Pre-Conference Session Details
Thursday November 14, 2013
This practical workshop will focus on relational and stabilization skills to improve regulation and decrease the need for dissociation in individuals with Complex PTSD and Dissociative Disorders. Treatment is as much about developmental and relational repair as it is about confrontation of traumatic memories for these individuals. Our clients are impacted not only by overwhelming events and neglect, but by the terrible harm done to their developmental trajectories across the lifespan. These altered developmental pathways include underlying neurobiological changes that impact the very fabric of the clients everyday experience. Clients typically do not have the integrative capacity and skills to resolve traumatic memory without significant therapeutic work to stabilize and build regulatory skills. Attendees will learn specific and practical strategies for increasing the clients ability to reflect; appropriately use both relational and self regulation; resolve inner-directed phobias, such as the phobia of inner experience (e.g., thoughts, feelings, sensations, wishes, needs); develop inner calmness, safety and self-compassion; and to work with dissociative parts of the dissociative client in an integrative way. A specific approach to developing the therapeutic alliance that addresses the clients approach-avoidance strategies in relationships and minimizes dependency will be described.
Have we all gone mad? Understanding and working with complicated client-therapist interactions and covert communications in complex trauma and dissociative disorders.
Su Baker, M.Ed.; John O'Neil, M.D.
Your client comes into the office believing you are a skilled professional, with years of experience treating people with trauma disorders. You feel curious, confident, creative but as always, a little cautious. Fifty minutes pass in a flash and your client leaves the office. You feel frustrated, confused, bewildered, disoriented, frightened, and definitely deskilled. What just happened? Have you gone mad? One of the greatest challenges in the therapy of the developmentally traumatized patient, and especially of the patient with DID, is handling interpersonal patient-therapist complications. These are uncommonly complex because of two aspects of the past that remain present: the trauma suffered, and unmet attachment needs. In the patient with DID, these may be further complicated by simultaneous incompatible ego state-therapist interactions. Often, being in touch with how we feel, think, and act in the therapeutic relationship is the best route to understanding and treating our patients relational needs and the trauma they have suffered.
This advanced workshop will address the use of the framework of therapy, the use of therapists feelings, thoughts, and acts, and the use of dramas inadvertently re-enacted by the therapeutic couple as a guide to the resolution of traumatic and attachment material as it plays out in the therapy. The first half of the workshop will be didactic, a presentation of the role of alter personalities both in traumatic reenacting (through their relationships with each other and their interactions with the therapist) and also in preserving and striving for a secure attachment in the face of fear of attachment and dependency. In appreciating this double role, therapist and patient achieve new and deeper understanding of the process of therapy to repair relational damage.
In the second half, a single clinical case will be presented as illustration. Selected vignettes will be presented from various stages of treatment, which will focus on typical traumatic and attachment issues as experienced by the therapist. Participants will be encouraged to brainstorm with the presenters to deepen understanding and promote clinical skills.
Workshop participants are encouraged to bring in relevant case material to discuss. Such case material may also be translated into role-play in order to underscore the centrality of the process of therapy.
In this workshop, Dr. Silberg will cover some of the key insights that led to her theoretical model and treatment approach. Each of these insights will be illustrated with clinical material that will have applicability to practice with children and adolescents. Issues covered will be --how chaotic systems stabilize, how dissociative states should be seen as processes and not "entities", the important role of attachment in the resolution of dissociative states, the roles families unwittingly play in the encouragement of dissociation, the natural course of the disorder with and without intervention, and the necessary and contradictory stance of the therapist who must believe simultaneously that the client both can and cannot change. These major points will be illustrated with clinical vignettes and client's art work, writings and clinical work. This workshop is appropriate for all clinicians at all levels of skill.
Charles H. Rousell, M.D.
Recovery of trauma survivors requires the detection of a spectrum of dissociative symptoms and disorders, as well as treatment designed specifically to address these disturbances. A significant percentage of survivors of childhood trauma fall into the category of DSM5s Other Specified Dissociative Disorder (OSDD, formerly DDNOS), which is similar to, but not as severe as, Dissociative Identity Disorder (formerly MPD). Unlike those with DID, Other Specified Dissociative Disorder patients do not have overt personality states which spontaneously take executive control of their behavior. Instead they may have developed covert ego states which influence their thought and behavior, and which are often difficult to detect. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D, American Psychiatric Press, 1994) represents a significant advance in diagnosis and assessment of dissociation and can be used to diagnose the dissociative disorders based on DSM-V. Participants will examine video interviews illustrating how covert ego states may be better detected and engaged; how conflicts among ego states may be resolved by using group and family approaches; and how an integrated internal family of ego states may be developed. This course integrates systematic diagnosis of dissociative disorders with the principles of ego state therapy and is recommended for clinical and research professionals working with adults and adolescents with histories of childhood disrupted attachment, neglect, and sexual, physical, emotional, and verbal abuse. The course will utilize lectures, slides, and video sessions with clients.
