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Kid's Korner

Therapy with Dissociated Youth, Using the STAR Model

Giles Sieburg, MFTLP

Giles Sieburg

Treating dissociation at times can feel like groping around in the dark. We know we are in the right ballpark, but every session can be an act of straining to interpret and understand what is being presented.

Ever since I started doing treatment and parenting as a therapeutic foster parent, I wanted desperately to have a decoder ring to understand what was going on, and how to engage and respond.
In my pursuit, I have connected with Fran Waters, LMSW, DCSW, LMFT to understand her STAR Theoretical Model (Waters, 2016) as a framework or a lens to make sense of what was being presented by my clients and foster children.

Waters’s (2016) work was 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 presentations that she was seeing in these youth. Initially, she created what she coined the Quadri-Theoretical Model which incorporated the work of attachment theory (informed by Bowlby) , developmental theory (informed by Erikson), family systems theory (informed by Satir), and dissociation theory (informed by Janet, Putnam, Van der Hart, Watkins, Silberg, and Freyd). 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 to, 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).

The impact this has had on my treatment of my clients is significant because the behaviors presented now made sense and were supported by the vast resources within the fields of study in dissociation, attachment, neurobiology, family systems, and developmental psychology.

In order to show how the STAR model can be used for case conceptualization and treatment, I will share a vignette from one of the clients I treated. (All names and details have been changed for confidentiality purposes. Vignette inclusion was approved by the client and her family.)

A 13-year-old girl, Charlotte, came to my office with her family in order to receive treatment for what they suspected to be Dissociative Identity Disorder. The family had been through several different treatment protocols and medication regimens. In addition, their daughter experienced several hospitalizations that were ineffective in helping her stabilize and heal.

Charlotte came into therapy identifying several parts of self, each with their own names, purposes, and backstories concerning their “lives” before they came to be a part of Charlotte. These parts of self came to be as a result of significant childhood sexual abuse by a peer over the course of several years.
The initial assessment of this youth began with assessing the dissociative symptomatology by going through an A-DES assessment which indicated that a dissociative disorder was possible. Further assessment and clinical interviewing solidified this diagnosis. I then began to assess through Waters (2016) Sixteen Warning Signs of Dissociation, recognizing indicators of dissociation related to Charlotte’s traumatic history, moments of switching and the presence of different parts.

The next stage of utilizing the STAR model was the intervention of psychoeduction for the child and family about dissociation and communicating the treatment goal of integration. I put a special emphasis on communicating to the child’s system how “brave and strong they are”, and how “my goal was not to get rid of the parts but to help them work together”. I also spent significant time focusing on safety building so that the child and her parts knew that I was not going to harm them and would pace our work according to what she and her states could tolerate.

The psychoeducation of dissociation is a crucial step because it allows the therapist to conceptualize the behaviors and symptoms for the family to make it understandable with clear guidelines for stabilization of behaviors.

Assessing attachment is something done over time by tuning into the relational dynamics with the parents by including them in sessions. This can help build safety in the sessions as well because the parents are more attached to the child than the therapist, and because attachment is central to treatment. Attachment wounds and betrayal trauma must be worked on and resolved to move towards integration.

Charlotte’s relationship with her mother, while being secure at times, suffered because the abuse of a peer happened in her own home, where the child felt the parent should have protected her. This was learned in the assessment phase of treatment and during the treatment phase, I circled back to this dynamic when a part of self that primarily held the rage towards its abuser took unilateral control for a couple months.

As part of therapy, Charlotte’s mother, father, and her sister (with whom there is relational disconnect as well) wrote letters to Charlotte about how they were sorry she experienced the abuse and that they wished they could have protected her and stopped those events from happening. That was a stepping-stone to ‘grease the wheels of treatment’ because that dissociative part largely wanted to disengage and stop going to therapy, due to not wanting to address the homicidal behaviors it presented with. These homicidal behaviors were a means for this perpetrator introject to protect the child by redirecting the rage on her attachment figures. That part would often state “if my parents or sister were dead then I would not have to feel like this anymore, and even if I went to jail or was sad that they were gone that feeling would go away also”. This all indicated attachment needed to be addressed to continue to work through the trauma.

The influence of neurobiology is also a helpful psychoeducational piece for the parents to understand the impact of trauma with the polyvagal theory, and how stress is a mitigating factor in whether the child can stay within their window of tolerance or feel the need to rely on switching between parts. That allowed the parents to understand what was happening inside their child’s mind.

Within the assessment and the treatment stages, there is always an awareness of tuning into the child’s window of tolerance and being aware of stress and how to elicit safety in therapy sessions. If a child is resistant and non-participatory, then stress is elevated, safety is questioned and parts are presenting with a myriad of behaviors to distract and disrupt momentum in treatment.

I encouraged the parents to use their new understanding of the neurobiology of trauma to adjust their parenting approach. The golden rule when treating dissociative youth in this model is ‘connecting before correcting’ (Hughes & Baylin, 2012; Siegel & Payne Bryson, 2014) because it causes the parent to become curious about the child’s behavior to understand how the trauma is playing out specific behavioral coping scripts. It also allows for attachment repair to happen in the moment of triggering.

Charlotte’s different parts presented differently but they all tended to move into scripts that distanced and withdrew from family members, which led Charlotte to hide up in her room for significant lengths of time. The parents were bothered by this and wanted to correct it, but the tuning in of ‘connecting before correcting’ allowed Charlotte’s parents to move towards her and drew her out of seclusion into connection with them through cuddling, and one-on-one time.

Developmental psychology is a lens that allows for understanding where and what is going on within a dissociative child’s system. In the assessment phase, we were able to explore each of the different parts and identify developmental stages for each part. The little parts were younger developmentally and did not have the fine motor and academic skills needed for Charlotte to function in school.

Therefore in several sessions, I worked on helping the younger parts identify why and when they are triggered to come out and also helped them feel comfortable staying inside when the child was in school so that they could avoid times when Charlotte switched and became lost, frightened and disoriented in school. This goal is a short-term focus to allow for stability as the goal will eventually to developmentally grow the different parts up. The younger parts need to orient to the present where the child is safe and older so that different developmental stages do not conflict with current functioning.

