kluft handout only - international society for the study ...€¦ · cannot address hypnotic...

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“That’s why they’re called lessons,” said the Gryphon.

“Because they lessen day by day”

Reflections on the Treatment of DID 1970‐20132013

April 27, 2013Baltimore

Richard P. Kluft, M.D., Ph.D.

Disclosure Statements

Richard P. Kluft, M.D., Ph.D., reports having no financial relationships with any commercial interests or pharmaceutical companies. He will not be discussing the uses of any pharmaceuticals or the off‐label uses of pharmaceuticals in his presentation.

Event Planner Disclosure: The following event planners are reported as g p phaving no financial interest, arrangement or affiliation with commercial interests or pharmaceutical companies, over the past 12 months with pharmaceutical companies whose products may have relevance to the content of this presentation: Ellen Mongan, M.D., Robert Roca, M.D., Steven Sharfstein, M.D., Faith Dickerson, Ph.D., Caroline Cahn, LCSW‐C, Talya Nack, LCPC, Drew Pate, M.D., Desmond Kaplan, M.D., Jennifer Tornabene and Bonnie Katz.

Sheppard Pratt Health System Accreditation Statements

• Physician Accreditation: Sheppard Pratt Health System is accredited by The Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• Psychologist Accreditation: Sheppard Pratt Health System is authorized by the State Board of Examiners of Psychologists as a sponsor of continuing education. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt Health System designates this educational

ti it f i f 1 0 CEU h f P h l i tactivity for a maximum of 1.0 CEU hours for Psychologists.

• Social Work Accreditation: Sheppard Pratt Health System is authorized by the Board of Social Work Examiners of Maryland to offer continuing education for Social Workers. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. This activity is approved for 1.0 CEU contact hours in Category 1 for Social Workers.

• Counseling Accreditation: Sheppard Pratt Health System is an NBCC Approved Continuing Education Provider (ACEPTM) and may offer NBCC approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. This activity is designated for 1.0 contact hours for National Certified Counselors.

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Learning Objectives• Define hetero‐hypnosis, autohypnosis, and spontaneous trance.

• List at least 8 of the over 20 models of dissociation in the contemporary literature.

• Compare the concepts of integration and resolution.

CAVEAT EMPTOR!(Let the Buyer Beware!)

• Because of today’s stringent time limitations, which I shall try to respect, I will move rapidly and may bypass some slides after opening up an area of inquiry. All informational slides are in your hand o ts and ha e been ritten in a mannerhand‐outs, and have been written in a manner that hopefully is self‐explanatory. Consistent with my concerns about the environment, all non‐informational slides have omitted from your hand‐outs. I don’t mind perturbing electrons, but I do try to save trees.

Acknowledgements

• Aaron T. Beck, M.D.• Bennett G. Braun, M.D.• Ira Brenner, M.D.• Dabney Ewin, M.D.• Henri Ellenberger, M.D.

• John Nemiah, M.D.• Bernauer “Fig” Newton,

Ph.D.• Henry Parens, M.D.• Sydney Pulver, M.D.

id i l• Catherine G. Fine, Ph.D.• Edward J. Frischholz, Ph.D.• Selma Kramer, M.D.• Richard Lower, M.D.• Lester Luborsky, Ph.D.• Charles “Chuck” Mutter,

M.D.

• David Spiegel, M.D.• Herbert Spiegel, M.D.• Helen Watkins, M.A.• John H. Watkins, Ph.D.• Joseph Wolpe, M.D.• Many Anonymous Patients

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Reflections on the Treatment of DID/DDNOS – 1970 ‐ 2013

• As this meeting neared, and I began to put my thoughts together, I realized that personal reflections by senior clinicians can prove very boring.

• As I reflected further, I realized that comparing 23 models of dissociation could prove more boring still.

• Neither would be terribly useful to clinicians. • Therefore, looking back on 43 years in the field, I remain a learner still polishing my game, and I will say no more.

• About theories and models, it is probably more important to know how to think about theories rather than learn to recite them. I will try to demonstrate this.

Charles Lutwidge Dodgson

• Better known by his pen name Lewis Carroll, Dodgson was an English writer, Oxford mathematician & logician, Anglican deacon and photographer.

• Born: January 27, 1832, Died: January 14, 1898,

• His tales for children strangelyHis tales for children strangely resemble classical logical arguments reduced to the level of absurdity.

• One of his contributions to logic was so respected that it was republished with comments on the 100th

anniversary of its first publication. It concerns the infinite regress of arguments when two premises are both held to be true, but a conclusion drawn from them can be disqualified.

A Conversation About Learning

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WAELDER’S (1962)LEVELS OF OBSERVATION

• LEVEL OF OBSERVATION

• LEVEL OF CLINICAL INTERPRETATION

• LEVEL OF CLINICAL GENERALIZATIONS

• LEVEL OF CLINICAL THEORY

• LEVEL OF METAPSYCHOLOGY

• LEVEL OF FREUD’S/YOUR PHILOSOSPHY

CHARCOT AND KUHN

• CHARCOT – “A THEORY IS A NICE THING, BUT IT DOES NOT PREVENT OTHER THINGS FROM EXISTING.” (i.e., anything at Waelder’s levels 4‐6 should not be seen as trumping or disqualifying anything at Waelder’s levels 1‐3.)

