Previous Page TRAUMA AND HOMELESSNESS REV SUSAN BRANDT TRAUMA and HOMELESSNESS To be a woman homeless of our city streets is to be intensely targeted for violence, raped and sexually assaulted. Life is so unstable on the streets that the homeless are vulnerable to violence. Through various studies done within the homeless population we have learned [U of Ottawa] that a range from 10% to 40% of homeless men and women has been violently victimized at some time in their lives 91% of homeless women report being assaulted at some time in their lives. 90% of those who had been battered suffered at least one injury more serious than bruises during their worst beating. 42% of these long-term homeless women reported a assault incident within the last 12 months. 73% of the homeless women in one study reported that their most recent assault was from a present or former sexual partner Physical or sexual assault is a risk factor for depression, Post traumatic stress syndrome, alcoholism and drug abuse The diagnosis of posttraumatic stress disorder (PTSD) describes symptoms which result from trauma. In the language of the American Psychiatric Association (1994), PTSD can result when people have experienced "extreme traumatic stressors involving direct personal experience of an event that involves actual or threatened death or serious injury; or other threat to one's personal integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate". Exposure to these events may lead to the formation of a variety of symptoms: re-experiencing of the trauma in various forms, efforts to avoid stimuli which are similar to the trauma, a general numbing of responsiveness, and symptoms of physiologic hyper arousal. The grouping of such symptoms following trauma has been recognized as the clinical syndrome of Post-Traumatic Stress Disorder (PTSD). Authors of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) comment that PTSD may be especially severe or long lasting when the stressor is of human design (for example, rape and other torture). Out of fear newly homeless women may attach themselves to a man for protection even though this is often in exchange for sexual favors and enduring violent assaults. The homeless subculture tends to be quite "macho". As the time of homelessness is reduced the perceived need for male protection may decrease. Many women flee domestic violence only to end up homeless and subject to further violence. We often see these women bruised with sexually transmitted infections and soft tissue damage. Homeless women experience unintended pregnancies from rape or victimization more frequently than other women do. Over 50% of homeless women have experienced childhood physical abuse as well. Having run from riches to poverty, some women are escaping domestic violence and end up at a shelter. Aggressive behavior within the homeless population is often coupled with symptoms such as antisocial personality disorder, substance abuse, and major depression. Mostly perpetrated in city shelters, male sexual abuse victims often show up with mucosal injuries because of forced penetrating anal intercourse. Some homeless folks say they would rather be "on" the streets than stay in a shelter; this may be because city shelters are often over crowded, unsafe, poorly staffed and are run like a prison environment. The homeless mentally and those with physical or developmental disabilities are more susceptible to sexual and physical harm. They spend hours wandering in public places, displaying detachment and responding slowly to their environment due to their illness or disability. Many homeless folks prefer the illusion and numbing factor of substance abuse rather than facing such a daily harsh reality. Yet few treatment programs address trauma issues when offering detox and recovery services to this population. Once the "medicine" or numbing factor is removed from the homeless persons system, symptoms of post traumatic stress syndrome may surface and if left unaddressed may lead to further relapse. Should dual diagnosed treatment be offered to this population the ensuing healing and empowerment would in my opinion greatly facilitate a speedier journey from the curbside to independent housed living. Without an understanding of the psychological harm resulting from physical and sexual trauma, treating the homeless is impossible c. Rev.S.Brandt 2004 GROUNDING TECHNIQUES When someone has a flashback, seems “spaced out”[dissociated] or is regressed [acts childlike] -Ask yourself ‘Is the person physically safe’ -If person is having a flashback or is dissociating use deep slow belly breathing techniques to reduce hyperventilation or have the individual breathe into a paper bag -Don’t ever touch without permission -Try to establish eye contact, insist they keep their eyes open and look around tell them they are safe and no one will hurt