I worked together with Charlotte’s parental part (who took on the role of raising up one of the little’s) by helping the young part have internal space and tools to feel comfortable staying inside and also allowing for this part to have internal glasses (installed through EMDR) to help with the learning and growth process. Through this intervention, this younger part has grown to become an integral part of treatment because this part has been found to have influence or control over the perpetrator introject part of Charlotte’s system, allowing for therapeutic resistance to treatment to be mitigated.

Family systems work is key to understanding the child’s internal system because their internal systems mimic the systems in their birth and adoptive homes. Having a strong understanding of the family’s dynamics and roles helped me to understand what roles the internal parts had taken. Charlotte’s mother presented with her own trauma history and presented with a diagnosis of OCD. Charlotte’s system created a part of self that was oriented around parenting and is meticulous and controlled about the internal family and its dynamics, which seemed to mimic some traits similar to her mother’s OCD. This part had schedules, routines, educational lessons that it would force the internal family to follow through with.

There is also a part of self that is predominantly image-conscious and self-focused. This part tended to take after Charlotte’s older sister, which plays in the same family patterns because Charlotte was distant and not connected to this part of self, and often remarked on hating this part. In order to work through the internal family dynamics, we helped her external family dynamics. Charlotte would not be able to heal and integrate with her self-oriented part that mimicked traits of her sister if she did not work through the dynamics with her actual sister, and the same was true for her relationship with her mother. The reasoning can be quite symbolic and different for every child’s system, but for Charlotte, it was because each of those family members hurt her in different ways, so their behavioral scripts were wrapped up in pain and needed to grieve and unburden from those dynamics.

These five pathways can provide the therapist with a concrete assessment and foundation to treat these children. It gives hermeneutics, direction, and creates open windows for stabilization, and integration to take place.

Charlotte’s system improved significantly when stabilization and safety were achieved by utilizing these 5 pathways in the STAR theoretical model. It also allowed for clarity when treatment became a challenge and Charlotte was resistant. The model helped me interpret and identify a perpetrator introject and understand the impact of the family and attachment dynamics in play. The STAR Theoretical Model (Waters, 2016) is a comprehensive and directional primer and approach to treating dissociative clients.

References:
Hughes, D. A., & Baylin, J. (2012). Brain-based parenting: The neuroscience of caregiving for healthy attachment. New York, NY: W. W. Norton.
Siegel, D., & Payne Bryson, T. (2014). No-drama discipline: The whole-brain way to calm the chaos and nurture your child’s developing mind. New York, NY: Random House.
Waters, F. S., (2016). Healing the fractured child: Diagnosis and treatment of youth with dissociation. New York, N.Y., Springer Publishing Company.

News You Can Use

News You Can Use

Kate McMaugh, Editor, ISSTD News

Trauma Informed Yoga Explained

A new book by ISSTD Board Member and Secretary, Lisa Danylchuk, LMFT, is an essential for anyone interested in integrating yoga into trauma recovery, or for those interested in learning more about how yoga can help their clients.

Yoga for Trauma Recovery begins with a detailed section over-viewing the foundations of trauma and recovery before moving into the foundations of yoga therapy itself. These sections are nicely bridged by a chapter on somatic psychotherapy and the influence of the body on the mind. As such this book plays an important role in unifying the two fields. The book provides practical advice on yoga practice for trauma recovery and ends with several chapters dedicated to recovery in a section entitled ‘Growth: Keeping Joy Alive in the Face of Trauma’.

The book has had many positive reviews. The highly esteemed trauma scientist, Professor Stephen Porges writes

“Yoga for Trauma Recovery provides an accessible description of how yoga can be an effective therapeutic tool in the treatment of trauma. In this volume, Lisa Danylchuk effectively integrates classical yoga teachings and philosophy with contemporary psychotherapy and neuroscience. Based on her clinical experiences she provides compassionate examples of how yoga can foster recovery from trauma. By emphasizing how yoga, via breath and bodily movement, exercises the neural regulation of visceral organs, the reader is informed that yoga is an enabler of healing mechanisms that originate in the body and not from external agents.”

This foundational text is a must read for those interested in the healing capacities of trauma therapy and trauma-informed yoga. The book is available from:
Amazon (remember to use your Amazon smiles to raise money for ISSTD!) and from the publishers, Routledge.

An Infinite Mind Conference: Boston September 21, 2019

An Infinite Mind will be collaborating with McLean Hospital to hold a one-day Healing Together Conference in Boston on September 21, 2019 from 9AM- 5:30PM.

This conference will be a day of fun and education for people with dissociative disorders, their supporters, and mental health practitioners who work with individuals with dissociative disorders. Workshops will be led both by those with lived experience and by clinicians.

The Key Note Presentation will be given by Olga Trujillo, author of The Sum of My Parts: A Survivor Story of Dissociative Identity. She will discuss her experience of DID from an inside out perspective. Participants will explore her experience of DID & healing.

The Plenary Presentation will be given by Lauren Lebois PhD and Laura Ward, MBA, MPH from the Dissociative Disorders and Trauma Research Program at McLean Hospital. This talk will present recent findings on the biology of dissociative symptoms and the experiences of individuals seeking treatment for DID. They will also announce details of an upcoming randomized-control trial for DID treatment!

In addition, the day offers interesting break-out sessions covering a range of issues including: mindfulness as a grounding skills, creative arts and healing, orientating parts to the present and working with ambivalence in therapy.
For more information, or to register for the conference click here!

Welcome ISSTD’s New Members in June!

PROFESSIONAL MEMBERS
Dana Carretta-Stein
Alice Clark
Rachel Conway
Maria Crawford
Genevieve Cribb
Mary Fierst
Shelley Harvill
Daphne Kalaidjian
Colette Lord
Karla Manternach
Shahanshah Manzoor
Kathryn Maslowe
Carol Quintana
Angela Scanlon
Tara Shermann
Brandie Stevenson
Linda Valerian
EMERGING PROFESSIONAL MEMBERS
Umu Benjamin
Sandi Bohle
Carrie McDowell
Erick Panike
Lauren Stinson

STUDENT MEMBERS
Charla Jones

Do You Have News ISSTD Members Can Use?
We need your help to make NYCU a great feature, full of news and sharing the activities of our community members.
Do you have a book or book chapter coming out that you wish to share? Have you received an award for your work in the field? Have you been part of developing a new website or training course? Have you had a chance to develop something creative and unique that you wish to share with others in the field? If so, we want to hear from you! Don’t be shy, submit your news to us so that we can share with other members. (Please be aware: we do not offer book reviews, but a chance to share with others that your book has been published.)

