Heather Davediuk Gingrich, Ph.D. Denver Seminary heather.gingrich@denverseminary

1. Restoring the Shattered Self: Complex Traumatic Stress Disorder (CTSD) and MissionariesMental Health and Missions, 2013 Heather Davediuk Gingrich, Ph.D. Denver Seminary heather.gingrich@denverseminary.edu www.heathergingrich.com

2. My Background in this Specialization • Sexual abuse survivors • Dissociative disorders • Other trauma survivors (see Gingrich, 2002) • Research on dissociation and trauma in the Philippines • Recognition of overlap in treatment techniques

3. www.heathergingrich.com

4. Posttraumatic Stress Disorder - even single exposure - natural disasters - rape incident - witnessing violence - combat veterans - primarily cognitive-behavioral treatments - International Society for Traumatic Stress Studies (ISTSS) Complex Traumatic Stress Disorder (Disorders of Extreme Stress) - multiple exposures - incest survivors - child abuse and rape - multi-faceted treatment approaches - International Society for the Study of Trauma and Dissociation (ISSTD) Trauma Field Trauma Psychology, Division 56, APA

5. Posttraumatic Stress Disorder:DSM-IV Criteria • Exposure to traumatic event • Reexperiencing • Memories, thoughts, mental images, dreams, flashbacks • Avoidance/Numbing • thought stopping, social withdrawal, amnesia for the trauma, constriction of affect • Hyperarousal • Irritability, explosive anger, hypervigilance, problems with concentration, difficulty falling and staying asleep • Symptom duration of more than 1 month • Clinically significant distress/impairment in functioning American Psychiatric Association, 2000

6. DSM-5 – Selected Changes inCriteria for PTSD • Criterion A • Sexual assault listed as a possible traumatic event • Additional symptom cluster • Negative thoughts and mood or feelings • an inability to remember key aspects of the event. • Dissociative subtype • chosen when PTSD is seen with prominent dissociative symptoms • depersonalization • experiences of feeling detached from one’s own mind or body • derealization • experiences in which the world seems unreal, dreamlike or distorted. http://pro.psychcentral.com

7. DSM-5 PTSD Dissociative Subtype http://pro.psychcentral.com • chosen when PTSD is seen with prominent dissociative symptoms • depersonalization • experiences of feeling detached from one’s own mind or body • derealization • experiences in which the world seems unreal, dreamlike or distorted.

8. Whatabout Missionaries? Exposure to multiple traumatic events not uncommon Increases risk of PTSD Complex traumatic stress may go unnoticed History of complex trauma can make a missionary more susceptible to being triggered as a result of trauma on the field

9. Purpose of this Presentation Identify complex traumatic stress disorder (CTSD) in missionaries Outline the entire long-term treatment process Focus on how a missionary counselor or a member care worker can help further healing and contain symptoms even with short-term interventions

10. Importance of Subjective Evaluation of Event • “No trauma is so severe that almost everyone exposed to the experience develops PTSD”(McFarlane & Gerolama, 1996, p. 148) • Only 25-35 % of people who are exposed to a potentially traumatic experience develop PTSD (Carlson, 1997, p. 4) • A history of complex trauma increases this probability

11. Role of Peritraumatic Dissociation • “Dissociation at the moment of trauma appears to be the single most important predictor for the establishment of chronic PTSD.” (Van der Kolk, Weisaeth, & van der Hart, 1996, p. 66) • If a missionary has already learned to dissociate as a result of an earlier history of complex trauma they will likely already have learned how to dissociate

12. Other Reasons to Learn About Dissociation • Used by victims of all kinds of trauma • In addition to the link between peritraumatic dissociation and PTSD, there is a well-documented association between trauma and posttraumatic dissociation (see Gingrich, 2005) • Dissociative subtype of PTSD in DSM-5 • Explanation for why treatment techniques for dissociative disorders can also be helpful for other trauma survivors

13. DSM-5-Definition of Dissociation Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience Normal versus Pathological Dissociation