them - Ask people to sit down and feel their feet on the ground -Call person by name -Validate feelings,” this must be very frightening for you” or remind person “that was then this is now” -Engage the adult part of the person encourage healthy self-talk and establish self soothing -Focus on the here and now -Ask person to name 5 things they see, feel, touch or smell, -Shock the senses to encourage increased sensory stimulation [ie; for a moment put hands on ice cube, smells] -You don’t need to hear the persons story of trauma establish trust and safety and focus on hope July 2003 Rev.S.Brandt What is Post-Traumatic Stress Disorder (PTSD)? Introduction There is a growing awareness among healthcare providers that traumatic experiences are widespread and that it is common for people who have been traumatized to develop medical and psychological symptoms associated with the experience. Recent studies have shown that childhood abuse (particularly sexual abuse) is a strong predictor of the lifetime likelihood of developing PTSD. Although many people still equate PTSD with combat trauma, the experience most likely to produce PTSD is rape. PTSD is associated with an extremely high rate of medical and mental health service use, and possibly the highest per-capita cost of any psychological condition. But there is help and there is hope. PTSD is a long-term problem for many people. Studies show that 33-47 percent of people being treated for PTSD were still experiencing symptoms more than a year after the traumatic event. Without treatment many people may continue to have PTSD symptoms even decades after the traumatic event. What are the symptoms of PTSD? PTSD symptoms are divided into three categories. People who have been exposed to traumatic experiences may notice any number of symptoms in almost any combination. However, the diagnosis of PTSD means that someone has met very specific criteria. The symptoms for PTSD are listed below. • Intrusive Re-experiencing People with PTSD frequently feel as if the trauma is happening again. This is sometimes called a flashback, reliving experience or abreaction. The person may have intrusive pictures in his/her head about the trauma, have recurrent nightmares or may even experience hallucinations about the trauma. Intrusive symptoms sometimes cause people to lose touch with the "here and now" and react in ways that they did when the trauma originally occurred. For example, many years later a victim of child abuse may hide trembling in a closet when feeling threatened, even if the perceived threat is not abuse-related. • Avoidance People with PTSD work hard to avoid anything that might remind them of the traumatic experience. They may try to avoid people, places or things that are reminders, as well as numbing out emotions to avoid painful, overwhelming feelings. Numbing of thoughts and feelings in response to trauma is known as "dissociation" and is a hallmark of PTSD. Frequently, people with PTSD use drugs or alcohol to avoid trauma-related feelings and memories. • Arousal Symptoms of psychological and physiological arousal are very distinctive in people with PTSD. They may be very jumpy, easily startled, irritable and may have sleep disturbances like insomnia or nightmares. They may seem constantly on guard and may find it difficult to concentrate. Sometimes persons with PTSD will have panic attacks accompanied by shortness of breath and chest pain. Who gets PTSD? PTSD can affect anyone at any age who has been exposed to a traumatic event where he/she experienced terror, threat (or perceived threat) to life, limb or sanity and his/her ability to cope was overwhelmed. Conservative estimates show that nine-ten percent of the general population has PTSD. Among people who were victims of specific traumatic experiences (rape, child abuse, violent assaults, etc.), the rate of PTSD is 60-80 percent. Diagnosis Unfortunately, it is common for those with PTSD to avoid treatment. Also, it is common for those who do seek treatment to be misdiagnosed. Because PTSD often occurs at the same time as other physiological and mental health disorders, PTSD symptoms may be masked or difficult to identify. Examples of common co-occurring conditions are depression, substance use/dependence and bipolar disorder. Trauma survivors may also experience headaches, chest pain, digestive or gynecological problems as well. However, there is a growing number of clinicians who are skilled at recognizing PTSD and still others who are specializing in treatment of traumatic stress disorders. If you think you might have PTSD you should seek professional help for a thorough physical and mental health assessment. Can PTSD be treated? Yes. A person who has survived a traumatic event will probably never feel as if the event didn't happen, but the disruptive, distressing effects of PTSD are completely treatable. Depending