Submission Deadline: 20th of the month
Send to ISSTD Editor, Kate McMaugh: katemcmaughpsychology@gmail.com

Letter From The President

Presence, Patience, Dignity and Compassion: Unspoken Requirements of Being a Human

Christine Forner, BA, BSW, MSW

As I write this month’s Letter, I am struck by the mini-series: ‘When they see us.’ This mini-series leads me to examine the role of parents within the area of complex trauma and dissociation. What is really circling around in my mind is how much children need their parents and the consequences which occur when parents are removed. Conversely, what also happens when parents are around.

The Netflix movie “When they See US” is a docudrama about the “Central Park Five”, a group of boys ages 14-16, who were accused of raping a woman, and the subsequent trial and jail time they all faced.

A story of a group of people or a person who is falsely accused of a crime is not all that novel. What was novel to me was how the film-makers portrayed the parents and caregivers of these boys. In each case the show highlighted how the parents were affected by these events. What really struck me was how most of the parents stayed on their children’s side. In between scene after scene of the horror, racism, ageism, injustice and violence were messages of strong, unwavering support of these adolescents from those who loved and cared for them. Within each story line the creators of this story filled in the spaces with language of human pride and dignity coming from the caregivers. Instead of making the injustice, the racism or the violence the main focus of the story, I feel they made the unwavering care, and the positive outcomes of that care, the primary focus.

I was able to see depictions of mothers who gave speeches of unconditional love and passionate care towards their sons. I saw incidents where a prison guard went out of his way to help. This series showed fathers taking the time to talk to their sons and not leave them. It showed, albeit, subtly, the connection between how these boys endured these traumatic experiences and the support they received from their families. It also showed that those who had the least amount of support did not have the best outcomes. This show provided a level of dignity and humanity over sensationalism and it was an excellent change.

Research shows that the number one need of our young is to have sustained and attuned parental (or adult) care. But what does this mean? What does ‘care’ mean? I suspect that many are confusing love with care. Love can be quite an easy thing, but the everyday care that children require is not all that easy.

Care, to me, means presence, patience, dignity, compassion and awareness. What I refer to when I use the word presence is the need to be there, to witness, to endure, to know, to feel, to attune, to engage in all that the child is doing. It is to be present with the child’s pain, joy, boredom, suffering, fears, aloneness, boundaries, growth, etc., so that adults can, with a great deal of accuracy, know what the child is experiencing. The goal of this is that the child’s only form of communication, emotions and feelings, are received clearly and accurately, so that the child’s needs are met. This requires a great deal of attention to that child. In colloquial terms, this is what the child seems to be expecting from us.

In all honesty, presence is what we expect from others, even if we have never felt it, experienced it or we are unable to provide it to others, ourselves. We, as an organization, and as individual researchers and clinicians have learned that when care is not there it is deeply wounding for the child. When care, presence, patience and dignity is there, it is the stuff that makes us thrive.

Presence seems to be what we crave from others. But it is also a rare commodity for the traumatized. Dissociation is the polar opposite to presence. Dissociation is the attempted anesthetic to our more difficult feelings and experiences. As therapists in this area, we have learned that some of the most powerful healing comes from sitting with others and providing presence to their pain and suffering.

Dignity is a much spoken-about word, but what this entails is the ability to be kind and make the general assumption that people are doing what they are doing for good reasons and that most people, when given the chance or opportunity, will do what they can to care for their children. I wish the powers-that-be understood that children are mirrors. They are not bad or good, they are human and as a humans they do what is shown to them. If you provide your child, or all the children that you are in contact with, with dignity, the child will become dignified. If you show them how to care, they will then know how to care. If we show children respect for sadness, anger, rage, fear, insecurity, failure, disappointment, attachment fear, vulnerability, pain, and suffering, then they will learn how to care for these things within themselves and for others.

Dignity is not a given when your world is full of fear, sadness, attachment attacks, threat or abandonment. The need for our inner world to be cared for is being missed and the human will seek this their whole lives if these needs are not met. The need to be treated in a dignified way seems to be an unconditional standard of human care. If we do not get dignity, or dignity is not provided, we will crave it, and get very symptomatic when we don’t get it.

Then there is compassion. The ability to be kind and understanding of others, especially to their pain and suffering. We seem to be missing this in almost every area of our world. Many of our clients have never been shown compassion, and when they first receive compassion they are very wary. (Many of our clients know through experience that seduction of children can be done under the guise of false compassion.) But we also have difficulty with self compassion, and if this is the case, then you, yourself, are missing the experience of others being compassionate to you.

I have learned that most people have an interest in others being okay, but we seem to have lost the art of care, with presence, patience, dignity and compassion. I am thankful that within in this organization these notions are known well. We are a collection of professionals who see the problem and are attempting to help heal and to provide care.

As a motivation for this month see if you can detect when you have your presence, patience, dignity and compassion turned on. See what happens when you exaggerate these qualities and take note of what happens when they are not available. As we know, these qualities make life very livable and very difficult when they are lacking.

Donate to ISSTD

Donations Help ISSTD Complete Major Projects

Thank you to everyone who donated to ISSTD in 2017-2018 as part of our 35 for the 35th Donation Campaign. Through the generous donations of more than 100 individuals, we were able to raise $21,826.80 towards our $35,000 goal. While we did not meet our overall goal, these funds enabled us to complete a number of new projects including:

  • Introduction of the redesigned ISSTD website, including an update to our branding;
  • Launch of the ISSTDWorld platform where members can now access member resources, update their Find-a-Therapist listing and participate in community discussions, all in one location;
  • Increase of the number of online educational offerings including webinars and teleseminar courses;
  • Capture of slides and audio for a limited number of conference presentations which will be available individually and in packages for purchase with continuing education credits;
  • Development of additional content specifically for students and emerging professionals, including a conference track for psychiatric residents; and
  • Reduced pricing for students and emerging professionals for webinars.

