Review: Healing the Fractured Child Chapter 1 Part 2

 

“The brain functions in different states, much like a radio operates at AM and FM frequency bands…the brain is normally tuned to FM stations to access memories, but needs to be tuned to AM stations to access traumatic memories”- Jelena Radulovic

The reason for the part 2 of this chapter review is because of the central importance of Porges’ Polyvagal Theory, Bowlby’s Five Stages, and Perry’s Use-Dependent Development of the Brain Theory.

The Polyvagal Theory is an incremental part of conceptualizing dissociation. The theory is based on Porges’ finding that there is a third Autonomic Nervous System (ANS) (Parasympathetic, Sympathetic, Social Engagement). These 3 systems are also evolutionarily built from primitive to higher functioning systems.

This Social Engagement system is responsible for a persons ability to connect and respond to others socially.

One way  to explain the Polyvagal theory is through the use of a traffic light. The nervous system uses a scanning process of the environment called neuroception which acts as the brake system of a car and based on what is observed in the surroundings the switching of these different systems will occur (Porges, 2011).

Green Light (Social Engagement)– In this physiological state, the body presents with the following: slower heart rate, saliva, and digestion are stimulated, facial muscles are activated, increase eye contact and vocal tone, and middle-ear muscles turn on (Porges, 2011).

Fran (2016) emphasizes the importance of understanding this system by stating

The most advanced branch of the ANS is the social engagement system. It is mediated by the myelinated portion of the vagus nerve and fosters social communication and maternal bonding via facial expressions, vocalization, and listening. (p. 17)

Yellow Light (Sympathetic)– danger-fight or flight response is activated within this state, also the following: heart speeds up, pain tolerance goes up, flat facial affect, middle ear muscles turns off-hearing restricted to low and high frequency sounds  (Porges, 2011).

Red Light (Parasympathetic)– life threat-immobilization/freezing, and death feigning response is activated (dissociation falls under this parasympathetic system). Physiologically this presents as the following: turning off behavior and consciousness through reduced heart rate and blood pressure.  (Porges, 2011).

The vagus nerves acts a neural braking system either easing off the brake to move towards social engagement or putting the pedal to the floor for dissociative reaction to life threat.

Now that an understanding of the physiological structure of the autonomic nervous systems’ involuntary wiring due to trauma has been explored Fran utilized Bowlby’s model to connect attachment theory and trauma theory.

Fran relies on Bolwby’s Five Stages of Psychological Response to Grief and Mourning to bridge the gap between attachment theory and dissociation. Although, Bowlby’s whole attachment theory is the bedrock for the STM model.

The Five Stages of Grief act as a connection in that every trauma that a child experiences from a caregiver is a loss of the caregiver. The stages are as follows:

(1) Thoughts and behaviors still directed towards the lost object.

(2) Hostility towards others.

(3) Appeals for help.

(4) Despair, withdrawal, regression, and disorganization.

(5) Reorganization of behavior directed toward a new object.

This is a benchmark when evaluating and assessing traumatized youth it is not exhaustive, sequential, or deterministic for each child. Children can navigate through all of these stages or not, nor do children necessarily develop discrete self-states as a result of the trauma. This is a lens for trauma assessment through the eyes of attachment theory.

Lastly, Perry’s work on the Use-Dependent perspective on the brain is a lens for the STM model. This theory is a way to conceptualize how trauma changes brain structure in youth. Fran harkens to Perry’s explanation of this theory when he stated

…repetitive neural activation caused by repeated exposure to threatening stimuli causes sensitization of the nervous system. The more a neural network is activated, the more there will be use-dependent internalization of new information needed for survival. The more frequently a certain pattern of neural activation occurs, the more indelible the internal representation” (p. 18)

The internal representation becomes a template from which the child understands experiences moving forward. This also could be the reason why self-states can be trait-oriented such as being the angry or sad part. Because the brain utilizes these internal representations to manage new experience the consistent use entrenches these internal representations into discrete self-states that are characteristic of Dissociative Identity Disorder.

All of these theories and their constructs act as the infrastructure to the Star theoretical model. Each of these theories provides interpretive power and a lens to assess and treat the multi-dimensional impact of trauma.

Next time I will be reviewing chapter 2 What’s Going On With This Child? Recognizing Warning Signs of Dissociation in Traumatized Children. 

 

Reference:

Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W.W. Norton.

Waters, F.  (2016). Healing the fractured child: Diagnosis and treatment of youth with dissociation. Springer publishing company.

Medications and Dissociation

When it comes to the treatment of cPTSD and DID there are no medications that successfully treat these diagnoses.

