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ASSESSMENT DETAILS

Unit/Module: Working With Crisis and Trauma

Educator: Peter Wilson

Assessment Name: Academic essay: Risk Factors and Treatment for Survivors.

Assessment Number: 2

Term & Year: 1_2012

Word Count: 3232


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This paper will use a case study to demonstrate how unresolved trauma from abuse and

neglect on a young child can direct the survivors behaviour and reactions towards crisis,

trauma and complicated grief in later life. Such variables can lead to a more risk reactions.

Conversely, depending on the surviv ors cognitive schema and resilience , a survivor may

develop greater resilience and more easily process traumatic events. This case will examine

risk factors and trauma reactions as a result of the su dden and unexpected death of Graces

mother. Wiger & Harowski (2003) describe a traumatic event as when a person/child actually

believes there is risk of injury or death and loss of personal integrity including despair, horror,

rage, loss of hope and feelings of helplessness (American Psychiatric association, 2012).

Multifactorial attachment patterns will be discussed including a discussion of some of the

best fit therapeutic practices. Discussion will also focus on Dissociative Identity Disorder

(DID ) diagnosis as it reflects Graces proc essing and expression of complicated grief,

somatization and dissociation in bereavement (Diagnostic and Statistical Manual of Mental

Disorders, 2000). An analysis of this case will confirm that understanding DID, as well as

timely and correct diagnosis can lead to better predictions for a client at risk for adverse

reactions, and therefore more timely treatment strategies.

Shulman and Shewbert (2005) suggest that medical crises are an inevitable part of the

human experience (p. 633). In August, 2010 Graces mother, Frances, 72 years old took ill

and died within the space of a week. Grace had rung her mother on the Monday. She noticed

Frances sounded a little vague and her asthma was bad. During the conversation Grace asked

if her mother was ok, and Frances said she was going to the doctors the next day. By Friday,

Frances was in intensive care on life support.

Furthermore, Frances had pneumonia, a major heart attack, and brain damage. The

specialist informed the family that Frances only had a small chance of surviving should they

take the intubation tube out. The choice for the family was either to risk trying to keep


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Frances alive, with disabilities, or let her die. Frances had told her children never to keep her

alive if she had to be put in a nursing home. The family decided to let Frances go, and

stressed there was to be as little pain as possible. Over the next three hours the family

watched their mother as Frances slipped away. The death certificate said that Frances had

cancer throughout her body. Had she survived this trauma, Frances would not have survived

the cancer.

According to Kersting (1998), new insights have come to light about the bio-

psychocial effects of traumatic stress and complicated grief risk reactions. It is advisable to

identify individuals at risk of negative behavioural, cognitive and affective reactions resulting

from loss. In addition, Fonagy (2001) states that females who have undergone earlier trauma

are at greater risk of re-traumatization if they experience later trauma.

In addition Wayment, Vierthaler, & Jennifer (2002) explored links between attachment

styles and risk factors. Variables included attachment to the deceased and suddenness of

death. It was determined that survivors with stronger bonds with the person who has died

reported greater levels of grief. However, the study only included ninety one participants, so

the results are not statistically valid and can be used as a basic guide only.

Moreover, Niemeyer (2001) and his co-horts have attempted to define the risk factors

for complicated grief determined by the way the loved one died. The most valid factors in

statistical analysis included sudden, traumatic and unexpected death, attachment to the

bereaved, and the death of a child. Grace is at risk since her system of alters depended on

Frances to help with her familial children and other aspects of Graces life.

As a result, therapy to help Grace has been hindered by the continuing difficulties with

her teenage twin daughters, lack of family support, and her personal inability to access

available peer and community help. These factors are mediated by Graces resilience and

inner resources on any given day. Grace sees her trauma therapist fortnightly. Wiger &


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Harowski (2003) indicate that as Grace goes through therapy, she will require support for the

constant disequilibrium in her current life. Grace has remained stuck in an active state of

emotional dis -regularity for eighteen months and is experiencing emotional trauma and

complicated grief as a result.

According to Green (2000) , survivors who are able to communicate distress are more

likely to return to a state of equilibrium. Grief is the way a person reacts to major loss. For

Grace this involves witnessing the death of her mother. Grace s normal grief response

includes her separation from Frances, thinking about and missing her. The traumatic response

for Grace is causing her distress from renumerating on viewing the actual death process and

the loss of her safest childhood attachment figure (Fonagy, 2001).