While the 35 for the 35th Donation Campaign has concluded, we hope that you will consider a donation to the ISSTD General Fund in 2019 so that we can continue to expand our member and public resources.

Thank You to Our 2019 Donors
(as of June 30, 2019)

  • Theresa Albini
  • Orit Badouk Epstein
  • Kathy Barclay
  • Jemima Bem
  • Marcus Bem
  • Dee Blinka
  • Valerie Bryant
  • Thomas G. Carlton
  • Juliana Cocola
  • Frank Corrigan
  • Christine A. Courtois
  • D. Michael Coy
  • Lynn Crook
  • Faith Curtin Koch
  • Anne David
  • Irina Diyankova
  • Paula Eagle
  • Robert Emond
  • Catia Fath
  • Eda Flores-Miranda
  • Wendy Forbush
  • Christine Forner
  • Sharon Green McLendon
  • Margaret Hainer
  • Mary Pat Hanlin
  • Kim Havenner
  • Linda Heaviside
  • Rick Hohfeler
  • Elizabeth Howell
  • Marta Illueca
  • Sheldon Itzkowitz
  • Terry Kerler
  • Deborah Korn
  • Marilyn Korzekwa
  • Andreas Laddis
  • Ulrich Lanius
  • Rebecca B Lee
  • Joselito Libres
  • Lori Lickstein
  • Warren Malach
  • Yael Margolin-Rice
  • Warwick Middleton
  • Sarah Mills
  • Joyce Morene
  • Randall O’Brien
  • Tanya Oleskowicz
  • Nancy Payne
  • Sarah Perkins
  • Valerie Pronovost
  • Katherine Quam
  • Michael Quinones
  • Herbert Jay Rosenfield
  • Bruce Ruekberg
  • Kris SantaMaria
  • Bart Schofield
  • Ruth M. Schofield
  • Valerie Sinason
  • Ann Smith
  • Gail Straw
  • Rocio Tharp
  • Onno van der Hart
  • Cynthia Wilson
  • Sowmya Yeturo
  • Anonymous

2020 Annual Conference

Announcing Our 2020 Annual Conference Plenary Speakers

ISSTD 37th Annual International Conference
The World Congress on Complex Trauma and Dissociation
2020: Envisioning the Coming Decade
March 12 – March 16, 2020
InterContinental Hotel San Francisco

2020 Call for Proposals and Plenary Speaker Information

The International Society for the Study of Trauma & Dissociation is pleased to announce our Call for Proposals for our 2020 Conference will run August 1 through September 23, 2019.

We are looking for creative, innovative, and exciting presentations on all aspects of understanding, researching, and treating complex trauma and dissociative disorders. We encourage solid scientific and clinically grounded presentations that broaden our knowledge base and sharpen our clinical skills. The use of experiential, interactive, and multi-media presentations is encouraged.

To help you plan your proposal, we proudly announce our slate of plenary speakers: Pat Ogden, PhD; Karlen Lyons-Ruth, PhD, and A.A.T. Simone Reinders, PhD. We will announce our pre-conference workshop lineup in late July to coincide with the launch of our conference website which will include updated submission guidelines.

Registration for the 2020 Annual Conference will open on September 1, 2019 and early bird rates will run through January 15, 2020.

2021 Conference Dates and Location Announcement

Also, save the date as ISSTD will be headed to Louisville, Kentucky for our 2021 Annual Conference. The conference will be held at the Onmi Louisville April 8-12, 2021.

Committee Spotlight

The Goodwin Fund: Increasing Access to Training in Trauma and Dissociation

Christine Forner, BA, BSW, MSW

The Goodwin Fund was created in the name of Jean Goodwin. Jean Goodwin is a psychiatrist and psychoanalyst specializing in the treatment of patients suffering from the consequences of sexual abuse, incest and family violence. A co-founder of the Houston Galveston Trauma Institute, Dr. Goodwin is currently a faculty member of the Houston Galveston Psychoanalytic Institute and Professor of Clinical Psychiatry at the University of Texas Medical Branch in Galveston.

The background story is that Jean was treating someone for complex trauma and dissociation and the person was very upset that there were, and are, so few resources and competent therapists in this area, that they felt something needed to be done about it. Jean was one of the few therapists who specialized in complex trauma and dissociation. The funder saw the great need to train more therapists so that they could become competent in the treatment of trauma and dissociation. One of the most significant aspects of this fund is that it is intended to go to those who otherwise would not be able to afford to take our training.

We received an initial donation of around $10,000.00 and this amount has been added to several more times. There is now a significant amount of money available for distribution. The Goodwin Educational Fund was created to defray the cost of training activity offered through ISSTD for ISSTD Members who would otherwise be unable to obtain appropriate instruction in the treatment of complex trauma and dissociation. The main reasons are financial ones.

Individuals who are in other countries, people who are working in regions with particularly high cost of living, and those who work in low paying not-for-profit organizations are all excellent examples of individuals who would qualify for the fund. Rather than supplement the professional development budget of Members, this fund is intended to support those who are truly under-privileged or disadvantaged.

We have been able to give out ten awards so far. There are two separate application dates annually. One in August and one in January. The intent is to assist in our Professional Training Programs (PTP) and the other is offered at a time to assist with the annual conference. This year the Goodwin Fund was able to support five individuals from several different countries, including Africa.

The Goodwin Fund Committee is eager to promote this fund so that we are able to support individuals who may never get the opportunity to learn the valuable skills of working with severely traumatized humans. Our next round of applications will be taking place in July and awarded in August.

Keep an eye out in ISSTD News and on the ISSTD Website for more information.

Trauma & Dissociation in the News

World Refugee Day

Mary-Anne Kate, PhD

World Refugee Day, held every year on June 20th, commemorates the strength, courage and perseverance of millions of refugees, shows support for refugees, and requests that governments work together and do their fair share for refugees.