This can be disheartening because at times the symptoms from these diagnoses can feeling crippling and uncontrollable.

From the research and speaking with other Dissociative therapists, there are a couple of medications that are promising for the treatment of some of the symptoms of these disorders.

The first one that I have encountered and witnessed the effects of is Prazosin which is a sympatholytic medication. This medication has been shown effective in treating the nightmares that those suffering from these disorders can experience. This medication has not been a struggle for clients to be prescribed as it has approved for treating PTSD.

The second one that I have had some experience with albeit small is Naltrexone. This medication is primarily utilized to treat and prevent relapse with substance use. This medication is an opioid antagonist and works to block the opioid receptors in the brain.

Why would this medication be helpful to cPTSD and Dissociative clients?

Well, I will not get into the dense science to it but can suggest for further explanation refer to Neurobiology and treatment of traumatic dissociation: Towards an embodied self (Lanius et al., 2014). The authors do a great job explaining the science behind why Naltrexone is a helpful medication for this demographic.

The gist that I can describe is that dissociation uses opioid pathways in the brain in order to dissociate. Naltrexone blocks one or all of the receptors of opioids (depending on the dosage).

The research indicates that it can be helpful in decreasing depersonalization, derealization, less uncontrolled switching, as well as increased capacity to do ego states interventions” (Lanius et al., 2014, p. 503).

Side effects are low for this medication, and when utilizing low-dose regimens of Naltrexone they are even lower.

This medication is not FDA approved for the treatment of dissociation and therapeutic use for this medication would be off-label use. My experience has been that some insurance companies will agree to cover the prescription, and others will not.

It also can be a challenge to find psychiatrists or psychiatric nurse practitioners to prescribe the medication if is not the FDA approved use of the medication. Although there are some who are willing and knowledgeable of dissociation and treating it.

The final caveat of struggle when it comes to effectively utilizing this medication therapeutically is that getting the right dosing.

Naltrexone comes in 50mg and the recommendation based on the research is that low-dose may be more beneficial. The suggested dosing is “0.06mg per kg of body weight” (Lanius et al., 2014, p. 503).

The suggestion is to have the prescriber work with a compound pharmacy who can make the smaller dosage, but this could come as a struggle with insurance covering the prescription. I have seen clients easily get a 50mg prescription covered, but the compound pharmacy is not approved and the client had to shell out the full price for the medication.

My suggestion if all else fails one could potentially resize the dosing on their own with gelatin capsules, and a milligram scale that could go down to the 0.001 g.

All this to say there is ground being broken to provide some relief to the particular symptoms of dissociative disorders, and it might be worth exploring with a psychiatrist.

Medical Disclaimer: This Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical condition.

Reference:

Lanius, U. F., Paulsen, S. L., & Corrigan, F. M. (Eds.). (2014). Neurobiology and treatment of traumatic dissociation: Towards an embodied self. Springer Publishing Company.

Review: Healing the Fractured Child Chapter 1 Part 1

http://www.springerpub.com/healing-the-fractured-child-9780826199638.html

One of the most influential books that I utilize when it comes to the treatment of traumatized and dissociative clients is Fran Waters’ book Healing the Fractured Child Diagnosis and Treatment of Youth with Dissociation. I cannot recommend this book enough to practitioners and parents and as I was thinking about recommending it I decided to do a chapter by chapter review of Fran’s work.

First, before I get into the content of chapter 1 it would help to understand the structure of the book. The book is segmented into 3 parts: Theory, Assessment, and Treatment. So the first few chapters deal primarily with theory; specifically the theories that influence Fran’s model- The STAR theoretical model for assessment and treatment of childhood dissociation.

Fran’s work is built off a model that she developed as she worked with dissociative youth. The model that was created in order to develop a framework for understanding the mental health presentation that she was seeing in these youth. Initially, she created what she coined the Quadri-Theoretical Model which incorporated the work of attachment, child development, family systems, and dissociative theory. As she was influenced by neurobiology she adapted this model into the Star Theoretical Model (STM) because the findings were helpful in understanding the diagnostic makeup of dissociation.

The purpose of the model can be summed up as a tool that, “describes pathways that either lead or influence the use of dissociation in children and adolescents, and it guides the assessment and treatment of children with dissociation” (Waters, 2016, p. 4).

This is ultimately a necessary tool for practitioners. When it comes to the treatment of mental health there seems to be a lack of conceptual frameworks, and guides to navigate treatment. So when there can be a concise direction it can only benefit the therapist and the client.

