Caught up with Childhood Memories:

Is there a Short-Cut to Reparation?

Ellen K. K. Jepsen, MD
Dep. for Trauma Treatment, Modum Bad Psychiatric Center,
Vikersund, Norway.

Timisoara Late Summer School, Romania

September 15, 2012
Outline

I. Links between childhood abuse and sufferings in adulthood

II. Dissociation and dissociative disorders

III. Assessment: The identification of trauma-related symptoms and

dissociative disorders

IV. Treatment: The emerging inner dialogue

V. Prevention of child abuse

I. Child Maltreatment
Child maltreatment (CM) is the abuse and neglect that occurs to children
under 18 years of age.

It includes all types of physical and/or emotional ill-treatment, sexual

abuse, neglect, negligence and commercial or other exploitation, which
results in actual or potential harm to the child’s health, survival,
development or dignity in the context of a relationship of responsibility,
trust or power. Exposure to intimate partner violence is also sometimes
included as a form of child maltreatment.

Within this broad definition, five subtypes can be distinguished: physical

abuse; sexual abuse; neglect and negligent treatment; emotional abuse;
and exploitation.

(WHO, 2012)
Child Abuse and Neglect

Prevalence (difficult to study):

Approximately 20% of women and 5–10% of men report being sexually
abused as children, while 25–50% of all children report being
physically abused.

The majority of violent acts experienced by children is perpetrated by

people who are part of their lives: parents (incl. step- grand-),
employers, boyfriends, girlfriends

Occurs in the homes and families of the children, in schools and

educational settings, in care systems (e.g orphanages, children’s
homes, care homes), justice systems (police lock-ups, prisons,
juvenile detention facilities), in work settings, and in the community
(e.g. peer-, gang- or police violence, abduction, trafficking)
CM is Associated with
Longterm Health Problems
Child maltreatment causes stress that is associated with disruption in early
brain development. Extreme stress can impair the development of the
nervous and immune systems.
As adults, maltreated children are at increased risk for behavioural, physical
and mental health problems such as:
• perpetrating or being a victim of violence, depression, smoking, alcohol
and drug misuse, obesity, high-risk sexual behaviours, unintended
pregnancy
• Via these behavioural and mental health consequences, maltreatment can
contribute to heart disease, cancer, suicide and sexually transmitted
infections.
Beyond the health and social consequences of child maltreatment there is an
economic impact, including: costs of hospitalization, mental health
treatment, child welfare, and longer-term health costs. It can ultimately
slow a country's economic and social development.
Childhood Abuse is Related to
Health Problems in Adulthood (1)

Psychological:

Depression, suicidal ideation and attemts, selfmutilation, anxiety

(phobias, panic, social withdrawal, flashback), affect
dysregulation, moodswings, somatization, substance
abuse/dependency (alcohol, drugs, tobacco, narcotics), sleep
problems, difficulties with attention, dissociation, seksual
problems, risk behavior, relational problems, reduced
parentingskills (e.g. Nelson, 2002).
Childhood Abuse is Related to
Health Problems in Adulthood (2)
Somatic/somatoform:
Pain (stomach, head, muscles), gynecological problems,
’neurological’ symptoms, infections, seksually transmitted
diseases, cardio-vascular diseases, gastro-intestinal diseases,
urological diseases, astham, allegy, fibromyalgia, chronic
syndrome of exhaustion, diabetes, obesity, ets..

Other:
Early unwanted pegnancy, re-victimization (other types of abuse,
abuse in adulthood), socio- economical complications, etc..
Long-term consequences:
Children are at risk….
Individual characteristics:
• Mental capacity, integrative capacity: low age (un-
developed personality), poor integrative capacity (incl.
avoidant strategy, negative interpretation of the event)
• Genes and milieu: Personality can be defined as the
interaction between surroundings and genetically inherited
characteristics
• Lack of social support: children depend on caregivers help
for the integration of stressful events
• Hyper- and hypo-arousal during and following the event
• Meaning: children accuse themselves, induces pathological
shame
Longterm consequences:
Potential traumatizing events

Characteristics of potential traumatizing events:

Intense, sudden, unpredictable, uncontrollable, extreme negative,
interpersonal, involves physical harm or threat to life, loss of
attachment to caregiver, neglect, repeated, lack of social support

”Complex trauma”:
Accumulation of trauma (repeated, over time, in the family,
’caught in the relationship’, un-developed personality)
Coping Strategies: Two
dimensions with relevance for mental health
1. Approach coping strategies
- includes responses directed towards the stressors or one’s reaction
to it (e.g. active behaviors such as problem solving or seeking
support) – and are associated with better adjustment,

2. Avoidant coping strategies

- are characterized by behaviors oriented away from a stressor or
one’s reaction to it (e.g. denial, behavioral avoidance, wishful
thinking) – and are related to increase in distress. Avoidant coping
strategies can be successful for coping with short-term uncontrolled
stressors, but they are generally tied to increased distress and chronic
disease progression and mortality.