Who is a refugee?
A refugee is a person who has been forced to flee their country because of persecution, war or violence. Refugees by definition are traumatised individuals, with the legal criteria for refugee status requiring the person to have a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group and that, for these reasons, they are unable to return home or are afraid to do so. The right to seek asylum was enshrined in the 1951 Geneva Convention in the aftermath of World War II. War and ethnic, tribal and religious violence are leading causes of refugees fleeing their countries.

Parallels between the refugee experience and dissociation
Having worked in the refugee and migration field for over a decade and then completing a PhD about childhood trauma and dissociation, I find the similarity between the situation of refugees and individuals with Dissociative Disorders striking. Both have been traumatised by the actions (or inactions) of the very people who are responsible for protecting them, and this frequently results in the fragmentation of their identity. On one hand, refugees may find it difficult to continue to align themselves with their national, cultural, social or religious identities, as these are also aligned to those who persecuted them. On the other hand, they may continue to cling to these aspects, which forms a core part of their heritage and personal identity.

Furthermore, their new lives may be so discordant from their old, that they barely recognise themselves. This echoes the experiences of people who dissociate to cope with abusive and frightening caregivers, who they may continue to have love for, and loyalty to, even though their caregivers have harmed them in unspeakable ways. It is not surprising then that, like people who suffered chronic abuse at the hands of their caregivers, refugees have high rates of dissociation.

Refugees: a global perspective
There are 25 million refugees worldwide. Two-thirds of all refugees worldwide come from just five countries: Syria, Afghanistan, South Sudan, Myanmar and Somalia. In addition to refugees, there are 40 million Internally Displaced People (IDP) worldwide who have been forced to flee their home as a result of civil war, internal strife or natural disasters.

While many people in the West feel that their country is shouldering the burden of refugees this is far from the truth as 85% of refugees and IDPs reside in developing countries such as Uganda and Pakistan. Turkey alone hosts 3.5 million refugees. In comparison only 24,000 of these refugees were resettled in Europe in 2017. The most generous Western countries for refugee resettlement when the population of that country is taken into account, i.e. number of refugees resettled per thousand residents, are Monaco (.59), Norway (.53), Sweden (.34), and Luxembourg (.31), which is higher than the traditional refugee resettlement countries of Canada (.24) and Australia (.16) and the US (.08).

Seeking asylum in western countries
Only 1 in every 21 refugees residing in the country they fled to, who are in need of resettlement to a safe third country, will be given that opportunity due to the very limited number of resettlement places offered internationally. With scant opportunities for resettlement, it should not be surprising that many refugees and IDPs undertake a frequently perilous journey to seek asylum in a safe country. While we may have the impression of all asylum seekers heading to Western countries, this is incorrect as half seek asylum in developing countries. In 2017 over 3 million people were awaiting decisions on their asylum applications.

Memory, credibility, shame and disclosure
Research suggests that refugee status decision-makers typically have unrealistic expectations of what people can reasonably remember. They assume that the person should accurately recall dates, frequency, duration and sequence; and even peripheral information and verbatim wording of verbal exchanges. If the asylum-seeker cannot give a detailed account of events then their claim may be deemed not credible. These expectations about memory recall are too high for even normal events and do not take into consideration the neurobiology of traumatic memory or dissociative amnesia.

Having personally conducted several hundred refugee status determination interviews in North Africa, I often found the interviewees who could provide a detailed narrative of their experiences were the ones whose claims I found were not credible (which would become clear to me when I focused on their life generally outside the refugee claim and the two accounts would not match up).
I also noticed how shame, trauma, and a lack of trust and rapport also prevented genuine claims from being disclosed. Not unlike an initial therapy session for a dissociative client, there is little more than an hour to build rapport with a person that is fearful and distrustful of authority figures and to uncover the kernel of their story.

I recall interviewing a journalist who had been tortured for weeks and witnessed his cell mates killed in front of him. This man was physically and emotionally broken, could barely speak, and had no wish to recount his horrific and humiliating experiences. I interviewed three young women huddled together who were shaking in fear so intensely that I did not follow the normal protocol of separating them. I remember a woman telling me about being held captive by a ‘bad man’ and I strongly suspected she had been raped, but I knew she could not disclose that to me – rape is not only shameful, but a cultural stigma that can lead to a woman being outcast by her husband and her own family. However, if she had been able to tell me, it would have made her claim stronger. There is no way I could do justice to these people’s experience in the hour or so that I had with them. For the record, I did grant refugee or humanitarian status to these people who could then start a new life in Australia, but I knew that the outcome may have been different if the interviewer had been someone that was not as attuned to trauma as I was.

National asylum policies: a trauma-creating approach
Western countries are spending hundreds of billions of dollars on additional measures to stop asylum seekers reaching their soil. Many compete with each other in a race to the bottom to be the least desirable destination, sacrificing human rights in the process. For example, since 2001 the Australian government has prided itself on its initiatives to “stop the boats” to prevent the arrival of asylum-seekers in Australia, regardless of the strength of their refugee claims.

Australia began processing asylum-seekers off-shore on small islands in the pacific to avoid its responsibility under the Geneva convention. The detention centre on Manus Island, Papua New Guinea, was found to be illegal and unconstitutional and the Australian government was forced to pay a settlement to nearly 2,000 refugees and asylum-seekers for illegally detaining them in horrific conditions. Amnesty International reports also found that asylum seekers in detention on the island nation of Nauru were subjected to humiliation, neglect, abuse and poor physical and mental health care.

In the US, President Trump signed executive orders affecting asylum-seekers and refugees, including the proposal for the wall to be built along the USA-Mexico border; allowing the forcible return of asylum-seekers to their home country; and the increased detention of asylum-seekers and their families; and children being forcibly separated from asylum-seeking parents. In dealing with vulnerable and traumatised populations a trauma-informed approach is needed, but a trauma-generating approach has been implemented as the asylum-seeking process becomes a traumatic experience in itself, making individuals more traumatised.

