 5:30 pm adjournment

MONDAY NOVEMBER17

reaching for relationship: exploring the use of an attachment Paradigm in Work with dissociation
merchant Hotel

Sue Richardson, BA
SkiLL LeveL: intermediAte

This workshop explores the use of a new attachment paradigm (Heard, Lake & McCluskey, publication pending ) in work with dissociation. The paradigm identifies a dynamic process in which a number of goal corrected systems take part, including care-seeking and care-giving, to restore a persons sense of well being after s/he has been threatened. Interpersonal trauma disrupts this dynamic process and leads to the disruption of inter- and intra-personal relating, which becomes influenced by fear and the need for selfdefense. The consequences of traumatic disruption in those clients who have suffered extreme abuse is integrated into the workshop. The dissociative inner world is understood as one in which a person is unable to reach inter- and intra-personal goals, in particular personal care-giving. Patterns of intra-personal care-seeking and care-giving, the concept of an 'inner attachment interview' and the process of repair are examined. Clinical examples will illustrate how the dissociative internal world can be restructured during attachment-based therapy. Attachmentbased trajectories of repair are defined as
f i na l c o n f e r e n c e p ro g r a m a n d p ro c e e d i n g s

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