Coping strategies are nurtured by early environment – and genetics.

Coping Strategies and Health

• Adolescent girls who favor the use of approaching strategies to

face a common problem report less depressive symptoms than
adolescents who employ avoidant coping strategies on a more
regular basis

(Herman-Stahl, Stemmler, Peterson 1995)

Childhood sexual abuse and coping
• Greater reliance on avoidance coping strategies is associated with more
severe symptoms following trauma. For example, adolescent CSA survivors
reportedly experience more stress-related symptoms and use more
avoidant coping strategies and less support-seeking strategies than other
adolescents. These coping strategies may be specific to CSA rather than to
trauma more generally, with one study reporting that sexually abused
children displayed more aggression, thought problems, dissociation,
anxiety/depression, and avoidant coping strategies than children who had
experienced non-abuse traumas.
• Coping styles engaged following CSA are likely to be a major mechanism
through which CSA increases rates of psychological problems.
• Avoidant coping strategies were identified as a commonly documented
determinant of individual variation in symptom expression
• A growing research literature points to the negative impact of avoidant
coping on posttraumatic symptomatology.
(Barker-Collo & Read, 2003)
Attachment System

’Human beings has a strong, inborn, evolved disposition to seek help,

care, and comfort from a familiar member of their social group. Is
activated whenever human beings experience physical or emotional
pain, and whenever they, through the emotion of fear, perceive
themselves vulnerable in the face of danger. It is also activated by
separation from, and loss of, attachmen figures. Past interactions
with caregivers give rise to specific structures of memory and
expectation which shape and individualize the expression of this
inborn disposition…

When activated, the attachment co-ordinates not only specific

feelings and goal-directed behaviours, but also memories – both
consciousness and unonscious – and thoughts about self and
attachment figures.’
(e.g Liotti, 2009)
Attachment –
A Child’s Survival Ticket

The human being has a need for relatedness and a need for individuation.

Attachment system makes the child attach, with emotional bonding towards
a primary caregiver, and to maintain a physical closeness to this person.

Infant Attachment Patterns: Organized (1-3): 1) Secure; 2) Insecure-

avoidant; 3) Insecure-ambivalent; 4) Disorganized.

Secure attachment balances the needs for safe relatedness and autonomy,
insecure attachment does not allow this.

The attachment system mediateds individual responses to trauma:

Secure attachment is a protection in coping with stressful events.
The more insecure the attachment pattern is: the greater risk for
development of trauma-related emotional disorders following potential
traumatizing events
Disorganized Attachment
and Dissociation (ref. Liotti, 2009)
• Some infants fail to organize their attachment behavior according
to any of the secure or insecure-avoidant/ambivalent attachment
patterns. Instead they manifest: Disorganized attachment.
• Prevalence: 13% of low-risk families; 82% of high-risk families
• The infants’ organizing functions of consciousness, memory, and
identity appear to have failed.
• Because pathological dissociation is a disruption in the organizing
and usually integrated functions of consciousness, memory,
identity, and perception of the environment (APA, 1994),
disorganized attachment can be understood as a very early
dissociative process in personality development.
• Can be seen as a ’traumatized attachment pattern’ – a symptom
with clinical relevance in itself
Disorganized Attachment
and Dissociation
• Disorganized attachment is directly linked to development of
clinical symptoms:

• Longitudinal studies show increased tendency toward dissociative

experiences in adolescents and young adults with disorganized
attachment (Carlson, 1998; Ogawa et al., 1997)

• Support the hypothesis: Increased vulnerability towards

pathological dissociation
Disorganized Attachment
and Trauma

• Children with disorganized attachment: Directively traumatized

(abuse, neglect, by e.g. caregiver) or in-directlively traumatized
because of the caregivers disruption in affective communication with
the child – (a consequence of the caregivers own unsolved trauma)

• i.e. fear is induced by the very person who cares for the infant’s fear
and distress; ”fright without solution”; caregiver: ”the source and
the solution of the infant’s alarm”.

• In disorganized attachment infants display contradictory behaviour

patterns (e.g. approaching the parent while averting the head so as
to avoid meeting his/her gaze; calling loudly for the parent at the
closed door, followed by avoidance of the parent on entrance).
 II. Dissociation
Definition:
“A disruption in the functions of consciousness, memory, identity,
and perceptions of one’s environment, functions that are usually
integrated”,
(APA, 1994)

These are symptoms that mainly manifest:

1) mentally, i.e. psychoform dissociative symptoms like amnesia and
depersonalization, or
2) in the body, i.e. somatoform dissociative symptoms like numbing
and ‘pseudo-seizures’
(van der Hart, et al., 2006)
Dissociation in PTSD

• ”PTSD has been classically seen as a biphasic disorder with

persons alternately experiencing phases of intrusion and
numbing. The intrusive phase is associated with recurrent
and distressing recollections in thoughts or dreams, as well
as reliving the events in flashbacks. The numbing phase is
associated with efforts to avoid thoughts or feelings
associated with the trauma, emotional constriction, and
social withdrawal…”

(Chu, 1998; ref. Nijenhuis, 2004)

Dissociation in PTSD (cont.)

