Newsletter Volume 4 Number 1 June 2015 English-V1

EDITORIAL BOARD/
ESTD Newsletter
GRAPHIC DESIGN/
FRANK MYKLESTAD
JUNE ISSUE 2015
Volume 4 Number 2, June 2015
ORIT BADOUK-EPSTEIN
MARTIN DORAHY
WINJA LUTZ
DOLORES MOSQUERA
ANTONIO ONOFRI
JENNY ANN RYDBERG
VALERIE SINAISON
ONNO VAN DER HART
EUROPEAN SOCIETY FOR TRAUMA AND DISSOCIATION

PO BOX 31441 - 6503 CK NIJMEGEN THE NETHERLANDS
EMAIL: INFO@ESTD.ORG WEBSITE: WWW.ESTD.ORG
ESTD NEWSLETTER
Co-editors: Dolores Mosquera, Onno van der Hart, Orit Badouk-Epstein.
Table of contents
Volume 4, Number 2, June 2015
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35
ESTD Newsletter
QUARTERLY QUOTE
Though [the self] is a unit, it is not unitary [...]

The fact that all aspects of the self are not usually manifest simultaneously, and
that their different aspects can even be contradictory, may seem to present a
hopelessly complex problem. However, this simply means that different components
of the self reflect the operation of different brain systems, which can be but are
not always in sync. While explicit memory is mediated by a single system, there are
a variety of different brain systems that store information implicitly, allowing for
many aspects of the self to coexist. As William James said, Neither threats nor
pleadings can move a man unless they touch some one of his potential or actual
selves. In Orlando, Virginia Woolf pointed out, "A biography is considered complete
if it merely accounts for six or seven selves, whereas a person may well have as many
thousand." Or as the painter Paul Klee expressed it, the self is a dramatic ensemble.
(LeDoux, 2002, p. 31) Margaret J. Little (1993, p. 82)
ESTD Newsletter
LETTER FROM THE PRESIDENT
Dear ESTD members,
Shall we meet? The aim of ESTD is to promote and increase

knowledge on trauma and dissociation throughout Europe, and
we want to put a special focus right now on Eastern European
countries. For this to happen, its best if we meet!
I am happy to inform you that on 24-25 April 2015, Timisoara in Romania hosted a
wonderful and very successful conference on Trauma and Dissociation, organized
locally and supported by ESTD (See conference review by Anca Sabau, board
member of ESTD, in this issue). Four hundred and forty two participants from
different countries presented, connected and met intensely. This overwhelming success for a first
ESTD-sponsored conference in Romania promoted a lot of hope and enthusiasm for our work to
continue.
Eva Zimmermann
ESTD President
To help realize some of the visions of ESTD and to act in the same manner as our Timisoara
colleagues, I invite all members and country representatives (see list at the end of this newsletter)
to organize local meetings and conferences, to give interviews to the media and to talk with
colleagues about chronic traumatization and dissociation. On the one hand, this helps you to
connect and to grow as a community in your region or country. On the other hand, you help ESTD to
promote and to increase the knowledge among professionals and the general population. Victims
of chronic traumatization, violence, abuse and neglect need to know that psychotherapeutic help
and overcoming trauma-related disorders is possible. To be able to do this they must be able to
find and meet their therapists! So they must find you! For any planned activity, do not hesitate to
contact ESTD (info@estd.org) so we can announce your event on our website and support you
wherever it is possible.
I would also like to point out that our next conference in Amsterdam from April 14-16, 2016 is now
calling for abstracts. We are sure that our Amsterdam conference set in a wonderful venue will
be a big success. To promote discussions and exchange, it would be great if new colleagues would
be willing to submit their conference abstract. Keep the date to make sure you will be there! It will
be a wonderful opportunity to learn more about research and clinical implications about chronic
traumatization and dissociative disorders and to meet people and colleagues from your own or
from other European countries and other continents. Dont miss it! .