Chapter 1 then leads the reader to understand how each theory impacts the assessment and treatment of dissociation.

Before the theories are explored centrality on what dissociation is seems to be important.

The DSM-5 defines dissociation as a disturbance in the ongoing continuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior (American Psychiatric Association [APA], 2013, p. 291). This idea is then expounded upon by looking at dissociation as a spectrum ranging from normal (absorption in a movie, highway hypnosis) to pathological (derealization, depersonalization, self-states or parts, etc.).

The first and preeminent field of study that is included in the Star Theoretical Model (STM)  is attachment theory, and specifically, the work of Bowlby and those would follow in his work. Attachment is a predictor of much of a person well-being because a child’s successful development is largely dependent on their relationship with their caregivers. Out of Bowlby’s work, he identified that this dependent relationship that the child has with the caregiver develops an internal operating system of relational interaction called an attachment style. This is of particular interest when treating dissociative clients because of the close correlation to the development of disorganized attachment and the presence of dissociative symptomatology. Another crucial aspect of attachment and the dissociative client is the different parts of self can present with differing attachment styles and assessment and being aware of them is a necessary task of the therapist. With Fran’s work, she identified how even Bowlby saw the dissociative presentation when children experience relational loss with a caregiver. 

Another field of study that is incorporated in the STM model is that of developmental theory largely based on Erikson’s work. Flowing out of the child’s attachment relationship with their caregiver they are left with the task of growth and development. Fran identifies her reliance on Erikson’s work due to his developmental theory because of its centralized focus on the development of “consciousness of self that is developed through social interactions” which is of particular interest to assessment for dissociation (Waters, 2016). Developmental theory sees a child’s development based on their interconnectedness with their caregiver and their own development of self. It is easy to see of attachment theory binds nicely to Erikson’s model because a child’s developmental progress is intrinsically connected to their learned attachment style. They will begin to create a self in relation to that caregiver, and if that development of self is built on the foundation of disorganized attachment it precipitates the development of dissociation of self. The STM model adapts Erikson’s model to double-click on how trauma fragments the self and therefore fragments the developmental progression for the child. This can be shown in dissociative states being stuck developmentally regressed stages that the client has already mastered in other ANP states. In order to adequately understand the dissociative client, a therapist must be able to navigate these different dissociative states and identify their developmental stage to investigate and understand more about the development of that particular state, and its relation to the client’s trauma history.

Family systems theory is also incorporated in the STM model as it is a connected and interwoven thread to every client’s mental health picture. Fran poignantly states that “family interactions play a significant role in the pathology of children, who are often the identified patient” (Waters, 2016). This model bases it family systems informed lenses on the work of Satir who centered on the fact that children’s symptoms are the echoes of the family dynamics, communication patterns, and family rules. This idea informs the STM which prioritizes the inclusion of family members in therapeutic treatment, as attachment of the caregiver is a  predictor for progress being made towards integration of dissociative parts. 

The influence of neurobiology within STM model is related to understanding the nature of trauma, and what structures of the brain are involved in dissociation. Without a firm understanding of neurological processes dissociation can largely be seen as a mystery but based on the research in this field dissociation can be seen for what it is, a powerful coping mechanism for these defenseless children. When this is the interpretive focus dissociate clients can exist in a different category of brave survivalists, as opposed to marginalized liars.

The works of Janet, Putnam, Van der Hart, Watkins, Silberg, and Freyed are all influences to the specifics of understanding dissociative client’s presentations. There is influence from Putnam’s discrete behavioral states which is the understanding that self-states are an amalgamation of behavioral and psychology scripts created through unpredictable or unsafe relational patterns with a caregiver. These discrete behavioral states then hold the affect and behaviors exhibited in that relational dynamic in a separated state from consciousness. Structural dissociation theory is also part of this model which is the theory that these self-states (parts) are “goal-directed, adaptive, and defensive” falling into categories of  ANP (Apparently Normal Personality) states which are oriented around managing day to day life tasks and are avoidance based related to trauma, and EP (Emotional Personality) states which are oriented around traumatic memories (transfixed in the time of trauma) which causes them to be highly charged with emotions and affects (Waters, 2016). Ego states theory provides the understanding that each self-state is tethered to a common principle and due to the trauma it creates walls of amnesia between them. Affect avoidance theory develops the idea that each self-state is adaptive and focused on automatic defensive behaviors that act as scripts played out when the affect of the traumatic memory becomes too much for the child to manage. Betrayal trauma theory posits that experiencing trauma at the hands of a caregiver is a betrayal that leaves the child in an inescapable situation and therefore the child must dissociate from the trauma by the caregiver in order to survive and rely on the caregiver (Waters, 2016).