• KUHN – SCIENCE ADVANCES NOT BY ACCRETION, BUT IN JUMPS. AS ONE PARADIGM REPLACES ANOTHER, DIFFERENT MODELS AND DATA ARE PRIVILEGED. ADHERENTS OF DIFFERENT PARADIGMS VIRTUALLY LIVE IN DIFFERENT WORLDS. (i.e., Who cares about what resides in any of Waelder’s levels if they are YOURS instead of OURS?)

Kuhn and Laor

• Kuhn described how science advances in discontinuous leaps, with each new paradigm in succession privileging certain things as scientific, and casting some beyond the realm of the g yscientific. Adherents of different paradigms can view the same facts and see two different things, and live in different assumptive worlds.

• Laor pointed out that what is cast out may be nonetheless true and valid, even if out of favor.

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A Delicious Irony

• WHEN PARADIGMS CHANGE OR SHIFT, WHAT IS LEFT BEHIND WILL OFTEN INCLUDE VERY SOLID KNOWLEDGE, WHICH IS NO LONGER PRIVILEGED, AND MAY BE DEEMED NO LONGER RELEVANT OR SCIENTIFIC.

• AS A RESULT, PROGRESS CAN LEAD TO IGNORANCE!,

• THE SAME APPLIES EVEN MORE FORCEFULLY TO THE STUDY OF THE WEAK PARADIGMS OF OUR SCIENCE, WHICH ARE MORE LIKELY TO MUDDLE ON ALONGSIDE ONE ANOTHER THAN REPLACE ONE ANOTHER.

• IN EMBRACING ONE PARADIGM, WE MAY LOSE THE GENUINE CONTRIBUTIONS OF THE OTHER.

Three Good Things that Got Lost

• With the Switch from the DES – I to the DES – II the Usefulness of the Instrument Was Reduced.

• The Central Importance of Shame in Promoting Dissociation Was Well‐Known in the 19th Century, But as Interest in Fugue Lessened, So Did Interest in Shame. It had to be reintroduced by Kluft’s promoting the work of Nathanson and Tompkins.

• With a Diminution in Interest in Hypnosis, Much Valuable Knowledge and Many Important Techniques Were Lost or Watered Down.

Looking at Hypnosis

• The following is derived from Spiegel and Spiegel (1978):– Spiegel (1978): Hypnosis is a state of alert concentrated attention such that while certain objects of attention receive the vast majority of the attention, the rest of the j y ,stimuli the world has to offer and the remainder of one’s mental contents do not receive much attention. It involves elements of absorption (the capacity to give something one’s largely undivided and rapt attention), dissociation (the capacity to disconnect the links that usually bind some mental processes to others), and suggestibility.

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Forms of Hypnosis

• Heterohypnosis – Induced by Another• Autohypnosis – Induced by One’s Self• Spontaneous Trance – Inner or External Trigger‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐• Notice that while engaging in heterohypnosis and autohypnosis is subject to voluntary control, spontaneous trance is not.

• Therefore, with a hypnotizable patient, one can never state one is not using hypnosis, only that one is not doing so deliberately.

Hypnosis in Psychotherapy

• Coasting on the patient’s autohypnotic capacities

• Strategic or tactical deployment?

ili i h i i• Facilitating the ongoing process or stepping outside it.

• Imbrication or switching paradigms

The Trauma, Hypnosis, and Dissociation Interface

• TRAUMA CAN CAUSE DISSOCIATION, ONE OF THE COMPONENTS OF HYPNOSIS.

• DISSOCIATION OCCURS IN REAL TIME WITH THE TRAUMA, AND RETROACTIVELY.

• DISSOCIATIVITY IS NOT THE SAME AS HYPNOTIZABILITY, BUT THESE PHENOMENAMAY NOT BE DISTINGUISHABLEBUT THESE PHENOMENA MAY NOT BE DISTINGUISHABLE IF COPRESENT TO A HIGH DEGREE.

• THOSE PTSD PTS. WHOSE COURSE IS CHRONIC TYPICALLY ARE GENERALLY HYPNOTIC HIGHS.

• DISSSOCIATIVE DISORDER PATIENTS GENERALLY ARE HIGHLY HYPNOTIZABLE (DEPERSONALIZATION DISORDER MAY BE AN EXCEPTION).

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Using Hypnosis to Reduce the Dissociative Patient’s

“Home Field Advantage”

• HYPNOSIS IS AN INEVITABLE ASPECT OF THE TREATMENT OF DID/DDNOSTREATMENT OF DID/DDNOS

• THE DESKILLED POSITION OF THE CLINICIAN WHO CANNOT ADDRESS HYPNOTIC PHENOMENA THAT EMERGE.