14. CONTINUUM OF DISSOCIATION Adapted from Braun, B. G. (1988)

15. Developing the Capacity to Dissociate • We are born unintegrated (i.e., dissociated) • Healthy attachment leads to integration of behavioral states • Impact of child abuse • Dissociation as a defense • Mental disorder - dissociative disorder/other disorder with dissociative symptoms Putnam, 1997

16. Attachment Style and Dissociation Attuned, “good enough” parenting Secure attachment style Integration of self-states Inattentive/neglectful/abusive parenting Insecure (Ambivalent/Disorganized) attachment style Dissociated self-states (Gingrich, 2013)

17. Dissociative Symptoms • Amnesia:A specific and significant block of time that has passed but that cannot be accounted for by memory • Depersonalization:Sense of detachment from one’s self, e.g., a sense of looking at one’s self as if one is an outsider • Derealization: A feeling that one’s surroundings are strange or unreal. • Identityconfusion:Subjective feelings of uncertainty, puzzlement, or conflict about one’s identity • Identityalteration: Objective behavior indicating the assumption of different identities or ego states, much more distinct than different roles Steinberg (1994).

18. DSM-V Diagnoses Related to Dissociation • Dissociative disorders • Dissociative amnesia • Depersonalization/derealization disorder • Dissociative identity disorder (DID) • Dissociative disorder not otherwise specified • Selected other disorders with significant dissociative symptoms • Post-traumatic stress disorder (PTSD) • Somatic symptom and related disorders • Schizophrenia • Borderline personality disorder (BPD) • Others (e.g., eating and feeding, anxiety)

19. BASK MODEL OF DISSOCIATION • Behavior • Affect (emotions) • Sensation (physical) • Knowledge Full, integrated memory includes all four re-associated components. Braun, 1988

20. BASK - KNOWLEDGE • Trauma survivor has full or partial cognitive knowledge of traumatic event • Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation • Generally what people mean when they say “I remember”

21. BASK - BEHAVIOR • Behavior is dissociated from other aspects of memory • Individual acts in a certain manner without knowing why • Examples: -avoiding intimate relationships -vomiting after sexual intercourse -dislike of particular foods

22. BASK - AFFECT • Affect is dissociated from other aspects of memory • Example: feeling of fear for no apparent reason

23. BASK – AFFECT(continued) • There are no feelings attached to the cognitive knowledge of the memory -flat affect -matter-of-fact tone of voice e.g., can talk about being raped as though discussing the heat of the coming summer

24. BASK - SENSATION • Physical sensation is dissociated from other aspects of memory • Individual may have cognitive knowledge of the traumatic event, be aware of related affect, and understand some behavior, but not remember the pain or pleasure associated with the trauma • Examples: -body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained -sexual excitement

25. BASK Model Gingrich, H. D., 2013, p. 107

26. Three-Phase Treatment Process

27. Rationale for Phase-Oriented Model • Premature trauma processing can lead to destabilization • Hospitalization • Inability to function in job • Difficulty parenting • Basic coping capacities can be overwhelmed

28. Three Phases Phase I – Safety and Stabilization Phase II – Processing of Traumatic Memories Phase III – Consolidation and Restoration

29. Phase 1: Safety and Stabilization Where most missionary counselors/member care workers can be helpful

30. Safety within the Therapeutic Relationship • Developing rapport • Facilitative conditions • Becoming a safe person • Remember that every client is unique • Know your limitations • Give advance warning • Remaining a safe person • Keep appropriate therapeutic boundaries • Consult • Protect confidentiality

31. Safety from Others Helping individuals find physical safety Identifying healthy vs. unhealthy relationships Looking for signs of spiritual abuse

32. Safety from Self and Symptoms • Making sense of symptoms • Symptoms as attempts at coping • Warning signals • Therapeutic use of dissociation • Potentially assess use of dissociation • Somataform Dissociation Questionnaire (SDQ-5 or SDQ-20) (Nijenhuis, 1999) • Dissociative Experiences Scale-II (DES-II) (Putnam, 1997) • Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg, 1993) • Use of parts of self language • Contracting • symptom management • day to day activities • suicide • Ideomotor signaling