For many students and emerging professionals who first enter the field of dissociation and developmental trauma, there is often not a great deal of information that describes the theoretical foundations and history of the dissociative field. This workshop is intended for students, emerging professionals and others who are interested in learning about the fundamentals of dissociation as a distinct response to trauma. The premise of this workshop is to cover very basic fundamental information regarding dissociation and the dissociative disorders field. This course will cover 1) basic theories of developmental trauma and dissociation, 2) the history of the dissociative field, including theories and treatment recommendations from the 1800's, through to the eighties, nineties and today, 3) The impact of the false memory "war", 4) finer details of current dissociative models (covering various theoretical foundations, e.g. Structural dissociation, dissociative symptoms/phenomena (the DSM), dissociative defenses, developmental trauma 5) rate and prevalence 6) a breakdown of the dissociative disorders, 7) basic neurobiology of developmental trauma and dissociation, 8) assessment and evaluation, 9) current treatments and 10) a special section dedicate to answering students questions regarding research , academic settings and the academic field of trauma and dissociation. The basic goal of the pre-conference session is to equip those who attend with enough basic information to take into their scholarly or new professional practices as well as have a solid foundation for the rest of the conference.
This workshop is designed to demystify dissociation and provide participants with a broad based understanding of it as a response to overwhelming stress.
Friday, November 15, 2013
Clients with a history of chronic and complex interpersonal trauma often present with diverse clusters of symptoms, relational issues and dissociative defenses that stymie and thwart traditional treatment approaches. They often meet criteria for Borderline Personality Disorder and a range of other disorders as well, including eating disorders, addictions, depression, and anxiety disorders. With such a complex array of emotional and behavioral difficulties, it is no wonder that these clients are so often regarded as the difficult clients. This workshop will focus on clinical concerns and conflicts, common in the first two stages of treatment, which derail the therapy process. This is a practical workshop, emphasizing skills, techniques and perspectives that help the therapist connect with the client and help the client move beyond therapeutic impasses and acting out behaviors. The workshop will also address the common reactions of therapists in situations where the client's behavior leaves the therapist feeling lost, frustrated and confused. The practicum will include opportunities for participants to discuss their own clinical cases and apply the ideas of the workshop to them.
The impact of relational trauma on children is enormous -- the hurt inflicted by those they loved the most, the undying hope that they would be loved back, and the intense pain and confusion of trying to reconcile the utter betrayal by those they call mom and dad. Their only way to survive is to escape from themselves.
This one day advanced workshop will present how the attachment relationship is pivotal to the development of the self. Severe disruption of this relationship caused by neglect, frightening, and frightened behaviors from care-givers leads to an intrapsychic splitting of the growing childs mind. The trauma of relational abuse can have an even greater effect on the child than the actual form of abuse by their caretakers or others. The attachment relationship is also pivotal to the healing process.
We will examine the complexity of the relationship between attachment, trauma, and dissociation, including atypical attachment patterns experienced by traumatized children. The underlying dynamics that inhibit attachment repair and strategies to resolve the dissociative childs attachment dilemmas will be discussed with clinical examples. The discussion will be enriched with clinical vignettes, DVDs and artwork beginning from assessment through integration, with focus on the attachment component.
Temporizing Techniques and Advanced Hypnotic Interventions
Richard P. Kluft, M.D., Ph.D.
This advanced workshop brings together 1) efforts to make the treatment of traumatic material more gentle and tolerable for the patient; and 2) approaches to move assertively toward the completion of trauma work. While these two thrusts would seem to be antithetical, they are two sides of the same coin. Making trauma treatment less painful and demanding requires active and at times even aggressive efforts. The pursuit of safety and stability may require more vigor on the part of the therapist than carrying out the actual trauma work. Hypnotically-facilitated techniques and interventions assist the patient and therapist to become a team accustomed to taking strong, effective steps toward the patient’s recovery. Teaching methods will include lectures, discussion, and Socratic interactions with attendees. Basic knowledge of dissociative disorders treatment and completion of at least a basic workshop in hypnosis is required and assumed. Neither basic hypnosis nor basic trauma/dissociation treatment will be taught. Many topics to be discussed regard painful material. Participation in this workshop may be contraindicated for some conference attendees.