• ”This bi-phasic pattern is the result of dissociation: Traumatic

events are distanced and dissociated from usual conscious
awareness in the numbing phase, only to return in the intrusive
phase. In addition, patients with PTSD have long-standing
heightened autonomic activation that results in chronic anxiety,
disturbed sleep, hypervigilance, startle responses, and irritability.
It is this last set of symptoms that has caused PTSD to be classified
with anxiety disorders rather than with dissociative disorders,
althoug there remains considerable controversy over this
classification.”

(Chu, 1998; ref. Nijenhuis, 2004)

• Pierre Janet (1889, 1907): Dissociation describes a ”division of the
personality”

• Van der Hart, Nijenhuis, Steele (2004): ”Structural dissociation of

the personality”
Traumatization,
Dissociation and Personality (1)
Dissociative parts of the personality:

1. An apparently normal part of the personality (ANP):

Fixated in trying to go on with normal life, daily functioning, i.e.
food, caretaking, attachment, social life, work, parenting, play,
exploration, reproduction.
Avoids everything related to traumatic memories.
Retracted field of consciousness, but wider than EP.
Usually higher level of consciousness compared to EP, but lower
than in healthy minds.

Also labeled: ”The going on with normal life” – part of personality

(J. Fisher, 2012)
Traumatization,
Dissociation and Personality (2)
Dissociative parts of the personality:

2. An emotional part of the personality (EP):

Fixated in the action systems that were activated at the time of the
traumatization (e.g. defence - fight, flight, freeze, submission –
sexuality)
Fixated on traumatizing events
Disoriented in place, time, and identity
Retracted field of consciousness
May involve low level of consciousness

Also labeled: ”The traumatized part of the personality”,

(J. Fisher, 2012)
Primary Structural Dissociation
of Personality (van der Hart et al, 2006)

”Going on With Normal Life” Part The Traumatized Part

of the Personality (ANP) of the Personality (EP)

One predominant ANP and one EP, the latter is often not very elaborated
or autonomous.

Diagnoses:
Simple types of Acute stress disorder
Simple types of PTSD
Simple types of dissociative disorders, e.g. dissociative disorders of
movement and sensation
Secondary Structural Dissociation
of Personality (van der Hart et al, 2006)
When traumatizing events are increasingly overwhelming or prolonged,
further division of EP may occur, while ANP remains intact.

”Going on with Normal Life” Traumatized Part of the

Part of the Personality (ANP) Personality (EP)

Fight Flight Freeze Submit Attach

One predominant ANP and one EP, the latter is often not very
elaborated or autonomous.
Diagnoses:
Complex PTSD, Disorder of extreme stress, not otherwise specified
(DESNOS)
Dissociative disorder, not otherwise specified (DDNOS-1)
Tertiary Structural Dissociation
of Personality (van der Hart et al, 2006)
Finally, division of ANP may occur, in addition to divisions of EP.
Occurs when inescapable aspect of daily life has become associated with
trauma. When functioning of ANP is so poor that normal life itself is
overwhelming, new ANP’s may develop.

”Going on with Normla Life” Part… Traumatized Part of Personality

Social
Paren- Explo- Sexua
Play Engage Fight Submit Etc.
ting ration -lity
-ment

More than one ANP and more than one EP. Often several of these parts are
more elaborated and autononomous (e.g. diff. names, age, etc..)
Diagnoses: Dissociative identity disorder (DID)
’Day and Night Child’

Day child:
numb, avoidant, detached, amnestic, focused on normal life

Night child:
recalls abuse, relives abuse, focused on defense

(ref. van der Hart et al., 2006)

Dissociative Symptoms
(van der Hart et al., 2006)

Psychoform Somatoform
Negative: Negative:
amnesia analgesia
depersonalization bodily anesthesia
emotional anesthesia motor inhibition

Positive: Positive:
hearing voices localized pain
re-experiencing trauma – re-experiencing trauma,
affective and bodily components
cognitive components
III. Identification of
Trauma-Related Symptoms and Disorders

Does the persona have

1) History of (childhood) trauma?
2) PTSD?
3) Dissociative Disorder?
4) Personality Disorder?

Assessment is needed for better treatment planning

Child Maltreatment and Dissociation
Traumatic experience and dissociation are related, and these
relations appear to be moderated by the frequency of trauma and the
development of status of the individual at the time of traumatic
exposure (e.g. age).