• ABREACTION AS AN EXAMPLE TODAY.

DISSOCIATIVE SPECTRUM VS. MORE THAN ONE DIMENSION OR FACTOR

OF CONCERN• WHILE MANY ASPECTS OF HYPNOTIZABILITY THAT ARE

DISSOCIATIVE MAY BE UNDERSTOOD TO EXIST ON A SPECTRUM, STUDIES DEMONSTRATE THAT CORE DISSOCIATIVE SYMPTOMS OF PSYCHOPATHOLOGY AREDISSOCIATIVE SYMPTOMS OF PSYCHOPATHOLOGY ARE NOT INCLUDED WITHIN THAT SPECTRUM.

• THEREFORE, THE DISSOCIATIVE DISORDERS (EXCLUDING TRANCE DISORDER) ARE NOT MERELY DIFFERENT POINTS ON A SPECTRUM – THEY INVOLVE DIFFERENT CLASSES OF PHENOMENA.

• KNOWING HYPNOSIS DOES NOT MEAN KNOWING DISSOCIATION, AND VICE‐VERSA.

Another Casualty of “Progress”

• One of the chief arguments made against the use of hypnosis has been the risk of inducing false memories.

• This reached a fever pitch in the mid‐1990s, and teaching about hypnosis plummeted (“lessened”) in ISST&D trainings.

• Left behind in this feverish rush to distance from hypnosis was a classic Sheehan & McConkey article from 1992 that demonstrated h h i d i f h i did i ifthat the induction of hypnosis did not increase memory artifacts –hypnotizability and misleading wording did the job, induction or not.

• Ergo, the dismissal of hypnosis occurred against the backdrop of its innocence of all charges against it. A more scientific approach would have been to teach clinicians to measure hypnotizability and to educate them on the more precise use of language, a skill usually taught where? In hypnosis training!!!

• Love irony? McConkey became a false memory sympathizer.

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DISSOCIATION: THEORETICAL AND PHENOMENOLOGICAL

• IT IS NOT GENERALLY ACKNOWLEDGED THAT DISSOCIATION AS IT IS DEPICTED IN OUR MAJOR THEORIES IS NOT ISOMORPHIC WITH THE DISSOCIATIVE PHENOMENA WHICH WE CONFRONT IN OUR CLINICAL PRACTICE.

• NO THEORY ENCOMPASSES ALL OF THE FOLLOWING PHENOMENA.

• I WILL NOT OFFER A THEORY TODAY, ONLY A WAY OF LOOKING AT THEORIES.

That with Which the Road to Hell is Paved…..

• Two Good Intentions Gone Bad…….

– The Attempt to Separate Normal from Abnormal DissociationDissociation

– The Attempt to Put Forth a Universal Theory of Dissociation and Its Treatment

DISSOCIATION: THEORETICAL AND PHENOMENOLOGICAL

(or, Why Did You Take Us to Middle Earth?)

• IT IS NOT GENERALLY ACKNOWLEDGED THAT DISSOCIATION AS IT IS DEPICTED IN OUR MAJOR THEORIES IS NOT ISOMORPHIC WITH THE DISSOCIATIVE PHENOMENA WHICH WE CONFRONT IN OUR CLINICAL PRACTICE.

• NO THEORY ENCOMPASSES ALL OF THE FOLLOWING PHENOMENA.

• THIS OFTEN IS THE SOURCE OF A RUDE AWAKENING IN THOSE WHO COME TO ME FOR CONSULTATION.

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CORE DISSOCIATIVE PHENOMENA - I

• Observed Categories of Dissociative Phenomena (Kluft, 2008)

1 Al l k li i– 1. Alters, also known as personalities, identities, personality states, etc.

– 2. Identity confusion

– 3. Amnesia

CORE DISSOCIATIVE PHENOMENA - II

4. Compartmentalization/modularity phenomena

a) Alters, as above

b) Segregation of some subsets of information from other subsets of information in a relatively rule‐bound manner (Spiegel, 1986)

c) BASK (Braun, 1988) dimensions (ablative

expressions)

CORE DISSOCIATIVE PHENOMENA - III

• 5. Detachment (as in depersonalization and derealization in the perception of self and/or others and also in concerns over whether memories are real or unreal; also seen in alters’ lacking senses of ownership or responsibility for the actions of other alters)

• 6. Absorption

• 7. Altered states of consciousness (e.g., hypnotic/autohypnotic/spontaneous trance phenomena)

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CORE DISSOCIATIVE PHENOMENA - IV

• 8. Failures of compartmentalization such as intrusion phenomena, including both alters, memories, and BASK (Braun, 1988) di i (i i i )1988) dimensions (intrusive expressions)

CORE DISSOCIATIVE PHENOMENA - V

9. Simultaneous operation of separate self‐ aware processes or states of mind, including parallel distributed processing, elsewhere thought known phenomena (Kluft, 1995), unconscious thought (Dijksterhuis et al., 2006), inner world activities, and creativity by alters not in apparent executive control

CORE DISSOCIATIVE PHENOMENA - VI

10. Simultaneous executive activity by separate self‐aware processes or states of mind (copresence phenomena [Kluft, 1984])

11. Inner world and third reality phenomena (events within that inner world that are accorded historical reality and whichthat inner world that are accorded historical reality and which sometimes intrude into ongoing experiences, and/or impact ongoing experiences from behind the scenes (Kluft, 1998)

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CORE DISSOCIATIVE PHENOMENA - VII

12. Switching and shifting

13. Multiple reality disorder (Kluft, 1991), for which dissociative identity disorder, formerly called multiple personality disorder is thecalled multiple personality disorder, is the delivery and maintenance system.

