Restoring the Shattered Self:
Complex Traumatic Stress
Disorder (CTSD) and
Missionaries
Mental Health and Missions,
2013
Heather Davediuk Gingrich, Ph.D.
Denver Seminary
heather.gingrich@denverseminary.edu
www.heathergingrich.com
My Background in this
Specialization
 Sexual abuse survivors
 Dissociative disorders
 Other trauma survivors (see Gingrich, 2002)
 Research on dissociation and trauma in the
Philippines
 Recognition of overlap in treatment
techniques
www.heathergingrich.com
Trauma Field
 Posttraumatic
Stress Disorder
- even single exposure
- natural disasters
 Complex Traumatic
Stress Disorder
(Disorders of Extreme Stress)
- multiple exposures
- incest survivors
- rape incident
- child abuse and rape
- witnessing violence
- multi-faceted treatment
- combat veterans
approaches
- primarily cognitive- International Society for
behavioral treatments
the Study of Trauma and
- International Society for
Dissociation (ISSTD)
Traumatic Stress Studies
(ISTSS)
Trauma Psychology, Division 56, APA
Posttraumatic Stress Disorder:
DSM-IV Criteria
 Exposure to traumatic event
 Reexperiencing
– Memories, thoughts, mental images, dreams, flashbacks
 Avoidance/Numbing
– thought stopping, social withdrawal, amnesia for the
trauma, constriction of affect
 Hyperarousal
– Irritability, explosive anger, hypervigilance, problems
with concentration, difficulty falling and staying asleep
 Symptom duration of more than 1 month
 Clinically significant distress/impairment in
functioning
American Psychiatric Association, 2000
DSM-5 – Selected Changes in
Criteria for PTSD
 Criterion A
– Sexual assault listed as a possible traumatic
event
 Additional symptom cluster
– Negative thoughts and mood or feelings
– an inability to remember key aspects of the
event.
 Dissociative subtype
– chosen when PTSD is seen with prominent
dissociative symptoms
– depersonalization
http://pro.psychcentral.com
DSM-5
PTSD Dissociative Subtype
 chosen when PTSD is seen with prominent
dissociative symptoms
– depersonalization
• experiences of feeling detached from one’s own
mind or body
– derealization
• experiences in which the world seems unreal,
dreamlike or distorted.
http://pro.psychcentral.com
What about Missionaries?
 Exposure to multiple traumatic events not
uncommon
 Increases risk of PTSD
 Complex traumatic stress may go
unnoticed
 History of complex trauma can make a
missionary more susceptible to being
triggered as a result of trauma on the field
Purpose of this Presentation
 Identify complex traumatic stress disorder
(CTSD) in missionaries
 Outline the entire long-term treatment
process
 Focus on how a missionary counselor or a
member care worker can help further
healing and contain symptoms even with
short-term interventions
Importance of Subjective
Evaluation of Event
 “No trauma is so severe that almost
everyone exposed to the experience
develops PTSD” (McFarlane & Gerolama, 1996, p. 148)
– Only 25-35 % of people who are exposed to a
potentially traumatic experience develop PTSD
(Carlson, 1997, p. 4)
– A history of complex trauma increases this
probability
Role of Peritraumatic
Dissociation
 “Dissociation at the moment of trauma
appears to be the single most important
predictor for the establishment of chronic
PTSD.” (Van der Kolk, Weisaeth, & van der Hart, 1996, p. 66)
 If a missionary has already learned to
dissociate as a result of an earlier history of
complex trauma they will likely already
have learned how to dissociate
Other Reasons to Learn About
Dissociation
 Used by victims of all kinds of trauma
 In addition to the link between
peritraumatic dissociation and PTSD, there
is a well-documented association between
trauma and posttraumatic dissociation (see
Gingrich, 2005)
 Dissociative subtype of PTSD in DSM-5
 Explanation for why treatment techniques
for dissociative disorders can also be
helpful for other trauma survivors
DSM-5-Definition of Dissociation
Disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity,
emotion, perception, body representation, motor
control, and behavior.