Dissociative and somatoform symptoms do not markedly respond to standard pharmacological interventions. However, opioid antagonists can be successfully used as adjunctive pharmacological agents in conjunction with psychotherapeutic interventions.
The presentation discusses underlying neurobiology of the opioid system, as well as opioid mediated neuromodulation and immune functioning. A specific focus is the role of attachment and stress on opioid mediated CNS function. Further, the role of opioids in the experience and expression of emotions, including active and passive defense responses and sensorimotor functioning is discussed, as well as how this relates to dissociative processes and somatoform dissociation.
It is suggested that opioid antagonists (e.g., Naloxone and naltrexone) bias the nervous system from passive defensive responses like immobilization and dissociative collapse towards either active defensive responses like fight and flight, or alternatively, within an established safe interpersonal or therapeutic relationship, towards an increase in ventro-vagal engagement. A theoretical rationale, as well as specific clinical applications and treatment strategies are discussed using multiple case studies.
Richard J. Loewenstein, M.D., Bethany Brand, Ph.D.
Clients with dissociative disorders (DD) typically present with a complex array of symptoms and comorbid conditions which can make it difficult to correctly diagnose these disorders. Differential diagnosis is further complicated because these patients often have significant mistrust, periods of amnesia for their life history, behaviors and symptoms, and they often elevate on validity scales on psychological tests. This day long workshop will provide an overview of how to accurately detect dissociation and make valid differential diagnoses of dissociative disorders through a specialized office mental status exam and psychological testing.
The Office Mental Status Examination for Dissociative Disorders
Dr. Loewenstein will present his Office Mental Status Examination for Dissociative Disorders during the morning of this day long assessment workshop. The OMSEDD uses a phenomological approach to symptom clusters that commonly appear in patients with DD and complex PTSD. The OMSEDD allows clinicians to explore six symptom clusters that are important to review in making differential diagnoses of dissociative disorders and complex PTSD. A video of a diagnostic interview of a patient with dissociative identity disorder will illustrate Dr. Loewenstein demonstrating how to conduct the OMSEDD.
Psychological Assessment of Dissociative Patients
Dr. Brand will describe ways to manage common assessment challenges such as mistrust, amnesia and conflicting and variable experiences of symptoms. She will review the behaviors exhibited by DD patients during psychological assessment and describe a method for obtaining useful assessment data from them. She will review some trauma-specific tests and structured interviews that are useful in making a differential diagnosis of DD for adults, as well as provide an overview of the research on DD patients’ profiles on structured personality inventories (MMPI-2; PAI) and unstructured performance tests (Rorschach). Research will be presented that provides insights into distinguishing genuine from feigned DID on the Structured Interview of Reported Symptoms (SIRS/SIRS-2) and MMPI-2.
Why is this client population likely to pose ethical dilemmas, experience ethical lapses in their care, and require the clinician to pay special attention to boundary, informed consent, dual roles, personal reactions and overall risk management? More to the point, how can the ethically informed clinician promote a therapeutic alliance that recognizes and resists ethical pressures?
With a particular emphasis on relational themes, using examples drawn from common moments in the work, this fast paced and interactive workshop will enhance your risk management skills, provide immediately useful tools for effective ethical practice under pressure, and in the process, will enhance your own self-care. Zeroing in on common moments & dilemmas in treatment, with group consideration of clinical vignettes, we’ll explore ethical issues and solutions related to reenactment pressures, traumatic transference & counter-transference, strong emotions in client or clinician, unexpected awkward moments, the impact of trance, and the creation of safe and realistic interactional agreements between therapist and client.
Our faculty is warm, compassionate and realistic – each deeply interested in the relationship between ethics and effective practice, and each with their own long-term experience with the territory we’ll explore. We invite you to join us if you too value puzzling through the special dilemmas and exploring the opportunities a focus on ethics can bring to the treatment of complex trauma & dissociation.
[This workshop should meet the continuing education requirements of most licensing jurisdictions.]
Last updated 10/20/2013
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