The Downside of Paradigms

• KLUFT (AFTER LAOR, PERSONAL COMMUNICATION):

– A PARADIGM IS LIKE THE BEAM OF AA PARADIGM IS LIKE THE BEAM OF A SEARCHLIGHT OR LIGHTHOUSE……..

– WHAT IT ILLUMINATES, IT ILLUMINATES

WITH TREMENDOUS CANDLEPOWER, BUT

WHAT FALLS OUTSIDE ITS BEAM IS RAPIDLY SHROUDED IN DARKNESS.

What Gets Lost? How Many of 23 Models of Dissociation Address These Core Phenomena?

Included: Clearly Partially/Vaguely All1. Alters 6 4 102. Identity Confusion 2 5 73. Amnesia 9 4 13 4. Compartmentalization 14 1 155 Detachment 5 2 75. Detachment 5 2 76. Absorption 3 0 37. Altered States 3 3 68. Failed Compartmentalization 3 3 69. Simultaneous Self‐Awareness 5 510. Simultaneous Executive Capacity 7 2 9 11. Inner/Third World Phenomena 5 3 8 12. Switching/Shifting 9 3 1213. Multiple Reality Disorder 2 3 5

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Ergo…..

• You have heard about the blind men and the elephant…

• The average model, given the benefit of the doubt of the total score, addresses 4.7 of the 13 core phenomena.

• No single model is adequate to encompass the broad realm of dissociative phenomena or to guide clinical decision‐making, notwithstanding that model’s use in research or theory‐building.

• Only 3 of 23, or 13% address absorption, the core phenomenon of normal dissociation and a core phenomenon of hypnosis.

Back to the Road to Hell…..

• The capacity to manifest hypnotic phenomena is genetically driven, and the genetic elements associated with higher hypnotizability are associated, not surprisingly, with aspects of attention. (Raz, et al., 2006)DID h th hi h t h ti bilit f• DID has the highest average hypnotizability scores of any condition, even though cooperation with the scales can be iffy. (Frischholz, et al., 1992).

• Hypnosis will occur in treatments of DID/DDNOS regardless of the wishes of therapist and/or patient.

• Formulations that omit absorption/hypnosis are taking a rather curious course of action……

The Normal/Abnormal Dissociation Perplex ‐ I

• Many scholars and groups have taken pains to try to distinguish normal dissociation, which is mostly a phenomenon of absorption, from pathological dissociation, which involves more classic dissociative disorder symptomatology. They start at Waelder’s higher levels.

• These arguments while of hermeneutic value bypass theThese arguments, while of hermeneutic value, bypass the fact that sustaining most pathological dissociative phenomena in fact involves redistribution of attention and sustained absorption in those redistributions.

• Ergo, pathological dissociation depends for its survival on so‐called normal dissociation, that aspect of dissociation that most overlaps with hypnosis. For sustained dissociative symptomatology, you can’t have one without the other.

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The Normal/Abnormal Dissociation Perplex ‐ II

• Recall that only 3/23 models made room for absorption, despite high absorption being a major aspect of DID/DDNOS patients.

• Despite their own expertise in hypnosis, the p p yp ,developers of a major theoretical model gaining ascendance world‐wide, Structural Dissociation (Van der Hart, Nijenhuis, & Steele, 2006) somehow managed to virtually omit it!

Structural Dissociation (Van der Hart, Nijenhuis, & Steele, 2006)

• OF THE 13 MAJOR PHENOMENA, 4 ARE ADDRESSED WELL, AND 3 MARGINALLY OR BY INFERENCE IN THIS MODEL.

• HYPNOSIS IS MENTIONED TWICE IN THEIR BOOK’S INDEX, BUT ONLY ONCE IN THE TEXT, AND THERE, IN PASSING, AS PART OF A LIST.

• OF ALL DEVELOPMENTAL LINES, ONLY ATTACHMENT IS ADDRESSED.

• ITS DEFINITIONS EXCLUDE MOST EARLY CASES, DECONTEXTUALIZING IT FROM MUCH LITERATURE.

ANOTHER LAYER OF IRONY

• Van der Hart, Nijenhuis, and Steele are all master clinicians. In their practice, they all use approaches they omit from their book.

• Last spring, Ellert Nijenhuis and I debated p g, jtheoretical issues in Stuttgart. We were worlds apart.