When the ‘safe’ country doesn’t feel safe
Like dissociative clients who have been abused by caregivers and develop a conceptual template that people and the world are unsafe, many refugees have a similar experience. To heal from trauma, one needs to feel safe. Most refugees have learned to be distrustful of authority, and too often the refugees are further traumatised, not only by their refugee journey, but by authority figures implementing the policies of the ‘safe’ countries to deter asylum-seekers. How then does a refugee feel safe in their host country?

Furthermore, a number of countries offer temporary, instead of permanent, protection which means that the refugee is living in limbo and not able to feel secure and settled given at any time they can be returned to their home country should the authorities deem it is safe to return.

Refugees and asylum seekers are our responsibility
“They have no business coming here” is a common phrase heard when the public are discussing asylum seekers whilst seemingly ignoring the right to do so that is enshrined in the Geneva convention.

The truth is that we are all responsible. International organizations, Western governments and their citizens all contribute to, or help to alleviate, the factors that create the conditions for refugees and IDPS. If people are living in a time of war or insurgency is military intervention protecting them from violent oppression, or creating greater dangers; and are there effective peacekeeping forces and diplomatic resolutions? If people are suffering as a result of war or natural disaster, is humanitarian assistance alleviating this? If people are living in abject poverty with little or no access to basic services such as water, health and education, is development assistance making their situation more tolerable? Are the goods and services produced for Western countries or the tourist market helping to provide locals with a basic income? Is the environmental inaction of Western countries (or our demand for products produced in that country) creating dangerous levels of pollution, or leading to desertification or coastal flooding in the area in which they live? Is their country struggling to cope with the ‘brain drain’ of professionals such as health care workers and engineers who are now working in our countries?

Hence, policies at the national and supranational level, and the decisions of individual consumers on what they buy and what charities they support contribute to strengthening or weakening push factors in the refugees’ countries of origin.

What would happen if these hundreds of billions spent on border security around the world were spent addressing the root causes of migration and refugee movements? Surely, if people had safety and reasonable future prospects they would not be desperate to flee their own countries in incredibly dangerous circumstances.

Community support
Refugees need a lot of support when they arrive in the host country. This may include assistance in finding suitable housing, tuition to learn the host country’s language, education and training, including getting recognition for qualifications and skills acquired in their home country, arranging schooling for children, and addressing unmet and ongoing health issues. When these needs are met, the person become more involved in the wider community (and their own cultural community) through employment, education, volunteering and civic engagement. It is through these wide range of experiences and interactions with the host society that a refugee may begin to feel safe in their new country. For refugee settlement to work well, there needs to be goodwill and practical support as well as protection from racism and other forms of discrimination.

Despite trauma being at the core of the refugee experience, mental health is rarely systematically addressed. Refugees may not seek mental health treatment as they are not aware of its benefits, are distrustful of it, lack access to it, or avoid it due to a cultural stigma surrounding mental health problems. Access to trauma-informed mental health care should be a priority for refugees, their families and their communities. Training and community education is equally important to ensure that services to refugees are delivered in a trauma-informed framework, including one that addresses dissociation.

Resources
Dissociation in refugees:
https://www.ncbi.nlm.nih.gov/pubmed/25415764
Refugee interviewing, credibility and memory:
https://academic.oup.com/ijrl/article-abstract/22/4/469/1520136
The responsibility of Western countries:
https://www.researchgate.net/publication/274007389_Kate_2011_’The_EU_migrants’_pathways_and_EU_policy_responses’_in_Ed_Novotny_Opening_the_door_Immigration_and_integration_in_the_European_Union_Centre_for_European_Studies_Brussels_ISBN_978-2-930632-11
Amnesty International:
https://www.amnesty.org/en/countries/
UNHCR statistics:
https://www.unhcr.org/en-au/figures-at-a-glance.html
https://www.unhcr.org/en-au/publications/fundraising/5a0c05027/unhcr-global-appeal-2018-2019-full-report.html
https://www.unhcr.org/en-au/protection/resettlement/5b28a7df4/projected-global-resettlement-needs-2019.html
https://www.unhcr.org/5b27be547.pdf

About Mary-Anne
Before specialising in Dissociative Disorders, Mary-Anne worked in the migration and refugee field for over a decade, including as a diplomat managing Australia’s refugee and migration programmes for North Africa; coordinating Australia’s National Integrated Settlement Strategy for migrants and refugees; and as a researcher and analyst for Europe’s most influential think-tank on migration and equality where she wrote policy for the European Commission. Mary-Anne completed her Master of Science at the University of Edinburgh and her dissertation on the inequity of protection for asylum seekers in Western countries was published by the United Nations High Commission for Refugees (UNHCR).

Publications of Interest

Publications of Interest Refugees, Trauma and Dissociation

 Kate McMaugh, Editor ISSTD News

Introducing our new Assistant Editor of Publications of Interest

I am really delighted to introduce our new Assistant Editor of Publications of Interest, our quarterly feature where we draw attention to a small selection of recently published articles around a certain theme.

Michael Serpico has kindly volunteered for this role and will be taking over POI from next quarter. Michael is a fourth year doctoral student at Nova Southeastern University, located in Fort Lauderdale, Florida. He is the Clinical Coordinator of the Intensive Psychodynamic Psychotherapy Clinic at Nova Southeastern University’s Psychology Services Center. His interests include psychodynamic psychotherapy: theory and practice, projective techniques, and personality theories. Other interests include human sexuality, evolutionary psychology, and trauma and dissociation. He earned his Bachelors in Psychology in 2011 from Long Island University Post in Brookville, New York, and his Masters in Clinical Psychology from Barry University in Miami Shores, Florida in 2015.

Recent Publication: Refugees, Trauma and Dissociation

To commemorate World Refugee Day on 20 June, the June POI is focusing on refugee trauma. Although the abstracts can only tell part of the picture each of these articles in full touches on issues very relevant to complex trauma and dissociation.