Level of dissociation is related to chronicity and severity of trauma in

retrospective self-report studies (e.g. Chu & Dill, 1990) and in a
prospective study (Ogawa et al., 1997).

Dissociation in adult non-clinical, clinical, and dissociative disordered

samples is associated with child sexual, physical abuse, and neglect

Loss in childhood and to witnessing violence are also related to

dissociation in adulthood
Instruments

• Screening, e.g.:
• Dissociation Experiences Scale (DES),
• Somatoform Dissociation Questionnaire (SDQ-20),
• MID

• Diagnostic interviews, e.g.:

• Semistructured Clinical Interview for Assessment of DSM-IV
Dissociative Disorders (SCID-D)
• Interview for Dissociative Disorders and Trauma-related Symptoms
(IDDTS)
Psychoform Dissociative Symptoms
DES Questions (Bernstein et al.):

• Some people have the experience of finding themselves in a place

and having no idea how they got there (amnesia)

• Some people have the experience of looking in the mirror and not
recognizing themselves (depersonalization)

• Some people have the experience of feeling that other people,

objects, and the world around them are not real (derealization)

• Some people sometimes find that they are approached by people

that they do not know who call them by another name or insist
that they have met them before. (identity fragmentation)
5 Core Symptoms (SCID-D)

1. Amnesia (basic symptom): memory gaps (shorter or longer duration),

fugue

2. Depersonalization: sense of detatchment from the self, feeling of

strangeness of the self, a sense that one is observing oneself from the
outside, feeling like acting as a robot, a sense that parts of the body are
separated from the rest of the body
Classical symptom: an observing and an acting part

3. Derealization: feeling that one’s home, workplace or other customary

environment is unknown or unfamiliar, sense that friends or relatives are
strange, unfamiliar, or unreal changes in visual perception of the
environment, e.g. a sense that buildings, furniture, or other objects are
changing size or shape, or that colors are becomming more or less
intense
5 core symptoms (SCID-D), cont.

4. Identity confusion: a subjective feeling of uncertainty,

puzzlement, or conflict about one’s own identity or sense of self

5. Identity alteration: a shift in one’s social role that is often

perceptile to others due to the patient’s changed behavior
patterns. May include the use of different names; the possession
of a learned skill, such as the ability to play a musical instrument
or to speak a foreign language, for which one can not account; and
discovery of items ine one’s possession that one cannot recall
having purchased.
Somatoform Dissociative Symptoms
• SDQ-20 questions (Nijenhuis et al.):

”My body, or part of it, is insensitive to pain” (analgesia)

”It is as if my body, or part of it has dissapeared” (visual/kinestetic

anesthesia)”

”I cannot speak (or only with great effort) or I can only whisper”
(motor inhibition)

”I have pain while urinating”

Major Dissociative Disorders (1)
Dissociative Identity Disorder (DID):

A. The presence of two or more distinct personality states (each

with its own relatively enduring pattern of perceiving, relating to,
and thinking about the environment and self).
B. At least two of these identities or personality states recurrently
take control of the person’s behavior.
C. Inability to recall important personal information that is too
extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct psychological effects of
a substance (e.g. blackouts or chaotic behavior during Alcohol
Intoxication) or a general medical condition (e.g. complex partial
seizures). (APA, 2000)
Major Dissociative Disorders (2)
Dissociative Disorder Not Otherwise Specified, subtype 1 (DDNOS-1):

Clinical presentation similar to Dissociative identity Disorder that fail

to meet the full criteria for this disorder.
Examples include presentations in which
a) there are not two or more distinct personality states, or
b) amnesia for important personal information does not occur.

(APA, 2000)
Dissociative Personality Parts

Each ’identity’ in the major DD patient has it ’own’ first-person

perspective and sense of its ’own’ self, as well as a perspective of
other parts as being ’not self’.
Switches among identities occur in response to change in emotional
state or to environmental demands, resulting in another identity
emerging to assume control.
Different identities have differnt roles, experiences, emotions,
memories and beliefs.
The identity that is in control usually speaks in the first person and
may disown other parts or be completely unaware of them.
Inner conflicts (phobia) between parts maintains dissociation
”All” are present, listening,
although not at front..
Categories of dissociative personality parts:

”Going on with normal life” Part

”Traumatized Part” : ” Traumatized part”:

fragile/victim controlling/persecutor
IV. Treatment of
Major Dissociative Disorders
International guidelines:
”Guidelines for Treating Dissociative Identity Disorder in Adults, Third
Revision. International Society for the Study of Trauma and
Dissociation. Journal of Trauma and Dissociation, 12, 115-187,
2011.

Treatment Goal: Integrated functioning.