Furthermore, grief is viewed as an adaptive process, influenced by environmental

factors and psychological foundations following a traumatic event (Green, 2000).This

explains why Grace displays much more grief and distress following the loss of her mother

than an individual who developed secure attachments. In addition, Pearlman & Saakvitne

(1995) believe that early childhood trauma can result in severe reactions including loss of

trust, safety, control, negative expectations and problems with intimacy.

Other risk factors for Grace involve intrusive cognitive distortions such as avoiding

people and places and sensory intrusions of thoughts, feelings, smells, sounds, tastes and

sights (McFarlane, 2003). For example, extreme hyper-arousal reactions involve irritability,

increased startle reactions as well as problems in sleep, memory and concentration. Because

Frances was traumatic, the experience was imprinted as horror within the Amygdala which

stores traumatic memories differently than every day memories (Raphael, 1986).

The core of the disequilibrium Grace is enduring lies with problems in her early

attachment process ( Kersting, 1998 ). For Grace, the grieving process is further complicated

because she is dealing with an unintegrated and fragmented sense of self. Grace has been


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diagnosed with DID which is now recognised as a developmental disorder. Graces fractured

psychological system includes identities of different ages, behaviours, cognitive schemas,

emotional reactions, varied maturities, memories and attachment patterns (Bowlby, 1988).

As such, dissociation is both a neurobiological as well as psychological coping strategy to get

through overwhelming abuse and trauma.

Attachment is the process of developing emotional bonds to significant others. It is

described as a biological mechanism to ensure survival by providing ones need for security

and safety (Hooyman & Kramer, 2006). The attachment process in DID is skewed because of

the effects of abandonment, neglect, toxic shame, physical, mental, sexual, emotional abuse,

and inconsistent responses from the primary care-giver/s (Foa & Kozak, 1986). Additionally,

the type of attachment a child displays towards their primary caregiver will influence how

relationships are formed and maintained with others throughout life.

Mary Ainsworth (1978) developed a means of categorising different patterns of

attachment observed in response to separation from the primary caregiver. Analysis of the

Strange Situation experiment indicated that there are three patterns of attachment. Sixty five

precent of toddlers have a secure attachment, thirty precent an insecure attachment and the

remaining 5 percept have disorganised /disoriented attachment styles. This study remains

stable across cultures and genders.

Importantly, Grace falls into the disorganised/disoriented attachment category which

reflects the greatest level of insecurity of attachment as well as impairment in neurological

development. Unfortunately, this group represents the greatest number in psychiatric

populations and have experienced serious neglect or abuse during early childhood (Ainsworth

1978).

The nature of crisis, trauma and complex grief reactions and the ways they impact a

survivor means that there are different ways of looking at therapy from clinical,


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phenomenological and theoretical constructs. Now that we have seen some of the more

pervasive risk factors through the case of Grace, it is important to brief and analyse some of

the strategies currently used in treatment (Bisson, 2008).

Cognitive Behaviour Therapy (CBT) analysis the ways in which a survivor views and

feels about events and then focuses on addressing cognitive distortions (Kase & Ledley,

2007). By challenging perceptions, beliefs and feelings, behaviours can change. CBT

strategies monitor the survivor s internal voices and dialogue, and attempts to create

equilibrium and collaboration of the system. It also uses available tools like mindfulness to

replace negative evaluations of self with positive ones. Psycho-education is an important

component of CBT since it empowers the survivor by giving him/her knowledge (Beck,

1995).

Narrative Therapy (NT) is also referred to as talk therapy. Psychotherapy uses

suggestion, instruction, persuasion and insight in order to bring memories to a conscious level

so they can be processed. These tools are geared at helping the survivor manage and

eventually overcome dissociative symptomology and create a cohesive identity.

Mindfulness (M) interventions look at pervasive symptoms such as depression, anxiety,

dysregulation of emotions and dissociative symptoms. Mindfulness exercises, meditations,

grounding and relaxation techniques aide the survivor to be more open. This allows access to

intrusive memories and emotional feelings such as anger fear shame and guilt left over from

the traumatic event (Brierre, 1996).