Simply put: Dissociation is compartmentalization,
or disconnection among aspects of self and
experience
Normal versus Pathological Dissociation
CONTINUUM OF DISSOCIATION
DISSOCIATIVE
EPISODE
NORMAL
•
•
•
•
hypnosis
ego states
automatisms
childhood
imaginary
play
•
•
•
•
•
•
fear/terror
repression
highway
hypnosis
sleepwalking
!mystical/
religious
experiences
(e.g.,
meditation,
ecstatic
experiences)
ACUTE
STRESS
DISORDER
(up to 4
wks.)
•
•
•
•
•
•
POST
TRAUMATIC
STRESS
DISORDER
(4 weeks +)
flashbacks
numbness,
detachment, absence
of emotional response
reduced awareness of
surroundings (dazed)
derealization
depersonalization
amnesia for aspects of
the trauma
DISSOCIATIVE
DISORDER
NOT
OTHERWISE
SPECIFIED
DISSOCIATIVE
DISORDER
•
•
•
Dissociative
amnesia
Dissociative
fugue
Depersonali
-zation
disorder
•
•
•
•
DDNOS
with
features of
DID
Polyfragmented
DDNOS
Dissociative
trance
disorder
Possession
trance
disorder
DISSOCIATIVE
IDENTITY
DISORDER
•
•
DID
Polyfragmented
DID
Adapted from Braun, B. G. (1988)
Developing the Capacity to
Dissociate
 We are born unintegrated (i.e., dissociated)
 Healthy attachment leads to integration of
behavioral states
 Impact of child abuse
 Dissociation as a defense
 Mental disorder
- dissociative disorder/other disorder with
dissociative symptoms
Putnam, 1997
Attachment Style and
Dissociation
 Attuned, “good enough” parenting
Secure attachment style
Integration of self-states
 Inattentive/neglectful/abusive parenting
Insecure (Ambivalent/Disorganized)
attachment style
Dissociated self-states
(Gingrich, 2013)
Dissociative Symptoms
 Amnesia: A specific and significant block of time that
has passed but that cannot be accounted for by memory
 Depersonalization: Sense of detachment from one’s
self, e.g., a sense of looking at one’s self as if one is an
outsider
 Derealization: A feeling that one’s surroundings are
strange or unreal.
 Identity confusion: Subjective feelings of uncertainty,
puzzlement, or conflict about one’s identity
 Identity alteration: Objective behavior indicating the
assumption of different identities or ego states, much more
distinct than different roles
Steinberg (1994).
DSM-V Diagnoses Related to
Dissociation
 Dissociative disorders
–
–
–
–
Dissociative amnesia
Depersonalization/derealization disorder
Dissociative identity disorder (DID)
Dissociative disorder not otherwise specified
 Selected other disorders with significant
dissociative symptoms
–
–
–
–
–
Post-traumatic stress disorder (PTSD)
Somatic symptom and related disorders
Schizophrenia
Borderline personality disorder (BPD)
Others (e.g., eating and feeding, anxiety)
BASK MODEL OF
DISSOCIATION
 Behavior
 Affect (emotions)
 Sensation (physical)
 Knowledge
Full, integrated memory includes all four re-associated
components.
