Shame and dissociation in complex trauma - PowerPoint Presentation

1. Shame and dissociation in complex trauma disorders: Emerging insights from the empirical literature Martin DorahyDepartment of PsychologyUniversity of CanterburyNew ZealandMartin.dorahy@canterbury.ac.nz

2. “Shame…is such an acutely painful and disorganizing experience that we wish it would end quickly and have no taste for introspecting it” H. B. Lewis, 1987, p.1

3. PlanShame: Overview, definitions, functions, manifestationsShame and TraumaShame, trauma and dissociationQ & AShame, dissociation and relationship functioningShame and therapy

4. Shame defined“Shame can be defined simply as the feeling we have when we evaluate our actions, feelings, or behavior, and conclude that we have done wrong. It encompasses the whole of ourselves; it generates a wish to hide, to disappear or even to die” (M. Lewis, 1992, p. 2)Shame is the affect of inferiority (Kaufman, 1989)‘Seeing oneself negatively in the eyes of others’ (Scheff, 2003, p. 244)‘Shame is an experience of one’s felt sense of self disintegrating in relation to a dysregulating other’ (DeYoung, 2015. p. xii).Shame is inherently a social emotion and signal threat to the social bond/relationships (Lewis, 1971; Scheff, 2003)SHAME IS RELATED TO THE SELF

5. 2 models on mechanism/origin of shameEvolutionary: shame as basic emotion present very early in life.E.g., embarr-shame-humil; Tomkins 1963Shame has adaptive value.Tomkins: Shame as inhibitor of positive feelingsGilbert: Shame signals threat or loss of social acceptanceCognitive-attributional: Shame comes online between 18m-3years with development of cognitive representations of selfTend to emphasis shame maladaptive character.Guilt adaptive, shame maladaptive.M. Lewis; Tangney

6. Shame and development“Shame is embedded in the attachment system and occurs in the first stages of life in response to perceived rejection or separation from caregivers. Shame alerts the child to the threat of separation, and then action can be taken to protect the attachment bond. The cycles of attachment rupture and repair in the infant-caregiver dyad are fundamental for emotional regulation and shame plays an important role in this process” Schimmenti, 2012, p. 202

7. Shame not by nature pathologicalShame is not pathological per se, but when it becomes pervasive or disavowed/dissociated (i.e., maladaptive regulation), it has a negative impact on a person’s life.Schimmenti, 2012

8. Feature of shame

9. Shame: Behavioural markers and actionsShameBlushingDiverting eye Gaze/breaking eye contactHunching of Shoulder/shrinking/compression of bodyDropping of the head/turning awayconcealmentNo/reduced self relev.Momentary Blank mind/inability to speakMovement from others

10. Shame & trauma

11. Shame and traumaShame intimately linked to traumatic events, especially those of a relational nature (Andrews, Brewin, Rose & Kirk, 2000; Dorahy, 2010; Dorahy & Clearwater, 2012; Harvey, Dorahy, Vertue, & Duthie, 2012; Feiring & Taska, 2005).Relational trauma characterised by dominance, subordination and control evokes a strong shame response

12. Trauma and shame (cont.)People feel ashamed for 1) What happened, 2) How they (e.g., their body) responded 3) Who they are Boon et al., 2011; Dorahy & Clearwater, 2012, Herman, 2011; Talbot, 1996Herman (2011) argues that PTSD resulting from relational trauma can be conceptualised as both an anxiety disorder and a shame disorder.

13. Abuse and shame2 key areas where early abuse directly relates to pathological shame is the development of:Healthy narcissism (so the individual can assert and defend oneself)Bad or malignant internal objects (so relationships are skewed and distorted – e.g., rejection is expected.Schimmenti, 2012

14. Identity development and shameIdentity development relies on complex processes, among them:Exploration: trying different ways of beingCommitment: holding onto specific ways of beingExploration and commitment influenced by internal and external (e.g., significant others) information and evaluation.Particularly evident in adolescen-ces

15. Identity solidificationExplorationCommitmentExp. of breadthExp. of depthExp. Alt.Deep. evale.g.,Ident. w/ com.Commit. makingRum. Exp.Anx. Exp.Consid. Alt.Inter-nal.e.g.,Czub, 2013Shame and IdentityIdentityIdentityIdentity