on the source of the trauma (manmade vs. natural), the nature of the trauma (accidental vs. purposeful), and the age of the victim at the time of the trauma, treatment strategies may vary. Treatment involves both managing symptoms and working through the traumatic event. Most experts agree that psychotherapy is an important part of recovery. Medications can help reduce some symptoms allowing psychotherapy to be more effective. ------------------------------------------------------------ Phase-Orientated Programing For Addiction and Trauma Treatment: ---------------------------------------------------- As a contemporary psychotraumatologist, Dr. Thomspon adheres to phase-orientated dual recovery programs and treatment generally accepted by trauma experts. Phase-orientated treatment divides the overall trauma and addiction treatment programs into discrete phases (stages) of treatment with specific treatment objectives (goals). There are three major phases to overall treatment and each phase is defined by a unique set of treatment problems and symptoms that become the focus of treatment at that stage only. Each phase requires a certan type of treatment alliance and is characterized by its own unique benchmarks of progess, treatment challenges and special problems to that stage. Understanding the Theory of Dissociated Traumatic Memory --------------------------------------------------------- Trauma experts assert that traumatic memory, unlike ordinary memory, may not be altered by the passage of time. Some argue that the traumatic memory is 'frozen in time or timeless, and inflexible, invariable, and immutable or not capable or susceptible to change." Traumatic Memories (TM): ------------------------ Traumatic Memories are unique and resist integration or are dissociated from ordinary verbal autobiographical memory. This lack of proper integration of intensely emotionally arousing experiences into the memory system results in dissociation and the formation of traumatic memory. The consequences of dissociation of traumatic memory, especially for clients with complex PTSD (Post Traumatic Stress Disorder) and DID (Dissociated Identity Disorder), is that various components of memory are dissociated from one another. These dissociated verbal memory fragments, in turn, are dissociated from the affect (feeling), beliefs, somatosensory (body, 5 senses) dimensions, and behaviors associated with the traumatic experiences, and each of these dimensions in turn is dissociated from each other. All of these non-verbal dimensions of the traumatic memory are known as the "behavioral memory for trauma" which exerts a powerful but implicit influence on ordinary consciousness and behavior. Therefore, the consequence of the dissociated traumtic memory is that the memory is not integrated into the conscious self representation (self-image), and has an alternate consciousness or personality state. Overwhelming traumatic events can result in the creation of a separate state of consciousness and associated self representations and beliefs(state-dependant memory, learning and behavior). Trauma experts assume that retrieval of traumatic memory is state and or context dependant. They commonly refer to specific cues that retrieve traumatic recollections as "triggers". State changes that can trigger traumatic recollections include: 1) non-specific physiological arousal, 2) emotional arousal unrelated to the orginal trauma, 3) emotional arousal associated with the orginal trauma, 4) exposure to subsequent traumatic events/arousal, 5) normal, phase-specific development changes, 6) being in a safe relationship, 7) sensory information associated with the orginal traumatic event, 8) stress in daily life and /or in therapy. Virtually anything can be a trigger for anyone at anytime and the activation of traumatic memory is subject to complex learning processes. For example, addictive (drinking) behavior is subject to complex conditioning forces or the long term result of the conditioning of (alcohol) dependance. At some point in the learning curve, the addictive behavior takes on a life of its own which represents the process of "emancipation" of dissociated traumatic memories from the conscious self. Therfore, through conditioning, traumatic memories take on a life of their own in a manner comparable to the conditioning of an addictive behavior (drinking) and transfrom ino a disease (alcoholism) or alter/"alien" part of self. The over-learned use of addictions or dissociated states is central to cause of DID. Dissociated states take on a life of their own in the form of alter personalites. Once these complex learning processes have occurred, it becomes exceedingly difficult to identify specific triggers and switching states becomes relatively automatic. The use of dissociation results in a paradox of both "knowing and not knowing" about