• At lunch, discussing cases, we were surprised to find that we were virtually identical twins re: what we would do in a given circumstance.

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Conclusion:

• In effect, most of our major theorists tend to forget or dismiss their roots and talk up what they perceive as uniquely their own.

• They behave like the hypocritical (i e typical)• They behave like the hypocritical (i.e., typical) parent who admonishes a child to:

– DO AS I SAY, NOT AS I DO!!!!

Moving On….

• We will discuss five clinical issues that may be of direct and pragmatic help to those who work with DID/DDNOS patientswork with DID/DDNOS patients….

• Note that these are bottom‐up Waelder 1‐3 matters and derived from the clinical experience of one clinician who has brought over 200 DID patients to integration.

Five More or Less “Lessened” Clinical Issues, 4 of 5 Hypnosis‐Related

• The Importance of Addressing Alters

• The Importance of Integrating Alters

• The Importance of Shame Reduction

• The Importance of Fractionated Abreaction

• The Importance of Adequate Closure for Therapy Sessions

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TWENTY REASONS TO ADDRESS ALTERS DIRECTLY - I

• It is intriguing to observe the passion with which some continue to argue against this practice.

• Here I will only note some reasons for yaddressing them directly, noting in passing that shame reduction and hypnotic interventions are the best ways of reaching and working with them.

• I will not comment on all 20, just a few.

TWENTY REASONS TO ADDRESS ALTERS DIRECTLY- 2

1. ACKNOWLEDGING THE DISSOCIATIVE SURFACE

2. DECODING THE DISSOCIATIVE SURFACESURFACE

3. MAKES ALTERS STAKEHOLDERS, INVESTED IN THE TREATMENT

4. PUTTING THE “HOST” IN PERSPECTIVE

TWENTY REASONS TO ADDRESS ALTERS DIRECTLY -3

5. APPROACHING RELUCTANCE RESPECTFULLY, FACILITATING PERSUASION

6. DECLINING TO COLLUDE WITH AVOIDANCE

7. UNDERSTANDING ALTERS/ALTERS’BEHAVIOR AS COMMUNICATIONS OF VITAL PSYCHODYNAMIC MATERIAL

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TWENTY REASONS TO ADDRESS ALTERS DIRECTLY- 4

8. ERODING AMNESIA BY ENGAGING THE ALTERS

9. EXPLORING AND RELIEVING SYMPTOMS DUE TO ALTERS’SYMPTOMS DUE TO ALTERSINTRUSIONS

10. DISABLING “BEING NORMAL” AS SELF-SABOTAGE

11. ENHANCING THE IMPACT OF EMPATHY


12. BRINGING “ABUSER ALTERS” INTO TREATMENT

13. NEGOTIATING WITH ALTERS AS AN ASPECT OF TREATMENTASPECT OF TREATMENT

14. MOBILIZING CURRENTLY INACCESSIBLE SKILLS

15. CREATING INTERACTIONS THAT ANTICIPATE INTEGRATION


16. REACHING OUT TO AND ENLISTING ALTERS IN THE THIRD REALITY

17. RESOLVING SHAME FACE-TO-FACE

18. ENLISTING MORE MATURE ALTERS TO CARE FOR CHILD ALTERS (PUTNAM)

19. AVOID RE-ENACTMENTS OF REJECTION AND NEGLECT

20. PAVING THE WAY FOR INTEGRATION

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16. REACHING OUT TO AND ENLISTING ALTERS IN THE THIRD REALITY

17. RESOLVING SHAME FACE-TO-FACE

18. ENLISTING MORE MATURE ALTERS TO CARE FOR CHILD ALTERS (PUTNAM)

19. AVOID RE-ENACTMENTS OF REJECTION AND NEGLECT

20. PAVING THE WAY FOR INTEGRATION

Why Push for Integration?

• “As for integration, we don’t even talk about that any more…” (Keynote Speaker, ESTD, March, 2012)

• Against the rationales that minimize its importance, and against the argument it is impossible because of ego state considerations (a perspective considered laughable by egoconsiderations (a perspective considered laughable by ego state therapy’s innovators, John and Helen Watkins, who gave patients the option of pursuing integration) there is…

• The fact that such arguments bypass risks of evasion of crucial issues, that ongoing multiplicity perpetuates multiple reality disorder and trance logic in daily life, with greater vulnerability to both relapse and to revictimization.

Steps Toward Making Trauma Therapy Less Traumatic

• Earlier, I fibbed a little. I actually will reflect on 43 years of treating DID/DDNOS.

• The main objectives I have tried to work toward and the changes in technique and philosophy I have adopted have concerned making treatment less traumatic for my patients. Gentle but firm treatments are more rapid for most (but not all) patients because there are fewer crises and complications. This leads to my axiom, “The slower you go, the faster you get there.”