Dialectical Behaviour Therapy (DBT) is a multifactorial treatment approach. It is often

implemented before the more invasive treatments such as exposure-based interventions to

address difficulties with emotion regulation and distress tolerance (Bisson, 2008). DBT

incorporates training in mindfulness as one of four areas of skill-building. In DBT,

mindfulness involves three "what" skills (observing, describing, and participating) and three


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"how" skills (taking a nonjudgmental stance, focusing on being present, and finding meaning

and happiness in ones life). The survivor is encouraged not to judge physiological and

psychological reactions and just to accept what is happening in the present moment.

Eye Movement Desensitisitisation Reprocessing (EMDR) holds a different philosophy

than other more common strategies. The survivor does not need to continue to go into story.

The survivors information processing system (Amygdala) is stimulated, memories are

activated, processed and reframed as narrative memory (Davis,1992).This means that the

survivor can now view the situation as being in the past (Shapiro, 2001).

Exposure Therapy (EP) works on the belief that a survivor habituates to situations that

annoy him/her, but are not in themselves dangerous today. The goal is to encourage the

survivor to face and confront the things they are afraid of (Brierre, 1996).

Group Therapy (GP) is often used as an adjunctive tool to enable survivors to share

their experiences within a safe environment with other survivors. This strategy is often very

powerful because of the group dynamics. The survivor can not only witness and learn from

other peoples experiences and the ways they deal with the after effects, but he/she can also

feel a sense of belonging to something very real and supportive.

Last of these chosen therapies includes the Phase Oriented Model of Trauma

Counselling elaborated below (Scott & Brierre, 2006). Brierre discussed the therapeutic

Treatment of complicated grief (CG) involves processing the emotions. However, for very

young alters, therapy becomes more complex since one is working with children who may not even

cognitively understand death (http://www.health.harvard.edu/fhg/ 2006). Children need age

appropriate interventions. The therapist provides support, comfort, listens to and answers questions.

The therapist also works with the older parts to encourage communication with the younger parts.

The goal is to teach survivors how to re -parent injured and grieving child alters.


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window. This is the psychological space between unhealthy avoidance and complete

overwhelm. It is also where the therapy alliance can lead to greatest psychological growth in

the areas of processing cognitions and desensitization.

Although most of the above post trauma interventions have been empirically tested and

proven valid, there still exist areas of controversy. These tend to centre around timely

exposure work, timing of therapeutic strategies in the case where comorbid conditions are

present, and insufficient debriefing work for both therapist and survivor. The therapist must

ensure that the client is in a safe enough place psychologically so that re-traumatisation does

not occur (Foa, Molnar & Cashman, 1995). According to the Australian Centre for

Posttraumatic Mental Health (2007b) there is a gap between evidence based practice and

routine clinical care (p. 3). It is thus imperative that therapists keep abreast of current

practices and empirically validated evidence and how these fit into their own therapeutic

schema.

Any action plan a therapist chooses to use needs to be streamlined to the survivors

personal needs. Graces therapist is using The Phase Oriented Model of Trauma Counselling

(Brierre, 1996) as the core treatment methodology. Although Grace has been in therapy for

three years, she is still in the first phase of trauma processing.

There are three phases within this model, the first of which is Stabilisation . This phase

focuses on cli ent safety. Graces therapist focuses on dealing with negative coping

mechanisms. Self- harm has been a problem for Grace in the past but she has not cut for two

years. Grace is an alcoholic. According to Brierre (1996), comorbid conditions are common

in survivors and need to be addressed. Fortunately , about a month after Frances death,

cessation began and is still holding 18 months later.

This phase of treatment uses psycho-education. Learning to communicate with and

understand the various parts of her system helps Grace maintain safety, and decreases her


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fear, anxiety, depression and grief. Grace is becoming better at accessing, expressing and

releasing feelings. Containment of emotion is an equally desirable goal of therapy. The idea is

that Grace will be able to choose expression and containment in appropriate situations.

Pharmacological interventions have been utilised with Grace for the past 19 years. She

is currently taking 300mg Effexor to help with the heightened anxiety and emotional

dysregulation; 100 mg Seroquel which helps with rapid switching and auditory hallucinations

and Valium at 10mg per day when needed. This is evidence of a holistic management care

plan through Graces local GP, Psychiatrist and Psychologist (Australian Centre for

Posttraumatic Mental Health, 2007).