16. Identity solidificationExplorationCurrent shame (state)Shame reg – adap/mal.Shame Prone (trait)CommitmentEarly abuse/insult to selfLess stable:Low Com. Making & Id w/ com.-high rum. & Exp. BreadthShame, identity and trauma IdentityIdentityIdentityCzub, 2013; Taylor, 2015

17. Trauma and shameMany theorists have proposed a link between exposure to trauma and increases in feeling shame (e.g., Chefetz, 2015; Herman, 2011; Lee et al., 2001; Schimmenti, 2012; Talbot, 1996; Wilson et al., 2006)EG., ‘Shame and shame regulation play a role in the exacerbation and perpetuation of posttrauma disorders’ (Taylor, 2015, p. 1)What about research findings?

18. Trauma and shame: The numbers, e.g.,AuthorsSampleTraumaEffect: rAndrews et al., 2000Victims of violent crime; n=157 Child abuse.23**DePrince et al., 2011Students n=98Interp. vs no inter. trauma.45**Community women n=94Betrayal.05IPA victims n=236Psych Aggres.Physic Aggres..18*.19*Platt & Freyd, 2015Students n=118High betrayal.21* (st.)Low betrayal.09 (st.)Shahar et al. 2014Non-clin community n=219CTQ-EA.30**CTQ-EN.10Leskela et al., 2002POWS n=107Retrospective combat exposure..00*p<.05; ** p<.01

19. Shame & trauma in trauma samplesAbuse: Rsq = 29%, F(5,65) = 6.58, p < .001CEACENCPAShameUniqR2=10%, p <.01CPNCSACorrel:CEA=.53CEN=.43CPA=.27CPN=.40CSA=.41 DD=39CPTSD=13MP=21Dorahy, Middleton et al., in press

20. PTSD and shame: The numbers, e.g.,AuthorsSamplePTSDEffect: rAndrews et al., 2000Victims of violent crime (n=157) Total - 1m.35**Total - 6m.37**Feiring et al., 2005Children 8-15y, all CSA n=118Reexp..60**Avoidance.62**Arousal.57**Dorahy et al., 2013Conflict-rel. Chron PTSD n=65CPTSD.58**Leskela et al., 2002POWSPTSD.48**Reexp..28**Avoidance.42**Arousal.48***p<.05; ** p<.01

21. Shame may underpin PTSD following interpersonal traumaAndrews, Brewin, Rose & Kirk (2000)Assault victims (outside household)N = 157 time 1 (1 month)N = 138 time 2 (6 months)Shame, anger, PTSD at 1 month PTSD at 6 months

22. Shame may underpin PTSD following interpersonal traumaTime 1 : Controlling age, gender, education, relationship status, trauma severity, SHAME AND ANGER PREDICTED PTSD AT 1 MTime 2: controlling above variables AND initial PTSD severity, SHAME PREDICTED PTSD AT 6 MSHAME MEDIATED BETWEEN CHILD ABUSE AND PTSD AT 6 MONTHSAndrews, Brewin, Rose & Kirk (2000)

23. Shame & dissociation in predicting complex PTSDAbuse: Rsq = 56%, F(3,61) = 27.8, p < .001Path.dissTrait ShameTrait GuiltComplex PTSD SymptomsUniqR2=38%, p <.001State shameState guiltCPTSD=65 – conflictDorahy et al., 2013Attack selfWithdraw.AvoidAttack otherUniqR2=15%, p <.001UniqR2=4%, p <.05

24. Shame and PTSDShame associated with slower recovery from PTSD (Brewin & Holmes, 2003

25. ‘shame as a traumatic memory’Matos & Pinto-Gouveia (2010) argued and found evidence for child and adolescent shame experiences having similar characteristics to trauma memories (e.g., intrusive, avoided, arousing).

26. ‘shame as a traumatic memory’Shame trauma memories acted as a moderator between shame feelings & depressioni.e., if shame experiences are represented internally like a trauma memory depression increases. ? Same for PTSD, CPTSD, DDs

27. Shame and current threatHarman & Lee (2010)49 trauma survivors (e.g., accidents, assaults); 45 PTSDShame positively correlated with self-criticism; self-hatredShame contributes to sense of ongoing threat that maintains PTSD symptoms like avoidance and arousal

28. Identity solidificationExplorationCurrent shame (state)Shame reg – adap/mal.Shame Prone (trait)CommitmentEarly abuse/insult to selfLess stable:Low Com. Making & Id w/ com.-high rum. & Exp. BreadthShame, identity and trauma IdentityIdentityIdentity