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The Metaphor of the Matador

• No matador fights an intact bull.• In preliminary events, the picadors and banderilleros weaken the neck muscles of the bull to make it possible for the matador to survive the encounter and kill the bull with a rather puny sword specialized for d li i ti l ki d f bldelivering a particular kind of blow.

• If I envision overwhelming trauma as a ferocious and dangerous adversary to our patient, Shame Work and Fractionated Abreaction are my Picadors and Banderilleros.

• I take steps to weaken the adversaries over which my patients must achieve victory.

Shame

• “Reading Nathanson’s Shame and Prideresulted in an overnight 10‐15% improvement in my effectiveness as a therapist.” (Kluft, 1991‐2.)

• Much of what passes for dissociation is motivated withholding, motivated by fear of shame.

• Shame reduction work before trauma work facilitates the processing of painful material.

Definitions/Descriptions of Shame

Tomkins:

“If distress is the affect of suffering, shame is the affect of indignity of transgression and ofthe affect of indignity, of transgression and of alienation. Though terror speaks to life and death and distress makes of the world a vale of tears, yet shame strikes deepest into the heart of man.”

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Definitions/Descriptions of Shame

Tomkins (continued):

“While terror and distress hurt, they are wounds inflicted from outside which penetrate the smooth

f f h b h i f l isurface of the ego; but shame is felt as an inner torment, a sickness of the soul. It does not matter whether the humiliated one has been shamed by derisive laughter or whether he mocks himself. In either event he feels himself naked, defeated, alienated, lacking in dignity or worth.”

Shame: A Negative Innate Affect

• Negative (II)– 9. Shame-

Humiliation

• Eyes down, head down and averted, blush

Scripts (Nathanson, 1992)

Intimately associated with affect is our history of reaction to it…So complex and pervasive are the habits and skills of script formation that we adults come to live more within these personal scripts for the modulation and detoxification of affect than in a world of innate affect…When an event occurs, we analyze it to see if it fits into a script; we try to interpret it as one of a series of events that has been analyzed before.

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The Compass of Shame

Withdrawal

Attack Other Attack SelfAttack Other Attack Self

Avoidance

Shame Cognitions and Dissociation

• The History of the Dissociative Disorders Demonstrates that Shame/Guilt Can Trigger Dissociative Amnesia, Dissociative Fugue, and Dissociative Disorder NOSDissociative Disorder NOS.

• Therefore, Every Pressure that Facilitates a Flight from Self Holds the Potential to Initiate, Activate, and/or Reinforce Dissociation

Shame Augments Dissociation

• No shame script involves accepting what is considered unacceptable.

• Shame is associated with superego injunctions to rid one’s self of or to avoid the nacceptablerid one s self of or to avoid the unacceptable.

• In shame, the individual is shorn from the herd; the same applies in the alter system.

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Treatment Implications of Imbricating Innate Affect Theory within the Treatment of DID I

It allows the therapist to approach all alters in a way that enhances the therapeutic alliance, because unlike working with trauma per sebecause unlike working with trauma per se, which many DID patients avoid, shame is always dysphoric, and the DID patient is always eager to reduce it.

Treatment Implications of Imbricating Innate Affect Theory within the Treatment of DID 2

• It reduces an alter’s motivation to distance itself from and/or suppress and/or attack other alters whose behavior or experiences it pconsiders unacceptable and ego‐alien.

• It leads to work on the disgust and dissmell affects, which further instigate and augment the pressure to dissociate and disavow particular alters or experiences.


Exposure is an essential aspect of successful trauma treatment. All shame scripts undermine exposure to affect, memories, and to crucial alters in the treatmentto crucial alters in the treatment.

Therefore, any reduction of excessive shame scripts facilitates toleration of exposure, encouragement of extinction, and integration.

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• After working with shame, DID patients find it easier to work directly on trauma.

• Avoidance and disavowal behaviors are reduced, facilitating psychotherapy.facilitating psychotherapy.

• Much of the behavior associated with ATTACK SELF and ATTACK OTHER scripts, which may result in a phenocopy of borderline phenomena, is reduced, leading to fewer crises, parasuicidal and suicidal behaviors, and hospitalizations, as well as fewer countertransference pressures.


Shame Script work offers an approach to work with the sexually-oriented and

ll i l h fsexually aggressive alters that are often difficult to manage and involved in the boundary violations that occur in therapist-patient sexual exploitations.


• Since the antidote to shame is competence, the patient is implicitly being coached toward mastery throughout the treatment.

• Since m ch navailable memory is withheld d e• Since much unavailable memory is withheld due to shame-related concerns, a treatment prioritizing shame management creates conditions favorable to sharing the previously withheld memories.

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Abreaction/Fractionated Abreaction

• Spontaneous abreactions tend to occur about 38 minutes into a 45 minute session.

• That often creates painful and difficult situations for patient and therapist alike.

• Classic abreactions (to the point of extinction)• Classic abreactions (to the point of extinction) can be lengthy, exhausting, and destabilizing.

• Flooding, Implosion, or prolonged exposure can be problematic for vulnerable traumatized populations.

• What is one to do?