Professional exchange and personal meetings are always the best way to connect and as you all
surely agree, are much richer than email and skype contacts.
Looking forward to meeting you!
Warmly
Eva Zimmermann
ESTD President
ESTD Newsletter
TO DISSOCIATE OR NOT TO
DISSOCIATE An exploration
of the complexity of dissociative

features in children and adolescents.
By Dr Rene Potgieter Marks
I cant take it any longer! The adoptive mother bursts into tears. Her last couple
of sentences about her 10-year-old adopted son, James, are left hanging in the
air. She has just described the stealing and the consistent, unnecessary lying that
apparently is taking place all of the time. The father appears overwhelmed by the adoptive
mothers emotion and the childs reported behaviour. After a brief heavy silence, the adoptive father says
how irritated he is by the school that keeps telling them that they have the most polite and considerate
son! He continues to explain how they as parents have to listen to hours of shouting and abuse from their
child, when in the next moment there is a sudden change and he becomes a child who wants a hug and
their attention. This, the adoptive father added is beyond what we can do at the time as we are so angry
and hurt after listening to all the abuse.
ESTD Newsletter
A conversation with the teacher does indeed reveal a model pupil who is an example to his peers within
the school environment. The teacher also goes as far as expressing in confidence that she and some of
the other teachers are concerned about the parents inability to deal with the child whom they consider
as lacking parenting skills.
As a therapist, this type of dichotomy between what parents experience in the home and teachers
experience at school is certainly not unfamiliar, and many, many years ago, as a less experienced therapist,
it may have been enough to make me doubt my own assessment of the child and family, question the
parents, and feel confused about what to do next. From my current position, as a much more experienced
therapist, with a more informed understanding of trauma and dissociation in children and how to work
with it, I now know that this presentation of a child in one setting as the ideal child and in the other as the
monster child is very typical of dissociative children. The stark reality is that this varied presentation
is not limited to school and home, but can also occur between school and home on the one side and family
members and professionals on the other side. The varied presentation of the child can also change from
moment to moment in the same setting. The adults surrounding the child are often left feeling confused
about the childs change in presentation or uncertain about the unpredictable behaviour and what to do
about it.
In training and supervising therapists who work with children who have experienced complex trauma
and display dissociative features, I often find a level of uncertainty about whether a child has significant
dissociation that needs to be addressed during therapy or whether the therapist should ignore the often
very obvious symptoms of dissociation. The struggle to determine whether it actually is dissociation
they are facing and not knowing how to deal with it, leaves them uncertain and doubting their skills.
The identification of signs or symptoms of dissociation in children in order to ascertain its presence
is further complicated if the therapist does not see the many signs or symptoms that are present in
the therapy room. Hornstein in Silberg (1996) wrote about children with dissociation that they . as a
group are uniquely presenting to the mental health system as polysymptomatic, traumatized children with
difficult behavior problems (Bowman, Blix, & Coons, 1985: Dell & Eisenhower, 1990; Fagan & McMahon,
1984; Hornstein & Putnam, 1992; Hornstein & Tyson, 1991; Kluft, 1984; Malenbaun and Russel, 1987;
Peterson, 1990; Riley & Mead, 1988; Vincent & Pickering, 1988; Weiss, Sutton & Utrecht, 1985) and as
challenging both to diagnostic acumen and to therapeutic expertise. In 1997, Putnam compiled symptom
clusters in pathological dissociation. These included amnesia, fugue episodes, perplexing fluctuations
in skills, habits and knowledge, fragmentary autobiographical recall, difficulty in determining the source
of recalled information, difficulty in remembering whether remembered experiences actually occurred
and dissociative flashbacks, depersonalization, derealisation, passive influence/interference experiences,
dissociative auditory hallucinations, trance-like states, alter personality states, switching behavior and
dissociative thought disorder .