Braun, 1988
BASK - KNOWLEDGE
 Trauma survivor has full or partial
cognitive knowledge of traumatic event
 Cognitive knowledge of the trauma is
dissociated from behavior, affect and
sensation
 Generally what people mean when they say
“I remember”
BASK - BEHAVIOR
 Behavior is dissociated from other aspects
of memory
 Individual acts in a certain manner without
knowing why
 Examples:
-avoiding intimate relationships
-vomiting after sexual intercourse
-dislike of particular foods
BASK - AFFECT
 Affect is dissociated from other
aspects of memory
 Example: feeling of fear for no
apparent reason
BASK – AFFECT
(continued)
 There are no feelings attached to the
cognitive knowledge of the memory
-flat affect
-matter-of-fact tone of voice
e.g., can talk about being raped as
though discussing the heat of the coming
summer
BASK - SENSATION
 Physical sensation is dissociated from other
aspects of memory
 Individual may have cognitive knowledge of the
traumatic event, be aware of related affect, and
understand some behavior, but not remember the
pain or pleasure associated with the trauma
 Examples:
-body memories – physical symptoms such as
bleeding or severe pain occur in the present but
are unexplained
-sexual excitement
BASK Model
Behavior
Affect
Behavior
Affect
Behavior
Affect
Sensation
Knowledge
Sensation
Knowledge
Sensation
Knowledge
Gingrich, H. D., 2013, p. 107
Three-Phase Treatment
Process
Rationale for Phase-Oriented Model
 Premature trauma processing can lead to
destabilization
– Hospitalization
– Inability to function in job
– Difficulty parenting
– Basic coping capacities can be overwhelmed
Three Phases
 Phase I – Safety and Stabilization
 Phase II – Processing of Traumatic
Memories
 Phase III – Consolidation and Restoration
Phase 1: Safety and
Stabilization
 Where most missionary
counselors/member care workers can be
helpful
Safety within the Therapeutic
Relationship
 Developing rapport
– Facilitative conditions
 Becoming a safe person
– Remember that every client is unique
– Know your limitations
– Give advance warning
 Remaining a safe person
– Keep appropriate therapeutic boundaries
– Consult
– Protect confidentiality
Safety from Others
 Helping individuals find physical
safety
 Identifying healthy vs. unhealthy
relationships
 Looking for signs of spiritual abuse
Safety from Self and Symptoms
 Making sense of symptoms
– Symptoms as attempts at coping
– Warning signals
 Therapeutic use of dissociation
– Potentially assess use of dissociation
• Somataform Dissociation Questionnaire (SDQ-5 or SDQ-20)
(Nijenhuis, 1999)
• Dissociative Experiences Scale-II (DES-II) (Putnam, 1997)
• Structured Clinical Interview for DSM-IV Dissociative
Disorders-Revised (SCID-D-R) (Steinberg, 1993)
– Use of parts of self language
– Contracting
• symptom management
• day to day activities
• suicide
– Ideomotor signaling
Phase II - Processing of Traumatic
Memories
 Readiness for Phase II Work
 Memory Work
– Nature of memory
– Accessing dissociated memories
• Deciding where to start
• When specific memories do not surface
– Is memory recovery the goal?
– Facilitating the integration of experience
•
•
•
•
•
•
•
The importance of details
Titrating the process
Extent to which reexperiencing is necessary
Grounding techniques
Checking in
Memory containment
Structuring the session and counseling relationship
BASK Model
Behavior
Affect
Behavior
Affect
Behavior
Affect
Sensation
Knowledge
Sensation
Knowledge
Sensation
Knowledge
Gingrich, H. D., 2013, p. 107
Phase II - Processing of
Traumatic Memories (cont’d)
 Facilitating Integration of Self and Identity
 Working through Intense Emotions
– General principles
– Understanding and dealing with specific emotions
•
•
•
•
Mourning: Denial, anger, and depression
Guilt, shame, and self-hatred
Fear of abandonment
Anxiety, terror, and fear
 Roadblocks for counselors
 Keeping Perspective
Levels of Integration of Self
No Integration
Partial Integration
Full Integration
Gingrich, H. D., 2013, p. 121
Integration of Self and Experience
Gingrich, H. D., 2013, p. 122
Is the Goal Full Integration?