Moving Toward a Solution….

• Many techniques were already in place that approached problems in a gradual and systematic manner, and that curtailed intrusive thoughtsintrusive thoughts.

Hypnosis and The Fractionated Abreaction

• It will be apparent that many techniques I will mention in passing in connection with The Fractionated Abreaction are hypnotic or hypnotic in origin.

• In order to focus on The Fractionated Abreaction, I will not linger over those others.

• Over recent years, much of what I have developed emerged in the context of collaboration and discussions with one gifted colleague.

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Special Acknowledgment

• I have worked for over 30 years in close association with an amazing colleague to whom I owe a profound debt of gratitude.

• Catherine G. Fine, Ph.D., and I developed a great number of ideas and techniques together Innumber of ideas and techniques together. In particular, she played a major role in developing The Fractionated Abreaction Technique, and has published her own version of this approach.

• Catherine G. Fine, Ph.D., also was my own role model for conceptualizing treatment sans hospital.

Fractionated Abreactions - I

• Indications:A. Compromised Ego StrengthB. Compromised Physical Strength and EnduranceC. Intercurrent StressorsD. Logistic Constraints

• Goals:A. Minimize RegressionB. Enhanced MasteryC. Self-Control of Spontaneous Abreactions and/or

FlashbacksD. Cognitive Corrections

Fractionated Abreactions - II

• Dimensions Suitable for Fractionation:

A. Temporal Sequences

B. Percentage Titrations

C Input DivisionsC. Input Divisions

(BASK Dimensions)

D. Alter Participants

(sequentials, overflows, numbers, protectors)

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Fractionation Subtypes

• Fine (1991, 1993) BASK‐Based Successive Approximations

l f ( 988 990) i i h• Kluft (1988, 1990) Mini‐Me Approaches

• Kluft (2012, 2013) Full Approach Published

Example of Fractionation

• Sandra (see Kluft, 2013, pp. 90‐91)

– Breaking down her father’s approach to her bedroom and subsequent sexual assault into smaller action segments. Abreact & process & g pstop. (That is a Mini‐Me F.A.T. – 1st dimension.)

– The affect could be ratcheted down (– 2nd)

– All alters but one could be put to sleep or distracted (‐3rd)

– Either affect or sensation could be ablated (‐4th)

Session Closure

• The most important achievement of any session is for the patient to leave in a stabilized condition.

• “Grounding” is a limited concept• For more reliable closure and restabilization:Th T ibl T• The Terrible Ts1) Truncate and Terminate Trauma Processing2) Truncate and Terminate Turmoil and

Trepidation3) Truncate and Terminate Trance

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Truncate and Terminate Trauma Processing

• Interruption (Beck, 1986)• Implicit or Explicit Rain checks• Interruptions and Eliciting Others’ Comments/Feedbacks‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐• Directive Countdowns if Necessary• Directive Countdowns if Necessary• Alter Doing Processing Steps Back and Enters Restorative

Situation or Therapeutic Sleep• Time Distortion• Screen Manipulations• Slow Leak Suggestions• Protective Barriers

Truncate and TerminateTurmoil and Trepidation

• Placing the affected alters and dsyphoria outside the mainstream of daily life.

– Realistic reassurance

– Compass of Shame work

– Safe Places, Diversions, Inactivations

– Scans, ideomotor and alter system

– Vaults and Time Locks

– Reconfigurations

Truncate and Terminate Trance

• Up to 85% of high hypnotizables who state that they are out of trance in fact remain somewhat entranced or in waking hypnosis (Kluft, 2012).

• Therefore, a therapist’s impression or a patient’s statement may not be accurate.

• While such concerns have been trivialized, a review of the characteristics of a person in trance may be informative.

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Characteristics of a Person in Trance

• “Of additional importance to the clinical encounter with dissociative patients is a phenomenon little noted outside the field of hypnosis: Highly hypnotizable individuals are vulnerable to slipping into alert trances in which, with eyes wide open, they manifest many of the qualities of the more formally and traditionally hypnotized subject. That is, they y y yp j , ymay demonstrate (among other phenomena) a decline in their generalized reality orientation (Shor, 1959) a reduction in the alertness and activity of their critical intellect, a toleration of mutually incompatible perceptions without reacting to their incompatibility (trance logic; Orne, 1962), the intensification of affect, rapid mobilization of transference phenomena, and an increased responsiveness to suggestions.” (Kluft, 2012)

A Clinical Dilemma with Ethical Dimensions

• Would you want your patient, your loved ones, or yourself to walk out into the world and conduct your life with those vulnerabilities in place?

• Because passive permissive methods of realerting are in vogue, it is important to understand that recent research (Kluft, 2012) has demonstrated that they don’t work well.

• Directive methods are far more successful.

But….

• How do you get a person out of trance, when the state of hypnosis has yet to be defined in a way that is generally accepted?

• How do you know that you are out of what it is hard to be sure that you are or were in?hard to be sure that you are or were in?