It is also important that Grace feels that she leading the therapy session. Her therapist

encourages, whilst providing support. For Grace, it is the congruent, consistent, trusting and

safe relationship she has with her therapist that forms the foundation for therapy and

recovery. Once Grace is ready to work on resolving the memories she has accessed, she will

enter into phase two, which is referred to as Treatment (Scott, Jones & Brierre, 2006).

Trauma memories that Grace has been able to access and bring to the surface will need

to be worked through, processed and stored as narrative memory. Graces therapist must be

careful not to rush through this stage at the risk of re -traumatisation. Lack of insight on behalf

of the therapist can send the Grace into overwhelm where she retreats into a state of

disequilibrium, may self - harm or end therapy.

In Graces case where trauma had occurred over many years, coping s trategies

including dissociation and denial have enabled Grace to adapt. Unfortunately these strategies

can be detrimental if they are utilised over long periods of time (Raphael, 1986). The infants

within Graces mind are effectively stuck in the time the abuse happened. Grace is

experiencing feelings of complicated grief, loss, aloneness and abandonment. Her child alters

still view Frances as the mummy who kept them safe and as someone who always loved


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them. Grace needs for her parts to remember and share the good memories, whether actual or

imagined in order for them to know that they will not physically die.

Grace has stated in therapy that her resilience to life stressors is diminishing.

Rak (2002) proposes that survivors draw strength along a continuum from defence including

flight, fight, freeze and dissociative responses, through to necessary adaptation and then

resilience. Graces case lends credence to the idea that childhood abuse encourages resilient

responses later in life. If one understands this, it also enables one to comprehend the concept

of resiliency as a positive and adaptive survival response which can lead to growth.

Linley & Joseph (2004) postulate post-traumatic growth is different to resilience.

According to Mancini & Bonanno (2006) resilience is the ability to maintain relatively

stable, healthy levels of psychological and physical functioning in the face of an extreme life

event (p. 978). However, post-traumatic growth extends this concept in that the survivor

improves to the point that their functioning state is greater than it was prior to the event/s.

The third phase is referred to as Personality and is about helping Grace to rehabilitate

and integrate her personality states. This part of the process involves getting to a point where

Grace is functioning at a high level in a number of primary areas. These include developing

the ability to form emotional, physical, intimate and sexual attachments to healthy people.

Neimeyer (2001) also believes that therapy is powerful when the client is able to utilize tools

to positively impact on his/her current life.

According to Neimeyer (2001), Grace needs to find meaning in the loss. This means

that she will need to access memories, or even reconstruct them in a way that is significant

and comforting for her and her parts. This appears to be imperative in the process of grieving,

especially memories that link grief with the way that Grace responds to loss involved in

attachment trauma.

Furthermore, the aim of grief counselling is in there being a continuing bond which


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continues after death. Grace talks to her mother, and focuses on good memories. Grace

knows that Frances has died, but at this stage her little parts cannot conceive of this and are

still yearning and searching for their mother. For Grace, her profound and unwavering belief

in a higher power has kept her alive.

Another goal of therapy is to allow Grace and her parts to understand that they are not

stuck in past trauma, the bad things are not happening now and they are safe in this moment

in time. The ability to separate past from present will enable Grace to assign trauma and grief

to the past.

Once this has been achieved, Grace will then be able to remember or at least create

new, happy memories which will include being able to feel: wonderment, joy, confidence,

happiness and love. Successful therapy will lead to further growth and strengthened resilience

(Mancini & Bonanno, 2006). The last thing to note with any therapeutic process, Grace may

go through the stages, then fall back and start over again. Grace knows that healing is a

process and this is part of the journey (Tedeschi &Calhoun, 1996).

Therefore by demonstrating the complex case study of Grace, it can be clearly seen that

early childhood abuse has serious consequences that can last a lifetime. Numerous risk

factors underlie the way a survivor deals with traumatic events, and there are currently many

treatment approaches and strategies to aid the survivor through recovery. There is much the

therapeutic community can learn by understanding these. This will lead to continuing positive

outcomes since new and better interventions can be developed and implemented (Bisson,

2008). However, existing strategies used today need to be tested with greater numbers to

achieve valid and statistical evidence-based practice. Lastly, the therapist must bear witness

to a survivor. In this way he/she will be able to live a life that is more conducive to positive

outcomes and health. It is also better to use a holistic approach when investigating coping


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strategies, resilience, environmental factors and beliefs so that better outcomes in the healing

journey can be achieved.


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