 Immediate goal is better functioning
 Some highly dissociative clients never
fully integrate
– May be afraid to (i.e., fear of death of parts of
self)
– Too much work and time
 The process of integration can begin to
happen from the beginning of therapy
Dealing with Spiritual Issues (1)




All phases, but particularly Phases II and III
Gradual, often difficult process
Allow client to set pace
Often are questions re: why God did not protect
from the trauma
 In time clients can often see that God was there,
and is currently involved in their healing process
 In highly dissociative clients, some parts of self
may have a relationship with Christ, while others
may not
– E.g., internal Bible study
Dealing with Spiritual Issues (2)
 Distinguish between parts of self and demonic
– Ultimately gift of discernment necessary
– Potentially VERY destructive to attempt deliverance
ministry
 If any kind of deliverance/exorcism ritual is
decided upon make sure that the following factors
are incorporated (Bull, Ellason, & Ross, 1998):
–
–
–
–
–
Permission of the individual
Noncoercion
Active participation by the individual
Understanding of DID dynamics by those in charge
Implementation of the procedure within the context of
psychotherapy
 See my article “Not all voices are demonic”
(Gingrich, 2005b)
Phase III – Consolidation and Resolution




Consolidating changes
Development of new coping strategies
Learning to live as an integrated whole
Navigating changing relationships
–
–
–
–
–
Marriage and parenting
Friendships
Relationship to God and church congregations
Community
Family of origin
 Employment
 Confronting the perpetrator
 Forgiveness
How the Church/Member Care
Organization Can Help …1
 Educating about CTSD
–
–
–
–
–
Process of healing for the missionary
How they can be of help
Length of commitment
Setting of appropriate boundaries
Self-care for helpers
How the Church/Member Care
Organization Can Help …2
 Providing emotional and spiritual support
– Formal care
– Groups
– Lay counseling
– Mentoring, spiritual direction and life
coaching
– Assigned helpers
– Informal care
How the Church/Member Care
Organization Can Help …3
 Availability in times of crisis
– Phone, email, Skype, prayer chains
 Churches, member care organizations and
Christian mental health professionals in
partnership
 Therapist should have one key contact
person (e.g., pastor, elder, designated lay
helper) who then communicates with other
support people
What Can I Do with This
Info?
 Counselor
– Be informed
– Get training on how to work with CTSD
 Pastor/Member Care Provider
– Understand the process of healing
• Be more empathic
• Know what to look for in making a counselor
referral
• Help gather other resources
• Use some grounding techniques
References
 American Psychiatric Association (2000). Diagnostic and
statistical manual of mental disorders (text revision).
Washington, DC: Author.
 American Psychiatric Association (2013). Diagnostic and
statistical manual of mental disorders, (5th ed).
Washington, DC: Author.
 Braun (1988). The BASK model of dissociation: Clinical
applications. Dissociation, 1(2), 16-23.
 Bull, D., Ellason, J., & Ross, C. (1998). Exorcism
revisited: Some positive outcomes with dissociative
identity disorder. Journal of Psychology and Theology, 26,
188-196.
 Carlson, E. (1997). Trauma assessments: A clinician’s
guide. New York, NY: Guilford Press.
 Gingrich, H. D. (2002). Stalked by Death: Cross-cultural
Trauma Work with a Tribal Missionary. Journal of
Psychology and Christianity, 21(3), 262-265.
 Gingrich, H. D. (2005a). Trauma and dissociation in the
Philippines. In G. F. Rhoades, Jr. and V. Sar (2005),
Trauma and dissociation in a cross-cultural perspective:
Not just a North American phenomenon. New York, NY:
Haworth Press.
 Gingrich, H. (2005b). Not all voices are demonic.
Phronesis, (Asian Theological Seminary/Alliance
Graduate School, Philippines)12, 81-104.
 Gingrich, H. D. (2013). Restoring the shattered self: A
Christian counselor’s guide to complex trauma. Downers
Grove, IL: InterVarsity Press
 McFarlane, A. & Girolamo, G. (1996). The nature of
traumatic stressors and the epidemiology of posttraumatic
reactions. In B. A. van der Kolk, A. C. McFarlane, & L.
Weisaeth (Eds.), Traumatic stress: The effects of
overwhelming experience on mind, body, and society. New
York, NY: Guilford Press.
 Nijenhuis, E. R. S. (1999). Somatoform dissociation:
Phenomena, measurement, and theoretical issues. Assen,
The Netherlands: Van Gorcum.
 Putnam, F. W. (1997). Dissociation in children and
adolescents: A developmental perspective. New York,
NY: Guilford Press.
 Steinberg, M. (1993). Structured Clinical Interview for
DSM-IV Dissociative Disorders (SCID-D). Washington,
DC: American Psychiatric Press.
 van der Kolk, B. A., Weisaeth, L., & van der Hart, O.
(1996). History of trauma in psychiatry. In B. A. vander
Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic
stress: The effects of overwhelming experience on mind,
body, and society. New York: Guilford Press.