Gradual: move toward better integrated functioning…

Therapist must
• keep that the DD patient is a ’whole adult person’, with the
identities sharing responsibilities for daily life
• hold ’the whole person’
Three Main Phases of Treatment

1. Symptom reduction and stabilization

Overcome
a. phobia of attachment and attachment loss
b. phobia of trauma-derived mental
actions
c. phobia of dissociative parts
Mindfulness

”Change happens through discovering how a client habitually organizes

experience in response to selected stimuli and then changing how that
experience is organized… The ’tool’ that we use to discover and then
transform the habitual organization of experience is mindfulness.”

”Notice…”;
”Let’s just notice that reaction you are having inside as..”
”Be curious, not judgmental…”
”Notice the sequence: You were alone at home, and then you started to
feel that you only wanted to die, and then you wanted to harm
yourself…
”What might have been the trigger? Let’s og back to that situation and
retrace your steps”
(Ogden, 2005; Fisher, 2012)
Mindful Curiosity and Observation
• Become curious and encourage the client’s curiosity about
how a certain part or reaction came up.

• ”Can we be curious about the... (reaction/part)? It is okay to

just notice it as a part/reaction? Could we be curious about
how it’s trying to help you?”

• Slowing the pace of thinking and talking, refraining from

interpretation in favor of observation, helping the patient to
focus on the flow of reactions (chain reaction).
(Fisher, 2012)
Mindfulness

• Notice the client’s repetitive responses: changes in

arousal, body language, tension, movements or gestures
• Interrupt trauma-related patterns: provide
psychoeducation about trauma symptoms learned
behavior, challenge old patterns by encouraging the
practice of new patterns
• Encourage non-judgmental observation of these
patterns. Appreciate the behaviors as ’survival
responses’
• Become curious and encourage the client’s curiosity
 ”Window of Tolerance” (WOT)
– important for patient as well as therapist
Level of Psycho-Physiological arousal

Sympathetic
Hyper-arousal-related symptoms: Axiety, panic, terror, dread, racing thoughts, anger, self-destructive

WOT -
(Optimal
Arousal)

Para-
sympathetic
Hypo-arousal-related symptoms: depression, sadness, numbing, submission, shame, can’t say ’no’…

Time
(Siegel, 1999; Ogden & Minton, 2000; Fisher, 2009, 2009)
Attachment in Treatment
• Chronically traumatized individuals have malevolent internal mental
representations of attachment figures, leaving them with little or no
capacity for internal soothing, support, etc
• They may be unable to adequately realize current relational cues
from the therapist, misreading them as danger signals, so that their
defenses are evoked, even whilde they desperately cling to the
therapist
• Unable to predict accurately much of what happens in halthy
relationships
Two conflicting sides of the phobias of attachment and attachment loss:
1) Phobia of attachment – parts are focused on defenses that avoid
attachment: ”You are paid to like me…”
2) Phobia of attachment cry/loss: ”Please do not leave me, I cannot live
without you”.
- the essence of disorganized attachment
Phobias of Attachment (1)
• a focus throughout treatment!
• 1st Phase: various levels of avoidance. Attempts by therapist
to connect may evoke serious aviodance/avoidance conflicts
(not always ’visible’).
• Therapist must be alert to signs of the dilemma within the
patient (i.e. conflict between the fear of and need for
attachment)
• Therapist must guide the relationship according to mental
capacity of the patient (W.O.T.)
• Find an optimal balance between relational closeness and
distance
• ”Empathic attunement, disruption, and repair”
Phobia of Attachment(2)

• Initial interventions towards the ”going with normal life” part of

personality – talk through ANP to EP
• Psychoeducation about therapeutic relationship, attachment,
dependency, and autonomy.
• Make initial attempts to alleviate unspoken fears by noting that
many people find it difficult to talk about themselves at first, that
the patient is welcome to share at his or her pace, that therapy
should not be overwhelming.
• Opportuinity for the patient to ask questions
• Communicate clear boundaries and explain them, understand that
trust is a long process.
Some Interventions to Overcome
the Phobia of Attachment (van der Hart et al., 2006)
• Do not over overly encourage attachment, but rather stay predictably (not
constantly) available
• Gently approach talking about the therapeutic relationship with all parts
• Recognize and challenge reflexive beliefs about attachment (e.g. ”Everyone is out to
get something”; ”Dependency is for weak ones”, etc)
• Initially engage avoidant parts within the range of their action systems (e.g. work)
and gradually support their awareness of and and engagement with other parts that
are more amenable to attachment
• Gradually help the patient as a whole to discuss fears of attachment (rejection,
feelings of need, etc.)
• Do not offer extra contact or transitional object unless the patient askes, but let the
patient know these are available if requested and helpful
• Talk about perceived advantages of minimal attachment (empathize with
resistance), and gradually lead in to the difficulties (e.g. loneliness, lack of support,
etc).
Phobia of Attachment Loss (1)

