This article briefly explores therapeutic theory and practice concerning the treatment of adults with severe infant childhood trauma (premature birth, ongoing serious illness, ongoing abuse, etc.), particularly those clients that as adults suffer from dissociative symptoms. It draws on a range of literature from the trauma field as well as specific literature on depersonalisation.
From the very earliest days of psychotherapy there has been a recognised link between trauma and mental and emotional disturbance, specifically that severe trauma can seriously affect people on an ongoing basis. In her classic book “Trauma and Recovery” Judith Herman (1992) describes trauma as events that overwhelm the ordinary adaptations to life and are characterised by terror and helplessness (pp. 33-35). This can have long-term self-perpetuating effects where the overwhelming events remain unintegrated in the psyche, damaging both one’s sense of self and relational capacities. She notes that for those whose trauma included a physiological freeze response (frozen with terror) are particularly prone to later problems. Where the trauma is from childhood she notes three major forms of adaptation: dissociative symptoms, a fragmented identity, and difficulty regulating emotional states (p. 110).
Dissociative symptoms include depersonalisation (feeling unreal), derealisation (feeling as if the world is unreal) or blanking out. Fragmented identity is associated with an unstable changeable personality or an internal sense of fragmentation. Difficulty regulating emotional states refers to symptoms of emotional instability and reactivity.
In treatment of traumatised clients Herman (1992, p. 155) proposes a three-stage model; establishment of safety, remembrance and mourning, and reconnection with ordinary life. She stresses the importance of a therapeutic relationship that validates, empowers, supports and encourages the client (p. 133). She notes that trauma memories are frozen and fragmented, and remembrance requires the reassembly of the components into “an organised, detailed, verbal account, orientated in time and historical context” (p. 177), including imagery, bodily sensation and meaning. The goal is integration of the fragmented experience and “constructing a new interpretation that affirms the dignity and value of the survivor” (p. 179), but Herman cautions that both therapist and client need a tolerance for uncertainty. She also warns that “Resolution of the trauma is never final; recovery is never complete. The impact of a traumatic event continues to reverberate throughout the survivor’s lifecycle” (p. 211).
Van der Kolk (1996) argues that overwhelming experiences can lead to a split in consciousness. This can result in complex adaptive responses with a cluster of associated symptoms of dissociation, physical symptoms and emotional instability. When trauma is experienced in childhood such responses can lead to complex characterological adaptations. This can include inability to identify emotional states. He suggests that treatment must encompass four areas; desensitisation of traumatic memories, discriminating past triggers from present circumstance, developing self-regulation, and making intellectual sense of the traumatic events and their impact on one’s life.
Briere (1992) also notes the long term impacts of childhood trauma. These typically involve watchful anxiety, a preoccupation with control, and misinterpretation of interpersonal situations as threatening, as well as disruption to ability to form relationships, and difficulties with emotional regulation. From this perspective, treatment involves completion of interrupted developmental tasks and skills.
Rothschild (2000; 2003) adds to Herman’s ideas by integrating neurological understandings of stress and memory. Explicit (conscious memory) and implicit (body memory) are stored in different parts of the brain. Simply put, traumatic incidents remain trapped and fragmented in the implicit memory system where they can be provoked, causing hyperarousal (i.e. flashbacks, panic attacks, etc.) but not in a way that can be understood or integrated (2003, pp. 5-11).
Rothschild sees the first goal of trauma therapy as learning how to “put the brakes on” – that is, keeping arousal at a manageable level (2003, p. 8). Recognising the fragmented nature of traumatic memory, she suggests Levine’s SIBAM model (sensation, images, behaviours, affects & meaning) as a framework for understanding the task of remembrance and integration (2003, p. 12). She proposes 10 principles of working with trauma that stress safety and relationship building, as well as the creative and collaborative use of tailored techniques drawn from an eclectic toolkit (pp. 18-22). This includes the caution that directly addressing traumatic material may not always be possible or advisable.
Depersonalisation is a dissociative disorder often associated with trauma. It can sometimes present like atypical depression and is often co-morbid with it (Baker et al., 2003, p. 428). The symptoms include feeling emotionless and detached from various aspects of self (RU, 2001, p. 128) and “Feelings of having the mind empty of thoughts, memories or images, and an inability to focus and sustain attention” (Sierra & Berrios, 2000, p. 154). Clients may report such things as “I don’t feel like a person” or “Most of the time I’m feeling empty” or “It’s very rarely that I can conjure up memory or emotions about the past or anything like that, because normally I can’t”.