• Enter another former student of mine, HedyHoward, M.D., now a colleague, who studied hypnosis with Peter Bloom, M.D., and now practices in the Washington, DC area. She solved a problem that had puzzled and stumped hypnosis scholars since the time of Mesmer.

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Howard’s Solution

• If all these great scientists could not solve this problem, I can’t either. Unless…..

• (Shades of Captain James Tiberius Kirk, who, as all Trekkies know, cracked the “unsolvable” Kobayashi Maru Problem)

• Kobayashi Maru: “A no‐win situation caused by a set of rules that can only be won by changing the rules in effectrules that can only be won by changing the rules, in effect, cheating.” (The Urban Dictionary)

• Dr. Howard found a phenomenon that co‐occurred with hypnosis that could be operationalized and measured. In a matter of weeks, she solved a problem that had left the best minds in hypnosis stumped.

• Like many great ideas, it is sheer simplicity: track alertness. All hypnotic phenomena imply decreased alertness.

Howard Alertness Scale ‐ I• Howard Alertness Scale

• 1. Pre‐hypnosis:

• We are going to measure how alert you are at this time. This will be measured on a scale from one to ten. On this scale one represents a very low level of alertness, and ten represents a very high level of alertness.

• To help you assess your level of alertness you will be asked to pay attention to the different ways that you perceive your environment, and also to the way that you are thinking. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

T k t t ti h k d l t f l t thi ti G th i f ti• Take a moment now to notice how awake and alert you feel at this time. Gather information from all your senses:

• Look around you and notice the various things that you see. Notice how the images appear and the clarity, the color. Notice the sounds around you and the quality of whatever you hear. Notice the feelings in your body including the feeling of the chair against your body and the feeling of your feet against the floor.

• Notice how connected you feel to your body and how aware you are of your surroundings

• Notice how present you feel in this time and place.

• Notice how clearly and logically you are thinking, and how your mind moves from thought to thought as you focus on different things around you.

Howard Alertness Scale ‐ II

• On a scale from 1 to 10, where one is very low, 2 is low, 5 is medium, 9 is high, and 10 is very high, find the number that best describes how alert you feel right now.

• (Circle subject’s level of alertness)I 2 3 4 5 6 7 8 9 10

• very low low medium high very highvery low low medium high very high • 2. Post‐hypnosis • On a scale from 1 to 10, where one is very low and 10 is very high, what

number best describes how alert you feel right now? • (Circle subject’s level of alertness)

• (Circle subject’s level of alertness)I 2 3 4 5 6 7 8 9 10

• very low low medium high very high

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A Suggestion

• This modification (Kluft, 2011) is being considered for inclusion in the revised HAS.

• Ask the subject to note an experience in each of several sensory modalities or senses of self, y ,and to scale them.

• On recheck, see if all of those have returned to baseline.

• This is more concrete, and more subjects give candid and useful answers.

Conclusion

• The most important dimensions to the treatment of DID/DDNOS are not those that conform with a particular theory or model of therapy, but those that enhance its safety by facilitating the compassionate empathic connection and holding p p genvironment that develops between therapist and patient. Techniques that support those endeavors and goals are invaluable. Working with the alters, shame reduction, and fractionated abreaction are among them, and hypnosis is invaluable in supporting those endeavors.

Selected References ‐ I

Fine, C.G. (1991). Treatment stabilization and crisis prevention: Pacing the therapy of multiple personality disorder patients. Psychiatric Clinics of North America, 14, 661‐675.

Fine, C.G. (1993). A tactical integrationalist perspective on the treatment of multiple personality disorder. In R.P. Kluft, & C.G. Fine (Eds.), Clinical perspectives on multiple personality disorder (pp 135 153) Washingtonperspectives on multiple personality disorder (pp. 135‐ 153). Washington, DC: American Psychiatric Press.

Fine, C.G. (2012). Cognitive behavioral hypnotherapy for dissociative disorders. American Journal of Clinical Hypnosis, 54, 331– 352.

Howard, H. (2008). Howard Alertness Scale. Reproduced, with permission, in Kluft (2013). (original almost impossible to access)

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Selected References ‐ II

Kluft, R.P. (2007). Applications of innate affect theory to the understanding and treatment of dissociative identity disorder. In E. Vermetten, M. Dorahy, & D. Spiegel (Eds.), Traumatic dissociation: Neurobiology and treatment (pp. 301‐316). Washington, DC: American Psychiatric Press.

Kluft, R.P. (2012). Kluft, R.P. (2012a). Hypnosis in the treatment of Dissociative Identity Disorder and allied states: An overview and case study. South African y yJournal of Psychology, 42, 146‐155.

Kluft, R.P. (2013). Shelter from the Storm. North Charleston, SC: CreateSpace Independent Publishing Platform.

Nathanson, D.L. (1992). Shame and pride. New York: Norton.

Putnam, F.W. (1989). Diagnosis and treatment of MPD. New York: Guilford.

kluft handout only - international society for the study ...€¦ · cannot address hypnotic...

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