Eunyoung Kim, Minwoo Yun, Jin Yong Jun & WoongSub Park (2019) Pre-migration Trauma, Repatriation Experiences, and PTSD Among North Korean Refugees Journal of Immigrant and Minority Health, 21:466–472. https://doi.org/10.1007/s10903-018-0742-5

Abstract
Many studies on refugees suggested that refugees’ traumatic events associated with post-traumatic stress disorder (PTSD). However, it is unknown whether refugees’ PTSD was caused by their negative experience before or after the entry of their destination country. Thus, a separation of refugees’ pre-migration from their post-migration experience is particularly important in understanding the causal impact of trauma. Using a sample from North Korean refugees, this study investigates the prevalence of PTSD symptoms, the impact of tortured trauma, repatriation experiences, on PTSD among North Korean refugees (n = 698). We found that North Korean refugees in our sample (a) demonstrated a high rate of current probable PTSD; (b) were demonstrated a higher frequency of repatriation experiences with a greater risk for PTSD symptoms. The findings suggest that particular types of trauma for populations with particular socio-demographic characteristics may be at a greater risk of PTSD.

Sumithra S. Raghavan (2019) Cultural Considerations in the Assessment of Survivors of Torture. Journal of Immigrant and Minority Health, 21:586–595. https://doi.org/10.1007/s10903-018-0787-5

Abstract
The cultural and ethnic landscape of North America is becoming increasingly diverse, with many refugees fleeing torture and persecution and seeking safety in the United States and Canada. In working with this population, clinicians must implement culturally appropriate methods of assessing and treating individuals from diverse backgrounds. Culture can exert a powerful and often misunderstood influence on psychological assessment, and the critical challenge is to account for both subjective experience of the client and the objective symptoms or behaviors present. The present review explores the literature on cross-cultural issues in the assessment of survivors of torture. I summarize best practices and review the theoretical and statistical bases for establishing the equivalence of constructs across cultures. Discussion centers around the utility of a cross-culturally valid measure of distress, and it is hoped that this review will encourage collaboration between clinicians and psychometricians to develop assessments for use with this vulnerable population.

Nina Thorup Dalgaard, Safwat Y. Diab, Edith Montgomery, Samir R. Qouta, Raija-Leena Punamaki, (2019). Is silence about trauma harmful for children? Transgenerational communication in Palestinian families. Transcultural Psychiatry, Vol. 56(2) 398–427 DOI: 10.1177/1363461518824430

Abstract
Style of family communication is considered important in the transgenerational transmission of trauma. This study had three aims: first, to identify the contents of family communication about past national trauma; second, to examine how parents’ current war trauma is associated with transgenerational communication; and third, to analyze the associations between transgenerational communication and children’s mental health, measured as posttraumatic stress disorder (PTSD), depression and psychological distress. The study sample consisted of 170 Palestinian families in Gaza Strip, in which both mothers (n¼170) and fathers (n¼170) participated, each with their 11–13-yearold child. Mothers and fathers responded separately to three questions: 1) what did their own parents tell them about the War of 1948, Nakba?; 2) what did they tell their own children about the Nakba?; and 3) What did they tell their own children about the 1967 Arab–Israeli War and military occupation? Current war trauma, as reported separately by mothers, fathers and their children, refers to the Gaza War 2008/09. Children reported their symptoms of PTSD, depression, and psychological distress.

Tobias Hecker, Stephanie Huber, Thomas Maier & Andreas Maercker (2018) Differential Associations Among PTSD and Complex PTSD Symptoms and Traumatic Experiences and Postmigration Difficulties in a Culturally Diverse Refugee Sample. Journal of Traumatic Stress, 31, 795–804. DOI: 10.1002/jts.22342

Abstract
Forced migration is one of the major challenges currently facing the international community. Many refugees have been affected by traumatic experiences at home and during their flight, putting them at a heightened risk of developing trauma-related disorders. The new version of the International Classification of Diseases (ICD-11) introduced two sibling disorders, posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). So far, little is known about risk and protective factors in refugees that are specifically associated with the disturbances in self-organization (DSO) characteristic of CPTSD. In this study, we aimed to investigate the association between PTSD and DSO symptoms and traumatic experiences, postmigration difficulties, and social support in a culturally diverse sample of refugees who resettled in Switzerland. A total of 94 refugees (85.1% male; M age = 31.60 years, SD = 10.14, range: 18–61 years) participated in this study. Trained assessors performed either guided questionnaire assessments or structured interviews. In our advice- and help-seeking sample, 32.9% of individuals suffered from PTSD and 21.3% from CPTSD. After controlling for potential gender differences, we found positive associations between PTSD symptoms and trauma exposure, β = .22, as well as between DSO symptoms and postmigration living difficulties, β = .42, and lack of social support, β = .22. Our findings support the notion that it is highly important to consider differential associations among PTSD and DSO symptoms and risk and protective factors to gain a deeper understanding of the trauma-related problems refugees face.

Nadia Vossoughi, Yo Jackson, Stephanie Gusler, and Katie Stone (2018) Mental Health Outcomes for Youth Living in Refugee Camps: A Review. Trauma, Violence, & Abuse, Vol. 19(5) 528-542 DOI: 10.1177/1524838016673602

Abstract
Currently, there are approximately 10.8 million child refugees worldwide. Youth living in refugee camps face a wide range of difficulties placing them at risk for trauma exposure and negative mental health outcomes. However, little is known about the mental health functioning of these youth. The present review provides a systematic review of mental health outcomes for refugee/ displaced youth residing in refugee camps. Twenty studies were included in the present review. Among these studies, the prevalence of mental health disorders varied greatly with some studies reporting null effects for disorders like posttraumatic stress disorder and others reporting prevalence as high as 87%. Levels of anxiety, somatic symptoms, depression, and aggression also varied across studies. The results point to the significant need for more research on the mental health of youth residing in refugee camps. Despite the wide range of measurement approaches, the evidence points to a fairly consistent finding of a range of maladjustment problems for youth living in refugee camps. Implications for improving the methodology for investigating mental health are discussed.

Committee Spotlight

Scientific Committee

Vedat Şar

Scientific Committee Chair, Vedat Sar, MD at ISSTD Annual Conference, 2018

ISSTD Scientific Committee has been active since 2012. Members of the Committee are selected for a three year term, which can be extended. One third of the Committee is replaced every year, enabling continuity. It is international and global in composition, and both clinicians and researchers are represented.