29. Shame regulation‘Because the experience of shame is often considered to be painful and disempowering, and because recognition of shame in itself can be felt as shameful, it has been suggested that it may evoke any one, or a combination of, maladaptive shame regulation strategies or defences’ (Taylor, 2015, p. 1) Shame regulationPsychopathlogy comes from maladaptive shame reg. (e.g., Czub, 2013; Elison, 2005)

30. Compass of shame (Nathanson, 1992) Attack selfWithdrawalAttack otherAvoidancee.g., -Dissociation-Self harm-AggressionKluft, 2007-importance of shame and shame scripts in DIDWhen I feel rejected by someone: -I soothe myself with distractions. (A)-I repeatedly think about my imperfections. (AS)-I withdraw from the situation. (W)-I get angry with them. (AO)

31. Shame and shame regulation scriptsShame scriptShame: rCPTSD (n=65)DDs (n=39, 36 DID)Students (n=55)Avoidance.18-.15.12Withdrawal.44**.54**.69**Attack self.49**.58**.66**Attack other.22.14.41**Dorahy et al., 2013Dorahy et al., unpub. From 2015 dataDorahy et al, 2015b

32. Trauma & shame regulation scripts39 DDs (26 DID), 13 CPTSD, 21 CA&N-related anxiety and depressionShame scriptAbuse: rEAPASAENPNTotalAvoidance-.10-.07-.03-.15-.09-.10Attack self.24*.15.12.12.08.19Withdrawal.31**.26*.28*.27*.27*.37**Attack other-.21.00-30*-.14-.13-.22Dorahy et al., in press

33. Dissociation & shame regulation scriptsShame scriptDissociation: rCPTSD (n=65)DDs (n=39, 36 DID)Mixed Psych (n=21)Avoidance.07-.27.44*Withdrawal.31*.41**.13Attack self.42**.18.33Attack other.16.05.35Dorahy et al., 2013Dorahy et al., unpub. From 2015 dataDorahy et al,unpub. From 2015 data

34. Shame, trauma & dissociation

35. Trauma, shame and dissociationShame typically has a positive and moderate-strong strength correlation to dissociation (e.g., ≈ r = .05)E.g.,Dorahy et al., 2013This relationship tends to be stronger in traumatised than non-traumatised individuals

36. Trauma, shame and dissociationFor example:Talbot, Talbot & Tu (2004):99 hospitalised females with and without CSAStep 1: CSA predicted dissociationStep 2: Shame predicted dissociationStep 3: shame and interaction between shame and CSA predicted dissociationSlope stronger in CSA (2.59 vs 1.14)Therefore, greater shame-proneness assoc with dissoc. in those abuse

37. Shame, Trauma and DissociationThomson & Jaque (2013)140 pre-prof. & prof dancers99 athletes (trained 5+years, compete)DES, Internal Shame Scale, Trauma. Ex. Q.Dancers higher shame and path. Dissociation than athletes

38. Shame, Trauma and DissociationThomson & Jaque (2013) rPath Diss – Trauma = .17Shame – Trauma = .25Shame – Path Diss = .47DissociationDancerTraumaShame4%5%13%

39. Connection between shame and dissociationShameDissociationShameDissociationShameDissociation

40. Shame & DissociationExperimental TaskPresentation of narratives (through head phones):Embarrassing/shame & neutral Second person (‘You’) to first person (‘I’) transformation when repeating (autobio, internalised)Counterbalanced

41. Embarrassment/shame

42. Control script

43. Embarrassment/shame induction and dissociationScripts given to students (McKendry, 2013) and patients in counselling (Scott, 2014)Assessing internal and external shame (Gilbert)Internal: perception of self as inferior, less than, useless External: perception of self as object of scorn, contempt or ridicule from others 3 conditionsSelf (Internal shame)Experimenter (External shame)Neutral (looking at white dots on black screen)

44. Internal shameExternal shameControlApparatus and conditionsEmotion induction and neutral induction(counterbalanced)

45. Dissociation increased after shame inductionPDEQ – for peri-experimental dissociationNo difference across conditionsBut difference across emotion (shame/Emb. Vs neutral), Scott: patients, F (1, 30) = 11.21, p = .002, p2= .27 McKendry: Students, F (1, 75) = 13.58, p = <0.001, p2 = 0.15

46. discussionDissociation is not related to specific kind on shame/embarrassment-inducing context. Rather, it seems to operate with a general increase in shame/embarrassment, regardless of whether one is in the company of others or not.