All of these aspects of treatment set out to be a holistic approach to dissociation. These children do not exhibit these presentations in a vacuum, and as a result, we must look through these lenses to do justice to the impact of trauma and how to treat it.

There is so much packed into Fran’s work that one post could not do justice to all that it contains, and as a result, there will be a part II to follow.

 

Presentations of Dissociation

As I have been working with the DID population, what continually peaks my interest is the spectrum of how it presents. I think that this is what can cause confusion or disbelief about the phenomenon.

Since there is a mainstream impression of dissociation it is easy to pigeon-hole the symptoms and presentation as extreme or think that the symptoms would be obvious to see from the outside.

My experience and the literature I have read would beg to differ. It can be a very nuanced and individual expression.

I have worked with some clients who have very distinct self-states that present with different names, genders, developmental aptitude, and ages. I have been able to do very direct work engaging and interacting with these ego-states which I think would be more akin to the mainstream observation of what DID would look like (though often people don’t believe it exists).

Other clients, I have worked with present a completely different experience that is far more internal, and less overt.

It is only once a therapeutic relationship is established, and dissociation is assessed for then the client’s internal world becomes clear, and they feel open to share what they experience inside.

Once that has been explored it can become very clear that DID is present, but it in no way looked like the aforementioned example.

Their experiences are more internal and are not externally presenting as obviously.

Understanding this piece, I think is crucial when assessing for dissociation, because when we only look for those external symptoms and presentations these different presentations go unseen and untreated.

Treating dissociation is a very specific type of treatment, and therapy is not one size fits all. So adequate assessment and exploration must be done so that correct diagnosis and treatment can be given.

 

Trauma and Dissociation in School

After working in human services and doing therapy with traumatized and dissociative youth one of the most common stressors/concerns for families is how can they make school work.

This is challenging question, and specific to each youth and their mental health presentation, but an all too familiar refrain from these families is that their children have been unsupported, mistreated, and misunderstood in these settings.

How can it be that schools are unable or unwilling to meet the needs of these youth?

This is not an indictment on the teachers and psychologists in the school that care, but more an indictment on the system itself.

It does not allow space for compassion and caring if it does not meet their stringent and vague criteria.

Part of the problem is that the structure in place does not know how to manage mental health symptoms to allow traumatized children equal access to education which they are federally mandated to do through the IDEA (Individuals with Disabilities Education Act).

The system must find these children, and fit them into a category and provide supports specific to that given category.

Traumatized youth usually fall into the category of Emotional Disturbance.

Winder (2015) talks about how this category is vague and challenging to assess from the school system. The worst reality about these classifications is that “research indicates that students determined to fall in the Emotional Disturbance classification have the worst outcomes of all special education classifications” (p.623).

So what can be done?

I suggest that the greatest ally for these families is their therapist.

Schools largely are unequipped to understand and support these traumatized children and the therapist can bridge the gap of understanding of the impact of trauma on these youth and help prioritize their needs.

Specifically, when it comes to dissociation there is a need for unpacking understanding.

Without a given context, schools can easily throw their hands up (and have all too often) feeling unable to meet the child’s needs.

Dissociation in school can be a range of presentation but in my experience with dissociative youth, they can develop parts that are mostly active at school. Often times these can be very studious and hardworking parts. Parents have shared that it can be hard to understand how the school day is for their children because once the youth have returned home they may have switched to a part that does not remember the experiences of the day.

Other youths have shown frequent switching because the school environment can feel unsafe causing disruptive and oppositionally oriented parts to come out in order to protect the child. These presentations can seem difficult or unmanageable for schools.

What ideas could be shared to help manage triggers, help youth stabilize, and ultimately plan for state-switching with parts that are developmentally regressed, or ones that contain high emotional affects? Are their physical tools available to help with grounding these youth?

The therapist should be on the front lines with these families who are already isolated, marginalized, and desperate for someone to understand.

This by no means is easy, nor something I claim perfection in, but a trajectory that I want to strive for because it is something I’ve had to fight for in my family life as well.

One tool I would encourage for families with traumatized youth who struggle in the school setting is a device called Touchpoints (https://thetouchpointsolution.com/) which uses bilateral stimulation to help youth with stabilization and calming down the stress response. I am currently exploring its effectiveness with families and hope to review them further in the future in the therapeutic and school settings.

Reference:

Winder, F. (2015). Childhood Trauma and Special Education: Why the Idea Is Failing Today’s Impacted Youth. Hofstra L. Rev., 44, 601.