There is no doubt that detecting dissociative symptoms in children continues to be a challenge for the
therapist. It requires an increasing knowledge base, advanced training, experience in working with these
children and effective clinical supervision to enable the therapist to identify dissociation in children and
adolescents more effectively. The challenge that dissociative children and adolescents can present in the
therapy room might also be one of the reasons why therapists might struggle to identify the dissociation.
This population of children and adolescents has the capacity to leave the therapist confused, anxious, and
at times even feeling unskilled. Managing the transference and countertransference in the room might also
at times be more important in the moment than actually identifying that the child is displaying significant
dissociative features.
Another concern is that a significant number of children, like James, appear to present in the therapy
room as the ANP (Apparently Normal part of the Personality). Van der Hart, Nijenhuis & Steele (2006)
ESTD Newsletter
state, The patient as ANP consciously and unconsciously avoids stimuli related to traumatic memories
(i.e., ANP is phobic to traumatic memories and related stimuli; see chapter 10). This evasion maintains
and strengthens amnesia, anesthesia and emotional constriction. This avoidance is not a goal in itself,
but assists the survivor as ANP to engage in daily life by excluding what seems too difficult to integrate.
This leads therapists who are unfamiliar with dissociation or the presentation of the ANP in children with
complex trauma, to be more easily persuaded that the child they see is the real child and so they never
see any difficult behaviour while the parents or school continue to report and struggle with extreme
behavioural difficulties. Due to the capacity of the ANP to avoid memories and stimuli related to the
trauma, the child is likely to avoid all toys, questions and interaction that will encourage this connection
in the therapy room. This repeated process may potentially waste many hours of precious therapy time
and finances and can lead to a culture where blaming parents and caregivers becomes the only logical
option as the child is cooperating very well with the therapist. It appears that this scenario is much more
prevalent in unstructured therapy where the child takes the lead and where the parent is not involved in
the therapy process.
Other children might at times in the therapy room display the ANP, and then suddenly make space for one
or various EPs (Emotional parts of the Personality) to appear. This change, referred to as switching, is
often easier to work with when it is observed in therapy. Van der Hart et al. (2006) state: There may be
complex mixtures of ANP and EP in very fragmented patients. Children who are abused and neglected
by their caretakers in early childhood with maltreatment constituting a substantial part of daily life, will
probably have particular difficulty in developing normative daily life systems. As the presentation of this
group of children can be particularly challenging in the therapy room, the focus is often inevitably placed
on containing or managing the childs behaviour rather than seeing this as possible dissociation in the
child. Wieland (2011) refers to Behavioural changes, Emotional shifts and Cognitive shifts that might
be observed by the therapist. Wieland indicated that behavioural changes might include a sudden change
in how the child acts or behaves for instance suddenly regresses or becomes aggressive while the child
would normally not display these behaviours. Emotional shifts refer to moving rapidly from one emotion
to another without the intermediate stages that are apparent in most children (Wieland, 2011). Wieland
includes signs of amnesia, variable performance where the child is able to do an assignment well on one
day, but unable to do it the next day and hearing voices or noises as part of the Cognitive shifts.
Silberg (2013) identified Five Classes of Symptoms Related to Dissociation.
They are:
Perplexing shifts of consciousness, i.e., feeling in a fog, momentary lapses of consciousness, flashback
states;
Vivid hallucinatory experiences, i.e., hearing voices, seeing imaginary entities, or vivid imaginary
friends;
Marked fluctuation in knowledge, moods or patterns of behaviour and relating, i.e., feeling that moods
have a mind of their own, and skills and abilities are inconsistent, and the sense of self is divided;
Perplexing memory lapses for ones own behaviour and recently experienced events, i.e., cannot
remember behaviour, cannot remember assignments.
Abnormal somatic experiences, i.e., self-harming behaviours, pain sensitivity, bowel or bladder
incontinence.