47. Shame, dissociation and relationship functioningDoes shame and dissociation relate to relationship functioning in traumatised groups?

48. Shame, dissociation and relationship functioningShame has a long tradition of being associated with relationship difficulties.Shame impedes social connection (‘severs interpersonal connection’ – Kluft, 2007)Intimacy fears are especially high in shame-prone individuals and they may avoid relationships fearing rejection from others (e.g., Schimmenti, 2012) Dissociation, less investigation (Lyons-Ruth, 2003, 2008)

49. MethodN = 65 Chronic PTSDConflict-related trauma (≈>90% CA&N; Dorahy et al., 2009) C-PTSD, n=13Age (sd)40 (12)Gender F/M21/44Dorahy et al., 2013

50. ScalesCompleted:Multidimensional Relationship Questionnaire (MRQ; Snell et al., 1996): Rel. preoccupation, Rel. anxiety, Rel. Dep. Fear of rels.; Rel. esteem, motivation, satisfaction. Personal Feelings Questionnaire-2 (PFQ-2; Harder & Lewis, 1987) The Compass of Shame Scale (CoSS; Elison et al., 2006) Avoidance, withdrawal, attack self, attack otherThe State Shame and Guilt Scale (SSGS; Marschall et al., 1994) Stress Reactions Checklist for Disorders of Extreme Stress (SRC; Ford et al., 2007) Dissociative Experiences Scale (Carlson & Putnam, 1993

51. What predicts rel. difficulties?Relationship Preoccupation: Rsq = 10%, p<.01Relationship Anxiety: Rsq = 14%, p<.01Relationship Depression: Rsq = 8%, p<.05Fear of Relationships: Rsq = 24%, p<.01ShameDESComplex PTSD SxRel. AnxietyRel. DepressionFear of Rels.Rel. Preocc.Shame Avoid.

52. MethodN = 73 psychiatric patientsNo sig for age [F(2,70) = 2.06, p = .14]No sig gender [(2) = 4.65, p = .10] All had child abuse and/or neglect DD (DID=36; OSDD=3), n=39C-PTSD, n=13MP (nonPTSD anx; dep), n=21Age (sd)44.67 (10.65)38.0841.62Gender F/M36/311/215/6Dorahy et al., 2015

53. Does dissociation or shame predict relationship problems?hierarchical regression on relationship anxiety, rel. depression and fear of relationshipsPredictors: Complex PTSD (without dissociation sx), Child abuse, guilt (step 1)Controlled for impact of these variablesShame (step 2); DES-T (step 3); Shame × DES-T (Step 4): To test whether dissociation has a moderating effect on relationship between shame and rel. difficulties

54. What predicts rel. difficulties?Relationship Anxiety: Rsq = 36.3%, F(6,63)=5.98, p<.001Relationship Depression: Rsq=23.4%, F(6,63)=3.20, p=.008Fear of Relationships: Rsq=31.2%, F(6,63)=4.75, p<.05.ShameDES-TShame by DES-TRel. AnxietyRel. DepressionFear of Rels.UniqR2=3%, p =. 09UniqR2=7%, p <.05

55. Shame, Dissociation, complex PTSD & relationship functioningDo shame and dissociation directly effect relationship difficulties or is the effect indirect and through complex PTSD symptoms?65 Chronic PTSD (Conflict)20 DID125 General populationDorahy et al., under review

56. Shame, Dissociation, complex PTSD & relationship functioning

57. ImplicationsTreating shame and dissociation is likely to reduce:Complex PTSD symptomsRelationship anxiety Relationship depressionFear of Relationships

58. Therapy

59. Shame is only occasionally felt but constantly anticipated Scheff, 2003

60. Why focus on shame in traumatised clients?“Overwhelming feelings of shame may contribute to early treatment drop-out or indeed may be the reason why some individuals never present for treatment in spite of suffering from debilitating symptoms of PTSD” (Lee et al., 2001, p. 464)Has implications for all stages of treatment (Herman, 2011)

61. Shame in therapyIn therapy, unaddressed shame is detrimental to:The therapeutic processThe client-therapist interactionHahn, 2004; Kluft, 2007; Retzinger, 1998