the traumatic event- knowing the sense of the implicit memory and not knowing in the sense of being disconnected from the actual concrete facts or the coherent narrative memory for the trauma. There are several unique characteristics of retrieved traumatic memories as they come to consciousness. Typically, trauma memory first makes it's way into the consciousness accompanied by intense physiological arousal. The reactivation of traumatic memories often has negative consequences- intense affective distress accompanying the intrusive recollection or the tendancy to reenact aspects of of the trauma in current life. Reactivation of traumatic memories exert harmful influences, for the activation of one dimension of traumatic memory generally activates all other dimensions, although not all other dimensions may come into explict memory at the same time known as "restitutio ad integrum". Activation of one element of traumatic memory and the concurrent activation of others does not mean all elements come into consciousness at the same time. Integration of traumatic memory elements over time entails a transformation of phenomenology of the memory over time. Primary and Secondary Dissociation: ------------------------------------ Dissociation is viewed as a structured seperation of mental processes (thoughts, emotions, conation (craving,impulse), memory, identity) that are normally integrated. At the center of the problem with dissociation is not only the apparent automaticity of the behavior but the intentionality of dissociative processes and the concurrent inablity to integrate compartmentalized aspects of the experience. The degree of dissociation at the moment of trauma is the greatest predictor of chronicity and severity of PTSD and is known as "peritraumatic dissociation". Dissociation of traumatic memories is therfore an asset and a liability. Individuals prone to dissociate have a coping strategy that they can readily draw on to cope with potentially overwhelming traumatic experiences. Dissociation may enable them to get through the experience but it also disrupts information processing of the event which makes it difficult to assimilate the dissociated recollections and associated affects over time. Therefore, the 3 important aspects of dissociation are: 1) separation or compartimentalization of mental processes, 2) integration failure, 3) intentionality as to how material out of conscious awareness can exert an implicit and tangible effect on consciousness. Normal hypnotizability in children and adults interacts with trauma. The development of "pathological" dissociation is seen as the outcome of autohypnotic attempts to cope with traumatic experiences. Primary dissociation (PD) refers to the structured seperation of the traumatic memories and associated affects, sensations, cognitions, behaviors and self representations form ordinary consciousness, the ordinary sense of self, and narrative autobiographical memory. PD is defined along two independant demensions: 1) lack of conscious awareness 2) involuntarism PD aspects of traumatic experiences intrude into consciousness in the form of post-traumatic of post- traumatic and/or dissociatied symptoms: 1) intrusive recollections 2) intrusive thoughts 3) intrusive images 4) intrusive flashbacks 5) intrusive anxiety-related affects 6) implicity influence unfolding conscious experience and behavior. Secondary dissociation (SD) occurs once the traumatized individual is already in a dissociated state. SD refers to dissociation within the traumatic memory system itself. Secondary dissociation is evidence by: 1) a distancing of the self from an occuring traumatic experience 2) thereafter during this reactivation by dissociation the observing and experiencing parts of the ego by leaving the body or disappearing. 3) dissociation of components of the traumatic memory itself, BASK (behavioral, affective, somato-sensory, kinaesthetic). 4) separation of BASK compenents 5) dissociation of sub-components within each of the components of traumatic memory into numerous narrative fragements. 6) compartmentalization of all affects associated with the traumatic experience into separate affect constellations (ie) fear, rage, despair. Tertiary Dissociation (TD): --------------------------- TD allows people to maintian the existing schemata (diagrammatic presentation), while separate states of mind process the traumatic event. As a result, traumatic memories structures may contain trauma-related cognitions and self schemata that differ from one another and from the habitual state, since they rely on divergent life experiences. Complex forms are: 1) dissociated, internalized, pathological self representations (perpetrator, failed self protector, etc.) from the rest of the trauma-related self system. 