Another challenge is that many of the other symptoms of dissociation are not consistently present in
all areas of the childs life and often not seen in therapy. For instance, amnesia is often disguised as I
have forgotten or I dont know or even look, a spider to distract the therapist. It might appear to be
suggestive of resistance to the question. Amnesic barriers between dissociative states can be present
ESTD Newsletter
to the eye of the more experienced therapist, but might be missed by the therapist who has just started to
work in this field. Derealisation might appear like normal fantasy combined with a need to repetitively play
a particular game during therapy.
In practice it appears that in the assessment process, it might be critically important to obtain a very
comprehensive picture of the child, rather than to only trust the childs information or minimalistic signs
of dissociation. Information from parents/caregivers, and from school and grandparents/family/friends,
if they act as substitute caregiveers of the child, is important. Information about the presentation of the
child and its behaviours from the adults perspective, combined with the clinical assessment completed by
the therapist, are invaluable in providing a comprehensive picture of the child. In practice it is helpful to get
the CDC (Child Dissociative Checklist) completed by both the parents/caregivers and the adult at the school
who knows the child best. It is not unusual that both CDCs will provide significant dissociative scores, but
it is also not unusual that there will be different presentations at school than at home. For instance, the
school often reports the child going into a trance-like state or daydreaming, forgetfulness and variation in
skills, while parents are often exposed to the childs poor sense of time, rapid age regression or baby talk,
experience lying, switching, changes in voice and face, while it is possible that only the therapist at a much
later stage might find that the child also hears voices and has imaginary friends. This information is mostly
obtained by asking a direct question to the child, and is seldom spontaneously disclosed. It is possible that
the process of identifying dissociation in children and adolescents might at least initially be similar to that of
a forensic detective who has to find clues from various sources in order to build up the most comprehensive
and complete picture before making a final finding.
The clinician needs to be aware of the difference in expectations between a child who has experienced
complex trauma or dissociation and a child of the same age who has not. An understanding of child
development and an ability to explore the internal world of the child assists enormously in the process of
analysing the behaviours of the dissociative child more accurately.
The following case studies illustrate how some of the typical symptoms found in the literature present
themselves in the therapy room.
Case 1: Lying
Michael is a 9-year-old boy who is totally unable to cope with the fact that he is involved in unacceptable
behaviour at school and consistently denies it. Michael displays aggressive behaviour towards his peers at
school but obviously has a significant problem and might be using some form of dissociation to disconnect
the ideal self from the self who is executing the unacceptable behaviour on a regular basis. During a
comprehensive assessment of 9-year-old Michael, he was asked whether he has any special friends that
nobody knows about. Without hesitation, Michael explained that Angry Michael was living in his head and
that he was the one who was hitting children at school. Michael again confirmed that it was not he hitting
the children, but it was Angry Michael. Although Michael has had significant therapeutic input from other
professionals, this information had not previously been disclosed. Unless this question is directly asked, it
appears that the chance of getting this information might be similar to that of winning the lottery. Michael
perceived the problem of children getting hurt at school as that of Angry Michael and as such he, Michael,
did not need to own the responsibility for it.
This problem was relatively easily addressed as Michael decided to ask Angry Michael to go to a special
room where he could watch TV and eat biscuits while he, the 9-year-old Michael would still attend school. The
parents reminded Michael each morning to make sure that Angry Michael watches TV. The outcome of this
process was that suddenly all attacks at school stopped. Since this containing of the aggressive dissociative
state is only a short-term measure, the therapist continued to work with the attachments between Michael
ESTD Newsletter
and his parents and processed early trauma, including severe domestic violence, using EMDR. After many
months of processing his painful early experiences and his own anxiety and fear, Michael was finally able
to integrate Angry Michael.
This presentation in children is often referred to as lying or pathological lying but in reality the child is
using derealisation to ensure that at least the ANP will remain blameless and can continue with the normal
process of attending school and learning. Many hours of intervention were wasted trying to change the
lying behaviour, as well as two series of work completed with Michael for anger management, none of
which enabled him to connect to the presence of a dissociative state.