Physiologically depersonalisation is understood as a “heightened arousal combined with a dampening of emotional response, [and] is widely viewed as a defence mechanism in the face of severe stress, life-threatening situations or trauma” (DRU, 2001, p. 129). This view is shared by Sierra & Berrios who contend that depersonalisation “results from two simultaneous mechanisms: an inhibition of emotional processing, and a heightened state of alertness” (2000, p. 154).
All of the trauma authors considered above make the general link between trauma and dissociation and, as noted, Scaer makes the explicit link between the trauma of premature birth and its long-term impacts, including dissociation. Indeed in a study of the link between childhood interpersonal trauma and depersonalisation disorder Simeon, Guraknik, Schmeidler, Sirof, & Knutelska (2001, p. 1031) conclude that “childhood interpersonal trauma as a whole was highly predictive of both a diagnosis of depersonalisation disorder and dissociation” (2001, p. 1031).
Unfortunately depersonalisation is an understudied disorder and there is a paucity of treatment data (Baker et al., 2003; Depersonalisation Research Unit, 2001; Simeon, Guraknik, & Schmeidler, 2001, p. 341). Some limited treatment research has been undertaken on chronic depersonalisation using pharmacology (lamotrigine – an anticonvulsant) and CBT techniques to increase the client’s capacity to tolerate painful affect (Depersonalisation Research Unit, 2001, pp. 131-132). They report promising (but as yet unpublished) results.
When treating trauma from infancy or from premature birth Scaer (2001) notes that infants “are especially susceptible to dissociate or freeze in the face of trauma” (p. 136). He further notes that “little if anything in the Post Traumatic Stress Disorder (PTSD) literature addresses the terrible trauma to which premature infants are exposed, or the long-term behavioural and emotional sequelae of that trauma” (p. 152). With regard to treatment, he notes a variety of approaches but concludes “the therapeutic key to dispelling dissociation and [emotional] numbing remains an enigma”, yet optimistically notes “many victims of traumatic stress do respond to existing therapies” (p. 183).
Where severe early childhood trauma is pre-verbal and predates memory any resultant dissociative defences are likely to remain a characterological vulnerability. The recommended approach is a secure therapeutic environment for strengthening the self, and psychodynamic exploration to increase emotional tolerance. The trauma material should be allowed to arise in its own time while bearing in mind Rothschild’s principals and Levine’s model of integration.
All of our therapists are experienced with trauma and dissociation. Contact any of our Auckland Therapists for more information or an appointment.
Baker, D., Hunter, E., Lawrence,
N., Patel, M., Senior, C., Sierra, M., et al. (2003). Depersonalisation
disorder: Clinical features of 204 cases. British journal of psychiatry,
Briere, J. N. (1992). Child abuse trauma: Theory and treatment of the lasting effects. London: Sage.
Depersonalisation Research Unit. (2001). Depersonalisation. The psychologist, 14(3), 128-132.
Fay, J. (1988). Psychotherapeutic ideal types. (Unpublished).
Herman, J. (1992). Trauma and recovery: The aftermath of violence - from domestic abuse to political terror. New York: Perseus.
Rothschild, B. (2000). The body remembers: The psychology of trauma and trauma treatment. New York: Norton.
Rothschild, B. (2003). The body remembers casebook: Unifying methods and models in the treatment of trauma and PTSD. New York: Norton.
Scaer, R. (2001). The body bears the burden: Trauma dissociation and disease. New York: Haworth.
Sierra, M., & Berrios, G. E. (2000). The Cambridge Depersonalisation Scale: a new instrument for the measurement of depersonalisation. Psychiatry research, 93, 153-164.
Simeon, D., Guraknik, O., & Schmeidler, J. (2001). Development of a depersonalisation severity scale. Journal of traumatic stress, 14(2), 341-349.
Simeon, D., Guraknik, O., Schmeidler, J., Sirof, B., & Knutelska, M. (2001). The role of childhood interpersonal trauma in depersonalisation disorder. American journal of psychiatry, 158(7), 1027-1033.
van der Kolk, B. A., David, P., Roth, S., Mandel, F., McFarlane, A. C., & Herman, J. (1996). Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. American Journal of Psychiatry, 153 July 1996 Festschrift supplement(7), 83-93.