Former presidents of ISSTD, Vedat Şar, MD (Turkey) and Warwick Middleton, MD (Australia) serve as Chair and Vice-Chair of the Committee. Current Committee members are Ruth Blizard (USA), Bethany Brand,PhD (USA), Paul F. Dell, PhD (USA), Martin J. Dorahy, PhD (New Zealand), Benedetto Farina, MD PhD (Italy), Heather Hall, MD (USA),Mary-Anne Kate, PhD (Australia), Milissa Kaufman, MD PhD (USA), Marilyn Korzekwa, MD (Canada), Christa Kruger, MD (South Africa), Andreas Laddis, MD (USA), Lauren A.M.Lebois, PhD (USA) Alfonso Martinez-Taboas, PhD (Puerto Rico), Dana Ross, MD (Canada), Adah Sachs, PhD (United Kingdom), Michael Salter, PhD (Australia), Adriano Schimmenti, PhD (Italy).

Scientific Committee Vice Chair, Warwick Middleton, MD with fellow committee member Martin Dorahy

In the seven years since its establishment, committee members have been able to publish several reviews and opinion papers on trauma and dissociation which are products of collaborative efforts.

A current project is a collaboration between the ISSTD and ESTD Scientific Committees. Review articles are being prepared on six dissociation-related topics which are considered strategically important.

Committee Members Heather Hall, MD and Michael Salter, PhD presenting at ISSTD Annual Conference, 2019

The Committee discusses future possible activities which usually emerge through spontaneous proposals from its members. In this context, the Committee has decided to organize a two-hour face to face meeting during the 36th Annual Conference of ISSTD in San Francisco. The agenda of this meeting will cover identification of the research areas which are strategically important for the field; ways of expanding the representation of research output in the annual conference programs; potential projects of editorial books; and programs to reach out to emerging researchers and clinicians, among other topics which will emerge during preparations. Thus, proposals by ISSTD members about topics to be covered are also welcome.

Scientific Committee members Michael Salter and Paul Dell at the ISSTD Annual Conference, 2019

The experience of seven years in the Scientific Committee has led to the conclusion that Dissociative Identity Disorder, the prototype diagnostic category of our field, is no longer a subject of prejudice and stigmatization. What we need, now, is to continue to focus on how to serve our patients to the highest standard.

The work of the field still only represents a tiny portion of all research production (approximately 3,600 published papers listed by Science Citation Index over 45 years). However, this field has immense potential. It is hoped that the work of the Scientific Committee will play a role in facilitating the study of dissociation to enable an expansion into many areas of mental health (clinical psychiatry, psychology, neurobiology, pharmacology etc) which would enable researchers and clinicians to influence the wider mental health field.

Volunteer Spotlight

Spotlight on Volunteers: Michael Salter

Michael Salter

Tell us a bit about yourself.

I’m an Associate Professor of Criminology and research fellow based at the University of New South Wales, Sydney. My research is focused on the the organised sexual abuse of children. A lot of my research involves detailed interview work with adult survivors, and I’m really interested in survivor experiences of the mental health system, law enforcement and other key agencies.

Tell us something most of us may not know about you.

I’m a twin! I have a wonderful twin sister, Rachael. My parents apparently didn’t realise they had given us almost identical first names until it was too late.

What lead you to join ISSTD? What is your favorite thing about ISSTD?

Many of the survivors who I have interviewed have described being ritually abused as children. There are very few organisations who have been willing to grapple with the challenges and controversies over ritual abuse in the way that the ISSTD has. My favourite thing about the ISSTD is its commitment to examining all the factors that contribute to dissociation, including those that make us uncomfortable or uneasy. I think that takes real courage.

What are your volunteer roles in ISSTD? And what led you to volunteer?

Michael Salter and Paul Dell at the ISSTD Annual Conference, 2019

I’m not sure “volunteer” is the right word – “drafted” is probably a better one! Just kidding (… am I?). I’m on the Board of Directors and I’m also a member of the Scientific Committee. I’m the Past Chair of the Ritual Abuse, Mind Control and Organised Abuse Special Interest Group. I’m also on the Christchurch Conference Organising Committee. And probably some other Committees that have slipped my mind …

What’s good about volunteering? What do you get from it?

Personally, I really enjoy working with the hard working and dedicated people that keep the ISSTD going, including our all-important staff but also the other volunteers. And I enjoy feeling like I can make a real difference for survivors and for the complex trauma field.

What do you find most valuable about being involved in ISSTD?

The sense of collegiality and solidarity that I get at the ISSTD is very special. Academia is a fairly isolated profession, particularly in an area like organised abuse which has not attracted a lot of scholarly attention. Being involved with the ISSTD means spending time with other people who understand, at a fine-grained level, the kinds of issues that I encounter in my work, and why I persist.

Heather Hall, MD and Michael Salter, PhD presenting at ISSTD Annual Conference, 2019

What are you working on right now for ISSTD?

For the last year, I’ve been working with Heather Hall on the Public Health Taskforce, where we have been developing a public health framework for trauma and dissociation with a focus on primary prevention. Working with Heather on the Taskforce has been really enriching, as we’ve been developing a shared vision based on her clinical experience and my research background. We are currently writing up our findings at the moment, with a focus on the personal and social role of shame in complex trauma.

What else are you working on?

I’ve just returned from nine weeks working in the United States and Canada. I spent May at the Canadian Centre for Child Protection, which is doing incredible work promoting the rights of survivors whose abuse was recorded and distributed. I’m doing some research with the Centre at the moment on the role of organised abuse in online child sexual abuse images/video. We are pushing for significant policy reform to reduce the enormous amount of abuse material currently online.

I have a few research studies on the go. I’m currently finishing a large national study examining service responses to women with complex trauma. The project team includes the ISSTD’s Warwick Middleton and Jackie Burke as well as other colleagues. I’m also leading a government-funded study on the role of parents in the production of child sexual abuse material of their children. It’s great to see increased government and police recognition that abusive families have a major role to play in child sexual exploitation. In a few weeks, I’m off to Interpol in Singapore to discuss online child protection challenges with international law enforcement and industry stakeholders.

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