33. Phase II - Processing of Traumatic Memories • Readiness for Phase II Work • Memory Work • Nature of memory • Accessing dissociated memories • Deciding where to start • When specific memories do not surface • Is memory recovery the goal? • Facilitating the integration of experience • The importance of details • Titrating the process • Extent to which reexperiencing is necessary • Grounding techniques • Checking in • Memory containment • Structuring the session and counseling relationship

34. BASK Model Gingrich, H. D., 2013, p. 107

35. Phase II - Processing of Traumatic Memories (cont’d) • Facilitating Integration of Self and Identity • Working through Intense Emotions • General principles • Understanding and dealing with specific emotions • Mourning: Denial, anger, and depression • Guilt, shame, and self-hatred • Fear of abandonment • Anxiety, terror, and fear • Roadblocks for counselors • Keeping Perspective

36. Levels of Integration of Self Partial Integration Full Integration No Integration Gingrich, H. D., 2013, p. 121

37. Integration of Self and Experience Gingrich, H. D., 2013, p. 122

38. Is the Goal Full Integration? • Immediate goal is better functioning • Some highly dissociative clients never fully integrate • May be afraid to (i.e., fear of death of parts of self) • Too much work and time • The process of integration can begin to happen from the beginning of therapy

39. Dealing with Spiritual Issues (1) • All phases, but particularly Phases II and III • Gradual, often difficult process • Allow client to set pace • Often are questions re: why God did not protect from the trauma • In time clients can often see that God was there, and is currently involved in their healing process • In highly dissociative clients, some parts of self may have a relationship with Christ, while others may not • E.g., internal Bible study

40. Dealing with Spiritual Issues (2) • Distinguish between parts of self and demonic • Ultimately gift of discernment necessary • Potentially VERY destructive to attempt deliverance ministry • If any kind of deliverance/exorcism ritual is decided upon make sure that the following factors are incorporated (Bull, Ellason, & Ross, 1998): • Permission of the individual • Noncoercion • Active participation by the individual • Understanding of DID dynamics by those in charge • Implementation of the procedure within the context of psychotherapy • See my article “Not all voices are demonic” (Gingrich, 2005b)

41. Phase III – Consolidation and Resolution • Consolidating changes • Development of new coping strategies • Learning to live as an integrated whole • Navigating changing relationships • Marriage and parenting • Friendships • Relationship to God and church congregations • Community • Family of origin • Employment • Confronting the perpetrator • Forgiveness

42. How the Church/Member Care Organization Can Help …1 • Educating about CTSD • Process of healing for the missionary • How they can be of help • Length of commitment • Setting of appropriate boundaries • Self-care for helpers

43. How the Church/Member Care Organization Can Help …2 • Providing emotional and spiritual support • Formal care • Groups • Lay counseling • Mentoring, spiritual direction and life coaching • Assigned helpers • Informal care

44. How the Church/Member Care Organization Can Help …3 • Availability in times of crisis • Phone, email, Skype, prayer chains • Churches, member care organizations and Christian mental health professionals in partnership • Therapist should have one key contact person (e.g., pastor, elder, designated lay helper) who then communicates with other support people

45. What Can I Do with This Info? • Counselor • Be informed • Get training on how to work with CTSD • Pastor/Member Care Provider • Understand the process of healing • Be more empathic • Know what to look for in making a counselor referral • Help gather other resources • Use some grounding techniques

46. References • American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author. • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed). Washington, DC: Author. • Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16-23. • Bull, D., Ellason, J., & Ross, C. (1998). Exorcism revisited: Some positive outcomes with dissociative identity disorder. Journal of Psychology and Theology, 26, 188-196. • Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press. • Gingrich, H. D. (2002). Stalked by Death: Cross-cultural Trauma Work with a Tribal Missionary.Journal of Psychology and Christianity, 21(3), 262-265.

47. Gingrich, H. D. (2005a). Trauma and dissociation in the Philippines. In G. F. Rhoades, Jr. and V. Sar (2005), Trauma and dissociation in a cross-cultural perspective: Not just a North American phenomenon. New York, NY: Haworth Press. • Gingrich, H. (2005b). Not all voices are demonic. Phronesis, (Asian Theological Seminary/Alliance Graduate School, Philippines)12, 81-104. • Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: InterVarsity Press • McFarlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press. • Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum.

48. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press. Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press. van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.