62. Shame in therapyShame needs to be considered early and worked with patientlyGiven covert nature of shame assume it’s presence and allow yourself in the service of the clients to actively enquire about it.Anticipate resistance and reluctance

63. Three levels shame can be examined in therapyIntrapersonal shame Examination changes in self-conceptInterpersonal shame at intimate levele.g., Changes in personal relationshipsOccupational and societal level E.g., loss, isolation, and exclusion.Taylor, 2015

64. Identifying shame themes/scriptsThe clients story involves description of self as feeling “small”, “humiliated”, “weak”, “inferior”, “worthless”, “less than human” or “non-existent”, ‘dumb’, ‘idiotic’ (Herman, 2011). Client may judge self in the story as pathetic or despicable (Cloitre et al., 2006, p. 288)Often evoke strong responses in therapist: e.g., powerlessness, the desire to reassure, the desire to defend by e.g., feeling rage at perpetrator; or desire to stop feelings-e.g., rage at client or emotional/attentional withdrawal CT can identify & help understand shame & rage - e.g., concordant CT (e.g., powerlessness), complimentary CT (attack client mentally, withdraw)See Chefetz, 2015

65. Even the term ‘shame’ can be too muchNaming shame is important (Lewis, 1971).But, in some cases using the word ‘shame’ can be too strong.Thus start with ‘mortified’, ‘embarrassed’, ‘lowest of the low’ Herman, 2011

66. What is the best initial interventionIn a study of preferred interventions to highly-shame-inducing therapy stimuli (n = 55)Shame and surprised narratives by ‘clients’Dorahy et al., 2015

67. Therapist responsesFollowing each video: 5 therapist responses ranging from:Affect focused Affect Avoidant (complete non-avoidance) (complete avoidance)“If you were the client, how helpful would it be if the therapist said…”1 2 3 4 5 6 7 8 9 10(very unhelpful) (very helpful)

68. Therapist responsesEG“It must be very hard to feel this way about yourself. I know this may be difficult, but can you try staying with these feelings and tell me what this is like for you?” (Affect focused) “This sounds very distressing for you to discuss. Perhaps it might be best if we spoke about it when you are feeling better?” (Affect avoidant). “It must be so difficult to think this way about yourself. I’m wondering if you can tell me more about the thoughts you have about yourself when you feel like this?” (thoughts) “This must be such a tough experience for you. Does it trigger any memories of similar past experiences?” (history)“This must be difficult. Perhaps you can tell me some of the things you do to try and keep these feelings and thoughts at bay?” (Management strategies.)

69. Summary of resultsHigh shame-prone participants deemed unhelpful:Avoidance interventions (e.g., ‘talking about it later)Direct experience interventions (e.g., experience feeling).Interventions in the ‘middle’ that touched on management (i.e., how do you manage these feelings’) was deemed best.

70. Shame often ignored in therapyShame is often ignored in therapy.Not simply because of the pain it causes in the patient, But also the pain (and strategies to avoid it) it causes in the therapist.The recognition of shame is itself is often considered shamingLewis, 1971; Taylor, 2015; Wilson, 2006

71. “When shame is accepted and examined inside the consulting room, this becomes for the patient a crucial opportunity to repair his or her self-image and to restore a sense of a connected self” Schimmenti, 2012, p. 207)

72. Further therapy readingsChefetz, R. A. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: NortonGilbert, P. (1998b). Shame and humiliation in the treatment of complex case. In N. Tarrier, A. Wells & G. Haddock (Eds.), Treating complex cases: The cognitive behavioural therapy approach (pp. 241-271). Chichester: Wiley & Sons. Kluft, R. P. (2007). Application of innate affect theory to the understanding and treatment of dissociative identity disorder. In E. Vermetten, M. J. Dorahy and D. Spiegel (Eds.), Traumatic dissociation: Neurobiology and treatment (pp. 301-316). Arlington, VA: American Psychiatric Press. Lee, D. A., Scragg, P., & Turner, S. (2001). The role of shame and guilt in traumatic events: A clinical model of shame-based and guilt-based PTSD. British Journal of Medical Psychology, 74, 451-466.Stewart, B. L., Dadson, M. R., & Fallding, M. J. (2011). The application of attachment theory and mentalization in complex tertiary structural dissociation: A case study. Journal of Aggression, Maltreatment & Trauma, 20, 322–343.