• Phobic of being abandoned,

• Attempts to maximize actions that pull for attachment and also for
dependency
• Attachment cry involves panic – excessive focus on internal distress
states – tend toward enmeshed and intense relationships
• Preoccupied with the availability of the therapist, greatly upset by
planned or unplanned absences
• Are attuned to every nuance of the therapist’s actions, often
misperceiving them as rejecting or critical or a sign of abandonment
• Reflexive predictions, that the therapist will leave them, and
persecutory or protector EP’s may give internal threats about being
abandoned, which only serves to heighten their desparation
(van der Hart et al., 2006)
Phobia of Attachment Loss (2)
• ”When a patient begins manifesting intense phobia of attachment
loss, the therapist must immidiately work not only with those parts
fearful of rejection and abandonment, but also with those parts
that avoid attachment and seek to interfere internally with the
therapeutic relationship.
• Support the development of adaptive dependency that has a
specific goal of felt security rather than constant availability of
the therapist
• Certain therapeutic boundaries are neccessary to prevent
maladaptive dependency that unduly focus on attachment cry EPs
at the expense of functioning in daily life
• Patient must learn to more rely on the therapist, and also depend
on more functional parts of herself
(Steele et al., 2001)
Phobia of Attachment Loss (3)

• ANPs and Eps are encouraged to respond empathically to the needs

of the EP with attachment cry

• This also involves internal re-enactment of traumatic relationships

that must be resolved among parts.

• Maladaptive dependency needs can be overwhelming, resulting in

a negative cycle of dependency, desparation and helplessness.
Leads the patients to engage in maladaptive behavior, i.e. self-
harm, boundary violations towards self or others (therapist)

• Affect regulation is a major key to overcome the phobia of

attachment loss, that often is driven by shame, rage, and panic.
Clinical example

Addressing ’angry’, controlling parts:

Their beliefs:
”You are left on you own because you cry”
”The terapist leaves you because you cry..”

After inner communication:

Increased empathy among parts
Some Interventions to
Overcome the Phobia of Attachment Loss
• Begin and end session on time, and have the same appointment every week
• Extra contact and sessions should be given with careful consideration to
what the patient as a whole needs and can tolerate. More is no neccessarily
better, but neither is less
• Put up notice board that lists planned absences well in advance
• Provide a backup therapist for absences, if needed
• Describe what will happen if you or the patient misses a session
• Discuss patient’s fear of being abandoned without offering unrealistic
reassurance, e.g. do not promise to ”always be there”, or ”never leave”
• Recognize the role of persecutor parts in maintaining an internal
environment of rejection and critisism, ”You are such a cry-baby, no wonder
that stupid therapist hates you”.
• Sitting with hoplessness and despair is a very neccessary part of the process
• Return e-mails/phone calls predictably without reinforcing calls as a way to
have contact (van der Hart, et al., 2006)
Phobia of Attachment Loss –
Activation of ’protective’ part (1)
E-mail from Mari:
”I send this mail because I walk back and forward towards the
bathroom – almost cutting myself, because it hurts so much. I try
to write in order to stop it. Maybe it helps to send this mail.
I have found the plasters and the pair of cutting nippers to break up
the lady-shaver to get the blades out. Suddenly I may just do it –
take the things and do it. I do not want it, because I must handle
it now…!!!
When writing now, it may be that I put the things back.
- It is the ’child from children’s holiday camp’ that overwhelms me
totally. We will have to look at this more closely.
 (2)

When this extreme crying takes over, death-cry, then the legs turn
numb, they itch inside, there is an explosion in the whole body
and throat and then comes ’this feeling’ that I do not want and
that I do not understand why it appears in the midst of such
extreme pain….?
The muscles of the face hurt tremendously, also in the jaw and
muscles of teeths. I have such ’bone-pain’ in the hips and pain
down back’.
There is something we have to communicate on behalf of the child
from children’s holiday camp for which she is guilty – something
we do not understand why it turned out that way..” (Mari)
Stabilization Skills:
Learning to be in the Present
• Notice three objects you see in the room and pay close attention to their
details (shape, color, texture, size, etc.). Do not hurry. Name three
characteristics of the object out loud to yourself, for example, ”It is blue. It
is big. It is round.”
• Notice three sounds that you hear in the present (inside or outside of the
room). Listen to their quality. Are they loud or soft, constant or intermittent,
pleasant or unpleasant? Name three characteristics of the sound out loud to
yourself, for example, ”It is loud, grating, unpleasant.”
• Touch three objects close to you and describe out koud to yourself how they
feel, for example, rough, smooth, cold, varm, hard or soft, and so forth.
• Return to the three objects you have chosen to observe with your eyes. As
you notice them, concentrate on the fact that you are here and now with
these objects in the present, in this room. Next, notice the sounds and
concentrate on the fact that you are here in this room with these sounds.
Finally, do the same with the object you have touched.
(from Boon et al., 2011)
Stabilizational Skills: to be present
• Focus attention on ”here and now”
• Gain control over much dissociation by staying present