2) compartmentalization of the trauma-related self representations into a number of alter personalites each with its associated memory content and affects. Traumatic Amnesia (TA): ------------------------ On intial intake, clinicians find that most people with alleged trauma/abuse backgrounds do not enter treatment to 'recover' memories for they have a 'relatively continuous memory'. Complete/Full Amnesia: ------------------------- Generally, most clients enter treatment because of some situation has triggered a partial memory for the alleged trauma, and the intrusion of that recollection into the consciousness has been accompanied by serious emtional distress and/or intrusive reexperiencing and physiological PTSD symtoms. Rarely is amnesia the chief complaint and recover of memories is not the sole treatment focus. Hypermnesic (Relatively Continuous Memory): ------------------------------------------- Most clients would enter treatment with a wide range of problems: 1) wish to manage intrusive re-experiencing, 2) generalized numbing, 3) physiological PTSD symtoms, 4) dissociative shifts in state, 5) understand the impact of trauma on their current functioning. Partial Amnesia: --------------------- The manifestations of partial amnesia include: 1) Memory of the gist (essence) but not the details of the trauma, with or without intrusive/numbing PTSD symptoms. 2) Memory for the peripheral details but not for the gist of the central information about the trauma, with or without intrusive/numbing PTSD symtoms. 3) Patchy memory for the trauma, ie., some episodes, details are clear, but not others and there is a desire to know more. 4) Memory for the gist of the trauma is somewhat clear (not necessarily in details), but there is dissociation from the affects associated with the trauma. 5) Memory for the gist of the trauma is clear (not necessarily the details or affects), but there is not clear understanding of its meaning, the impact of the trauma on current life, or any possible causal realtionship to current symptoms. 6) Very partial memory, ie., a general sense of previous trauma background, without specific incidents or memory for the gist or details of such incidents. There is pattern of symtoms consistent with trauma, belief that trauma caused these symtoms, and expresses a desire to know the details about what happened. Continuum of Behavioral and Verbal Manifestations of Prior Trauma: ------------------------------------------------------------1) No knowledge of trauma. Memory for trauma is defined against and coexists with normal autobiographical memory without integration. 2) The trauma is reactivated in flashbacks, fugues, and other intrustive experiences. 3) Fragments of verbal memory occur but are decontexualized and thereby remain devoid of meaning. 4) The trauma is reenacted in transference phenomena. 5) The client has a narrative memory, but in telling the story loses perspective on current reality and spills for an "overpowering narrative" of the trauma. 6) The client has partially sublimated ('sublimate' def:to divert an expression from it's primative form to one that is considered more socially or culturally acceptable) the trauma but reenacts it in life themes. 7) The client has integrated the trauma and describe it objectively as a 'witnessed narrative'. 8) The client had moved beyond the trauma to complete developmental tasks and refers to the trauma primarily in metaphor. Pre-OutPatient Psychotherapy Requirements: ------------------------------------------- The following items are essential to address to allow progress form crisis treatment and enter into Phase-Orientated Treatment: 1) A plan an focus on stopping suicidal and other self destructive behaviours. 2) A plan for cessation of other self-destructive behaviors such as perpetuation of abuse and episodic dyscontrol. 3) A plan to address "therapy-interference behaviors", ie., - coming late or not showing up for treatment. - failing to pay the bill. - excessive requests for extra-theraputic time through "emergency phone calls". - maintianing a continuous-orientation that distracts from mutually established treatment goals. 4) A plan to address lifesyle issues that impact treatment, ie., - mismangement of financial resources. - significant addictive behavior. - lack of social supports. - presence of destabilizing social systems. Stabilization Treatment: ------------------------- Client's requiring stablization demonstrate acute, delayed, and/or chronic PTSD symptomology evidenced by: 1) less control over symtoms, 2) engaging in remarkable "self defeating behaviors" in therapy so that treatment outcomes are often negative. 3) preoccupation with intrusive reexperiencing of symptoms. 4) trauma is severely impacted upon a number of areas of daily functioning. Phase 1 stabilization helps the client develop/maintain: 1) a safe place and theraputic relationship, 2) clear treatment contracts for the client needs to demonstrate and ability to tolerate out patient psychotherapy. 