Case 2: Derealisation and Depersonalisation

When 8-year old Ryan came with his parents for an assessment, he was wearing a T-shirt with a picture
of the Transformers and was holding a Transformer in each hand. Ryan immediately started to tell the
therapist about how powerful his Autobot, Optimus Prime, was. The therapist quickly realized that
Ryan was not only consistently playing with the action figure but he was actually becoming the action
figure. Information from the parents indicated that Ryan ate and slept with these action figures and that
he insisted that his action figures should be part of every part of the familys life. Parents allowed and
welcomed the action figures, as it was the only calming influence on Ryan and trying to oppose this elicited
violent and oppositional behaviour. This compromise did of course cause significant disruption in daily
routine, where Ryan refused to eat with the family at times, asked for food at other times, delayed going
to bed and demanded to watch the TV programs of his choice. In the therapy room, Optimus Prime was
present and preferred to tell the therapist what to do (and of course that did not include therapy rather
making the therapist the action figures slave). There was a sense that a very important part of Ryan was
absorbed by Optimus Prime and that the most comfortable existence for this dissociative state in Ryan
was to live life through the action figure. This greatly limited Ryans capacity to execute age-appropriate
behaviours and to engage in relationships in the real world around him.
When Ryan was asked to draw the inside of his brain (Baita in Wieland, 2011) it came as no surprise that
Optimus Prime was the main dissociative state in Ryan acting as the controller. He was also accompanied
by other action figures.
In further exploration, we found that this had become much more than just an action figure, a toy, or an
activity. This fantasy had become a dissociative companion, a dissociative ally, and a dissociative world,
and helped Ryan to control the adults in his life or to protect some part of the vulnerable self from the
adults around him.
At times these action figures interfered with Ryans compliance and capacity to engage in work at school
and Ryan insisted at times that the teachers call him by the name of the action figure that was presenting
itself. Attempts from the teacher to distance Ryan from the action figure and introduce reality or to engage
in normal activity was met with significant resistance. The action figures also played a major role in how
Ryan interacted with his peers, always trying to be the boss. This problem is not only limited to action
figures, and can extend to include books, electronic games, and even music.
Of course all children enjoy fantasy and should have the freedom to explore this area of their lives. In
practice it appears that the dissociative child is much more prone to become addicted to the fantasy
world and any attempt from the adults to bring the child back or ground the child in the real world might
be met with resistance, control, and/or even abusive behaviour or a state of withdrawal. Children who are
not dissociative have a much easier and fluent transition from fantasy into reality.
ESTD Newsletter
There is a real concern with regard to the level of some childrens disconnection from reality in favour of
fantasy games, activities, books, and electronic games. This has a major impact on their relationships and
specifically the attachments to their caregivers. Like many of these children, 12-year-old Jane brought her
book with her to the intensive therapy. Intensive therapy includes working with the child and family 5 hours
per day for 10 days (Potgieter-Marks in Wieland, 2011). Initially reading during the breaks appeared to be
a positive activity and parents felt it enhanced her reading skills, until the third day when Jane refused to
engage with any person as she was too embroiled in her book to even hear or respond to any of the adults
around her. After various strategies and 2 hours later, Jane was engaged again in therapy, for the therapist
to discover that the book that she was reading was confirming her already existing fantasy world as it
was about a fantasy flight to outer space. Jane was also able to explain how she was kind of able to hear
us talk to her, but it was like she was watching everything from far away and she was not able to comply
with any our requests.
There is a radical change in these children when their fantasy life (dissociation) is exchanged for the
real life. Reality becomes a space of human connection, human interaction and human communication
where responsibility for behaviour is a reality and adaptation and change is required by social rules
and expectations. This is a very painful change for the dissociative child from the dissociative world of
disconnection, distanced relationships and taking no responsibility for behaviour and actions. The reality
is that if the child is spending more time and emotional investment on a consistent basis in fantasy, be
it books, toys, or electronic activities, and resists connection to reality and to people around him/her,
this should be seen as an area that might need to be explored in terms of possible dissociative features.