• Taste: ”carry a small item of food with you that has a pleasant but
intense taste, for example, mints, hard candy…. If you feel
ungrounded, pop it into your mouth and focus on the flavor and feel of
it in your mouth to help you be more ’here and now’.
• Smell: Carry something small with you that has a pleasant smell, for
example, a favorite hand lotion, perfume, aftershave, or an aromatic
fruit such as an orange. When you start to feel spacey or otherwise not
very present, a pleasant smell is a powerful reminder of the present.
• Breathing: When dissociating: ”Take time to slow and regulate your
breathing. Breathe in through your nose to a slow count of three, hold
to the count of three, and then breathe out through your mouth to a
slow count of three.”.. Repeat…. (from Boon, et al., 2011)
Stabilization Skills:
The Creation of ”Safe Place”
Reduce the Phobia for
Dissociative Symptoms
• For example: What is it like for you to hear about dissociation?
(Emotions, thoughts, sensations)
• Do they fit your experience, and how?
• Circle any of two dissociative symptoms that you may have noticed in
the past week:
- sense of fragmentation or division of self or personality
- amnesia in the present
- alienation from yourself or your body
- alienation from your surroundings
- experiencing too little: loss of functions
- experiencing too much: intrusions
- other changes in awareness
• Describe your exerience of each of these two symptoms and how they
affected your functioning at the time etc… (Boon et al., 2011)
Working with
Dissociative Parts: First Steps
Learn to acknowlege the parts, and accept the sense of being and feeling
fragmented
Support is needed for this stage to overcome shame and fear
Stay within the ”window of tolerance”
First dialogues among parts should be focused on building internal
communication and cooperation solely toward improving the quality of
daily life,
- including: Learning to deal with triggers (stimuli that evoke (aspects of)
traumatic memories; Inceasing internal and external safety; Working
together in therapy; Cooperating to complete daily life tasks.

Traumatic memories, emotions, or sensations should generally not be shared

among parts at this point
’The Emerging Inner Dialogue’

Gradually acknowledge and accept parts of yourself: become aware

of parts (”notice”). How do you think and feel when you become
aware of a part? Begin to accept them without judgement.
Gradually become more curious: how they function, how can you
work together?
Listen to and communicate with parts: many dissociative patients
hear voices that represent dissociative personality parts (inner
conversations). Imaginal exercise: to develop a better sense of
other parts. Like talking to a ’real person’. Set aside a specific,
quiet, calm time each day for inner communication. Deal with
inner threats from ’protective’ parts: increase their empathy
towards other parts. Start with that which feels comfortable.
Increase the cooperation regarding daily tasks (negotiation).
Techniques for
Inner Communication
• Written forms of communications (to tolerate more about part of
you in the present):
- writing to parts of yourself, introduce your therapy as an avenue
to healing, share your good intentions. Emphasize you want to get
to know all parts (even though you are scared or ashamed).
Emphasize that sharing of traumatic memories is for later..
• Talking inwardly (to connect parts to yourself):
- e.g. when you are agitated, anxious, distressed, etc.. Quietly
talk inwardly to all parts of yourself, calming and reassuring these
parts of you that you are safe, that you are willing to learn to care
for yourself, that you are getting help, etc. Remind all parts of the
present. Use your anchors.
Stabilization Skills: ”Meeting Place”
Outcome study – Modum Bad

Last 10 years:
a) increased awareness to patients’ dissociative problems
b) development of treatment program for patients with high levels of
dissociation

It was neccessary to investigate whether or not patients with major

dissociative diorders had poorer outcome following a 3-month inpatient
treatment program for adults with a history of childhood sexual abuse
comparedto those who did not have a major dissociative disorder

Study sample: 56 adults (52 women and 4 men)

All had a history of childhood sexual abuse and current traumarelated

disorder
Admitted 2003-2007
Treatment Program
• 3-months inpatient program for CSA survivors at Modum Bad Psychiatric Clinic,
• Norway

• Involves a combination of individual and group therapies

• Main focus: Stabilization and symptom reduction; with special

• attention to interpersonal functioning

• Team: multidisciplinary (psychiatrist, psychologists, nurses, occupational

• and art therapist, social worker, pastoral staff)

• Weekly schedule: psycho-education, group therapy, movement therapy,

• expressive art and occupational therapy, physical training

• Sessions included: individual supportive, cognitive and behavioral

• approaches, as well as psychodynamic issues

• Group work provided an arena for identifying and changing maladaptive

• patterns
V. Prevention of Child Maltreatment
“Key-facts” (WHO, 2012):
• Preventing child maltreatment before it starts is possible
and requires a multisectoral approach.

• Effective prevention programs support parents and teach

positive parenting skills.

• Ongoing care of children and families can reduce the risk of

maltreatment reoccurring and can minimize its
consequences.
Risk factors - Child

Children are the victims and are never to blame for

maltreatment!