3) a program of sobriety and abstinence from addictive substances and patterns, ie., 12 step group, sponsorship, etc. 4) better coping mechanisims and defenses (self control) 5) containment of intrustive re-experiencing to trauma memory. 6) evocation of numbing symptoms. Strategies To Help with Stabilization Include: ---------------------------------------------- a) a detailed history and assessment of PTSD symtoms, dissociative symtoms, and characterological problems, ie., flashbacks, hyperarousal, avoidance behaviors, alter personalites, anger, addictive behavior, etc. b) establishing a trusting theraputic alliance by building an adult treatment relationship (important for survivors of childhood trauma). c) address current life problems, d) reduce self destructive behaviors, e) enhance the client's ablility to cope with symptoms by collaboration and agree on relevant treatment strategies, ie., contracting, education, reframing symptoms, enhancing self efficacy, enhancing coping skills, direct-exposure based method, guided imagery, cognative processing of beliefs, stress inoculation, skills development, cognitive restructuring, theraputic metaphors, etc. f) psychoeducational interventions regarding traumatic stress. g) psychoeducational interventions regarding the nature of memory. h) overcoming isolation, stress management, and stress reduction. Phase 2 Integration Treatment: -------------------------------- Phase 2 treatment goals are to provide the client with: 1) A safe place and relationship to demonstrate an ability to stablize symptoms before integration work begins. 2) The opportunity to integrate the dissociated aspects of memory. 3) The opportunity to reassociate whatever is dissociated to obtain relief form trauma-induced dissociation. 4) The opportunity to achieve a sense of wholeness. * It is very important to realize that it is very difficult for your therapist to make a determination of the historical accuracy of the alleged trauma memories. ------------- Strategies to Help Integregration Include: ------------------------------------------- a) Presence of an established trusting therapeutic. b) Regression back to the experience of the trauma to facilitate the (eventual) fullest possible reexperiencing and recollecting of the trauma here and now. c) Reexperiencing and recollecting need to be guided through tolerable doses of awareness to prevent the extremes of denial and/or intrusive repetitiousness. d) Systematic re-experiencing of the trauma utilizing hypnosis and exposure-based interventions. -------------- DID/SRA survivors: * Should a survivor take therapy by hypnosis? I would recommend that any Christian not comfortable with hypnosis, that he/she take time to let his/her parts (of his/her personality) to gain trust for this process. * Should survivor try to go to court? Also, if any court case may be planned against perpetrators or abuser groups, results by hypnosis is not permitted as evidence of past abuse against the survivor. As I personally am more concerned with the recovery of the survivor than retribution against perpetrators, I would highly recommend survivors consider favoring clinical hypnosis, if it is done by a therapist they have learned to trust. Being well and whole is much more preferred than still struggling and fighting on the personal and family (or whoever the perp. is) fronts at the same time. * How does a survivor benifit from both "Pastoral Counseling" and "Psychotherapy"? If the survivor is a Christian, I highly recommend a combination of, 1) Pastoral Counseling where revelation is given via the Holy spirit, and 2) allowing the Holy Spirit to lead a survivor privately in daily processing of healing ('one step at a time' to healing one area of you past at a time, where 'He' is allowed to orchestrate bringing what He choses to the surface (of the buried memories), and 3) allowing your therapist to use psychotherapy methods to bring your parts of your personality to a place of readiness to process these traumatic events, one step at a time. The primary benifit of psychotherapy in this area is that it brings 'stabilization' on the psychological and body (physical) level.