Listen in to hear Melissa, Bridger and Caleb’s part 2 discussion on “Dependency in the Treatment of Complex Post-Traumatic Stress Disorder and Dissociative Disorders” focusing on the details of dissociation and pragmatics.

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Title: Dependency in the Treatment of Complex Post-Traumatic Stress Disorder and Dissociative Disorders (2001) Onno van der Hart

Overview: 

This article was written by a group that is influenced by psychoanalytic thought, Object Relations Theory and neurobiology. This article is a blend of all three of these concepts/theories. 

 

Recap on Last Episode:

  • We talked about dependency, including both secure and insecure dependency.
  • If you haven’t already, check out our last episode!

The Apparently Normal Parts (ANPs) and Emotional Parts (EPs):

  • ANPs are the parts that we usually show to others the majority of the time. ANPs would be how we’d explain ourselves to others. This comes to the surfaces naturally within interactions.
  • Understand that we have parts of self that are at the unconscious level. This understanding is very beneficial for the therapeutic process, as well as for self-compassion. 
  • Know that ANPs are not alone and that EPs are there as well.
  • ANPs are resistant to the intrusion of EPs because of the effect that comes along with anger, shame, sadness etc.
  • The way the EPs get dissociated is a direct result of trauma. 
  • Was this emotion allowed to be integrated into the rest of their personality or was it not? This most likely resulted in shame, fear, anger etc.
  • ANP learns to “unlearn or forget” the EP. The ANP became angry when the EP presented and remembered because it deliberately tried to make a distinction between it and the EP. The ANP didn’t want the EP to remain a part of them.
  • An EP that houses the state of dependency is relevant to this article.
  • The self is a form of the reflective appraisals of the other through development. EPs are formed through the reflective appraisals of the other and become dissociated because of this. 
  • Refer back to other episodes to see the connection between attachment styles and ANPs/EPs. Both dismissive and avoidant have EPs. 
  • Preoccupied attachment styles have aspects of self that are highly emotional, needy and child-like and since they’ve been helpful in the past, they are still used to getting their needs met.
  • Dismissive attachment styles had experiences where the needy and highly emotional parts were not helpful in their relational interactions and so they become EPs they are dissociated away. 

 

The Framework of Structural Dissociation- Crittenden:

  • Primary dissociation: A single EP and single ANP. This is said to be found in acute PTSD or a single traumatic event. 
  • Secondary dissociation: Two or more EPs and a single ANP. Secondary dissociation is found in PTSD, borderline personality disorder, and dissociative disorder. 
    • Borderline has a bouncing back between EPs. 
    • It is not a logical process of bouncing between EPs because the area of the brain in which it is occurring is not capable of logical/conscious thinking. The dissociation occurs in the reptilian and mammalian brain.
    • It’s not logical, it’s reality.
    • The example of seven trees with roots in the hindbrain. The brain organizes the sensory experience and chooses an effect that will engage behaviors to meet a need or mitigate danger.
    • Affects that are used the most will become the most readily available and those that have been unhelpful will be dissociated away. 
    • Fascia tissue and mycelium networks are so incredibly similar. Like trees, our affects are all interconnected.
  • Tertiary dissociation: Multiple ANPs and multiple EPs. In this article, this would be considered DID. 
    • The complexity of working with DID is each ANP will have a different experience of an EP.
    • The ANP is avoidant and is constantly seeking equilibrium within its system.

 

3 Phase Treatment Model:

  • Symptom Reduction and Stabilization
  • Treatment of Traumatic Memories 
  • Personality Reintegration and Rehabilitation 
  • This is a circular process, not a linear progression. This is a responsive model. 

 

Phobias:

  • Phobia 1: The phobia of attachment and contact with the therapist
    • Revealed in the anchoring and safety in the first couple sessions 
    • As you encounter your client for the first time, their adaptive strategies become enacted immediately. 
    • In context to dependency, this phobia of attachment shows up as the therapist in the first moment we find ourselves wondering “Am I making this too much about me?” This thought can occur when we use a session to explain and talk about how the client is experiencing me as the therapist. 
    • Boundaries are not to block attachment.
    • Integrative capacity
  • Phobia 2: The phobia of mental contents
    • Fear of sitting with thoughts and feeling our feelings.
    • “The Feeling of What Happens”
    • All of our experiences produce images and we have to be aware of these internal images and we have to be able to tolerate them. If they can’t be conscious of it, they won’t be able to integrate it. 
    • Don’t panic about our panic. It’s okay to be overwhelmed by emotion and affect. 
    • A parent who panicked about their child’s life, which then makes them fear the overwhelm of their emotions.
  • Phobia 3: Phobia of dissociative personalities
    • Intersubjective space
    • The therapist’s parts cannot fear the client’s parts.
    • For Melissa, two aspects of self that seem to get rejected and dissociated are anger and sexuality. If we as therapists are unable to tolerate these about ourselves then it will be difficult to tolerate these aspects of a client. 
    • Caleb often sees rage and grief dissociated. 
    • Be aware of our own rejected parts of self.

 

Phase 2: This phase is characterized by deeper restructuring and assessing where these dissociative parts emerged. 

  • Phobia of re-experiencing the trauma again. 
  • Phase 2 phobias are more specific phobias found in phase 1.
  • In phase 2, we are contending with all the old strategies while also trying to activate the traumatic memories for reprocessing. 
  • This phase gives the client a wonderful opportunity for self-compassion and self-understanding. 
  • When traumatic memories are released, this energy can be utilized in reintegration. 
  • Memory reconsolidation 

Phase 3: personality, reintegration and rehabilitation 

  • Phobia of intimacy and normal life
  • There’s almost a timid child-like effect of the positive feeling of the therapist, but not ready to take this out into the real world.
  • Thinking about the experience of feeling their feelings with the support is not the same type of intimacy that is reciprocal. This involves toleration of other’s emotions and affect. 
  • The wishful thinking of the therapist for their clients to have an ability to find intimacy in sexual relationships that is completely safe.

Allowing Access Outside of Session:

  • A client showing dependency can make the therapist automatically want to set stronger boundaries.
  • What if the therapy is working for their phobia of attachment?
  • Try to be upfront and honest to the client about noticing the client needing more contact with you and finding some solutions. Possibly another session during the week.
  • We shout “I’m here for you!” and we whisper, “and you don’t have to have a crisis for my attention.”
  • “As we encourage deep, and at times regressive, independent relationships to develop, to facilitate transference and therefore deeper change, we also implicitly agree to honor the depths and felt life-saving quality of that attachment.”- Dr. Constance Dalenberg