Characteristics of an individual child may increase the

likelihood of being maltreated, include:
- being either under four years old or an adolescent
- being unwanted, or failing to fulfil the expectations of
parents
- having special needs, crying persistently or having
abnormal physical features.
Risk factors – Parent or Caregiver

Characteristics of a parent or caregiver may increase

the risk of child maltreatment. These include:
• difficulty bonding with a newborn
• not nurturing the child
• having been maltreated themselves as a child
• lacking awareness of child development or having
unrealistic expectations
• misusing alcohol or drugs, including during pregnancy
• being involved in criminal activity
• experiencing financial difficulties
Risk factors - Relationships

Characteristics of relationships within families or among intimate

partners, friends and peers may increase the risk of child
maltreatment. These include:

• physical, developmental or mental health problems of a family

member
• family breakdown or violence between other family members
• being isolated in the community or lacking a support network
• a breakdown of support in child rearing from the extended family.
Risk Factors –
Community and Societal Factors
Characteristics of communities and societies may increase the risk of child
maltreatment. These include:

• gender and social inequality;

• lack of adequate housing or services to support families and institutions;
• high levels of unemployment or poverty;
• the easy availability of alcohol and drugs;
• inadequate policies and programmes to prevent child maltreatment, child
pornography, child prostitution and child labour;
• social and cultural norms that promote or glorify violence towards others,
support the use of corporal punishment, demand rigid gender roles, or diminish
the status of the child in parent–child relationships;
• social, economic, health and education policies that lead to poor living
standards, or to socioeconomic inequality or instability.
Prevention - Interventions
Norway:
Politically: 1) Violence against children forbidden since 1981; since 2010:
any violence is forbidden (also that which is part of ’up-bringing’)
2) Under the obligation of UN’s childconvention

Two categories: 1) Health promoting; 2) Prevention of illness

Interventions are:
Universal: towards all people, regardless of risk (all school children, all
parents)
Selective: towards people with increased risk (parents with low income or
psychiatric sufferings, incl traumatization; children with disabilities, etc.)
Indicated: towards individuals that have already been maltreated (to
prevent more abuse, prevent/limit development of symptoms and
additional problems)
Prevention

• Preventing child maltreatment requires a multisectoral approach.

Effective programmes are those that support parents and teach
positive parenting skills.

• These include:
• visits by nurses to parents and children in their homes to provide
support, education, and information;
• parent education, usually delivered in groups, to improve child-
rearing skills, increase knowledge of child development, and
encourage positive child management strategies; and
• multi-component interventions, which typically include support
and education of parents, pre-school education, and child care.
Little Research

• Little research is done on programs that protect against abuse

• Most research focuses on what is helpful to the child after the

abuse has taken place (resilience)

• Best evaluated with regard to prevention of child maltreatment:

Nurse-Family Partnership (NFP) selective home-visiting-program,
towards pregnant women with low income, pregnant with first
child. Has shown effect

• Triple P – Positive Parenting Program: ”Promising”. Different

levels of intervention: universal, selective, indicated.
Other Prevention Programmes
Showing ”Some Promise”

• Programmes to prevent abusive head trauma (also referred to as

shaken baby syndrome, shaken infant syndrome and inflicted
traumatic brain injury). These are usually hospital-based
programmes targeting new parents prior to discharge from the
hospital, informing of the dangers of shaken baby syndrome and
advising on how to deal with babies that cry inconsolably.
Other Preventional Programs…

Programs to prevent child sexual abuse. These are usually

delivered in schools and teach children about:
– body ownership
– the difference between good and bad touch
– how to recognize abusive situations
– how to say "no"
– how to disclose abuse to a trusted adult.

Such programmes are effective at strengthening protective

factors against child sexual abuse (e.g. knowledge of sexual
abuse and protective behaviours), but evidence about whether
such programmes reduce other kinds of abuse is lacking.
Prevention – Early Intervention

• The earlier such interventions occur in children's lives, the

greater the benefits to the child (e.g. cognitive
development, behavioural and social competence,
educational attainment) and to society (e.g. reduced
delinquency and crime).

• In addition, early case recognition coupled with ongoing care

of child victims and families can help reduce reoccurrence of
maltreatment and lessen its consequences.
WHO Recommendations

• To maximize the effects of prevention and care, WHO

recommends that interventions are delivered as part of a
four-step public health approach:
• defining the problem;
• identifying causes and risk factors;
• designing and testing interventions aimed at minimizing the
risk factors;
• disseminating information about the effectiveness of
interventions and increasing the scale of proven effective
interventions.
Prevention –
a ”short-cut” to societal healing?

• Why is prevention difficult?

• Possibilities for the inclusion of preventional interventions in our

daily context?
Thank you for your attention!

Ellen K. K. Jepsen
ellen.jepsen@modum.bad.no