<>} -------- f) Once the trauma can be re-experienced, it must be integrated with the clients conscious self-representation. g) Once the client has recollected the trauma, constructing a narrative account of the trauma will lead to integration, a sense of mastery,` and provide the opportunity to find meaning. h) Education on the nature of autobiographical memory, especially about its reconstructive nature, the possiblity that retrieval procedures can contaminate the memory, and that illusory memories are possible to create. i) Restructure his/her story and transform traumatic memory. j) Shift from 'victim" role to 'survivor" role. k) Constructing a coherent narrative memory for traumatic experiences despite depsite knowledge of historical accuracy. l) The therapist neither challenges the client's belief's in the authenticity of his/her account of traumatic experiences nor engages in suggestive memory procedures. Phase 3 Post-Integration Self and Relational Development Treatment: --------------------------------------------------------- Phase 3 treatment goals are to help the clients: 1) Support on-going integration of all positive and negative aspects of the trauma experience with the client's notion of who he/she was before, during and after the traumatic experience. 2) Work through long-standing maladaptive patterns in his/her relational life both within the transference and in the current life relationships outside therapy. 3) Establish healthy relational patterns. 4) Develop a healthy social support system. 5) Reconnect within the wider community. Strategies to Help With Wholeness and Realted Strategies: a) Stabilizing integration to allow for emotional reactions to unification. b) To blend their respective resources. c) To consolidate the respective transference of each alter personality into a single transference of an unitary personality toward the therapist. d) Reclaiming lost aspects of the self. e) Treatment has now shifted from the past to the present and future. f) Resolution of any percieved or real responsibility for an aspect of the traumatic event. g) Breaking of old patterns of behavior. h) Grief recovery work. i) Continue progess along the various major lines of development self, relational, affective. j) Help the client focus on examining factors that contribute to any one of a number of relational disturbances, ie., insecure attachments, and isolation, and disconnection. k) Shift to "thriver" role. l) Help the client develop a healthy system that will guide their current lifestyle. m) Relapse prevention skills. n) Termination of the therapeutic relationship. *Dissociation Indicators For DID And MPD ---------------- Personality Characteristics 1) High Intelligence. 2) High Creativity (music, drama, art, poet). 3) High suggestibility (ability to use imagery). 4) Urgency about time (rush in therapy, generalized urgency). 5) A sense of extreme deprivation (felling "ripped off' in life). 6) Very high need to please (acceptable in any circumstance). ------ 4 or more here suggests potential for a dissociative ability (DID). ------ Clinical Observations 1) Secretive or closed to reveal some types of personal experiences. 2) *Amnesia for previously covered material. 3) *Headaches or dizziness or sudden onset during therapy. 4) *Evidence of internal dialogue. 5) Sudden shift in mood or voice. 6) *Flashback/abreaction (reliving a traumatic experience). ------------ 4 or more suggests DID. ------------ Outside data 1) Uneven achievement in school. 2) *Reports hearing inner voices. 3) *History of sleep disturbance. 4) *Difficulty finding their parked car. 5) *High indecision about choosing the clothes they wear. 6) Denial of actions that were clearly observed by others. ------------- 4 or more suggests DID and/or M.P.D. 4 or more in all three sections is expected on a M.P.D. person's profile. * Scores for these items indicate a high likelihood of complete amnesia. *How does DID develop? Trigger Warning -------------------------------------- When faced with over whelming traumatic situations from where there is no physical escape, a child may resort to "going away" in his or head. Children typically use this ability as an extremely effective defence against acute physical and emotional pain. By this dissociative process, thoughts, feelings, memories, and perceptions of the traumatic experiences can be separated of psychologically, allowing the child to function as if the trauma had not occurred. DID/DD is often referred to as a highly creative survival technique, because it allows individuals enduring "hopeless" circumstances to preserve some areas healthy functioning. Over time, however, for a child who has been repeatedly physically and sexually assaulted , defensive dissociation becomes reinforced and conditioned. Because the dissociative is so effective, children who are very practiced at it may automatically use it whenever they feel threatened or anxious- even if the anxiety-producing situation is not abusive. Often, even after the traumatic circumstances are long past, the leftover pattern of defensive dissociation remains. Chronic defensive dissociation may lead to serious dysfunction in work, social, and daily activities. Repeated dissociation may result in a series of separate entities or mental states,........ which may eventually take on identities of their own. These entities may become 'inter personality states', in a DID (MPD) system. Changing between these states of consciousness is described as switching.