Fantasy toys, books, and electronic devises have become a modern escape for children with a history of
complex trauma and disorganized attachments, as a means of acceptable dissociation. The presence of
derealisation and depersonalisation can be such that it poses a challenge to the therapist to uncover the
dissociative features in this process.
Case 3: Amnesia and somatoform dissociation

10-year old Jane was referred to me due to the adoptive parent concern that it feels like we cannot reach
her and while Jane has lived with them for the past five years, it feels that she has not attached to us.
Another, more concerning problem was that Jane had enuresis and encopresis on a daily basis, without
any indication that she was aware of this. As Jane was getting older, this became an increasing problem.
During the assessment Jane appeared lethargic, slow in completing tasks, but compliant. No dissociative
features were observed in any of her drawings or information, but Jane often stared into space. Parents
completed a CDC that indicated some dissociative symptoms. During therapy it was significant that Jane
was unable to remember any information from previous sessions, she was unable to remember significant
information like an expensive holiday a week before and it became increasingly difficult to engage with Jane,
as she did not appear present at all. Shirar (1996) refers to amnesia in children as Forgetting, especially
forgetfulness that doesnt make sense and also includes loss of time where the child behaves as if he
were in the past, or seems to have no memory of the intervening time period.
The therapist started to involve the mother and Jane in attachment-based therapy, which they had to
repeat at home. Janes memory of these activities and especially the positive times between her and her
mother was non-existent. It was evident that Jane suffered from significant amnesia. The therapist asked
Jane whether she knew why she could not remember the information. The answer was predictable and with
a shrug of her shoulders, she confirmed the suspicion that she did not know at all. The therapist asked Jane
to close her eyes and look inside her head to see whether she could find the reason for not remembering.
Jane only saw Black. The therapist asked Jane to draw Black and with exploration, accompanied with EMDR
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10
bilateral stimulation, Jane linked Black to her past experiences while living with her extremely neglectful
birth mother. Jane was able to talk to Black and let it know that she has moved in the meantime to a safe
home and a safe family and safe parents and the bad things will not happen any more. Jane closed her
eyes and conveyed the message to Black. Jane finally started to see some light in Black and it changed to
Colour. Jane felt relieved.
The next session was very much a repetition of all the others. There was still no memory of information.
(Parents reported no significant problems at school and Jane was doing well on an academic level). Once
again the therapist explored the reason for the amnesia. This time, the therapist asked Jane whether she
would be able to look inside her head to see whether she could find anything that could help her understand
why she struggles to remember. Jane lowered her head, closed her eyes and after a long silence, Jane looked
up, she smiled and said she had found Gappy who was eating all my memories. With further internal
communication with Gappy, Jane shared that he eats my memories so that I dont need to remember the
bad stuff that happened to me.
This was the start of a process where Gappy was finally integrated and Jane started to remember
increasingly more information and finding more significant dissociative states. One year later Jane was able
for the first time in her life to remember Christmassomething that she had never been able to do before.
Finally Jane was on her way to start to live life in reality. The enuresis and encopresis persisted. Silberg
(2013) refers to Nijenhuis (2004) and states: Dissociative children may experience a wide rage of somatic
symptoms with no apparent physical cause that appear to be related to past traumas. Later during
therapy, a dissociative state that was much younger appeared and she believed that she was still living with
the birth mother and was unaware that she was living in the body of 10-year old Jane. Waters in Wieland
(2011) refers to Nijenhuis (2009) and explains that somatoform dissociative symptoms are nonorganic
(no medical cause) and occur when there is trauma that causes a severe threat to the body. It is an animal
defensive response in which the body holds the unprocessed memories somatically, causing a loss of
sensation of unexplained pain that is experienced by one dissociative part but not by another dissociative
part. The symptoms can come and go depending on whether the part with a particular symptom is present.
Many children with amnesia forget significant information for example that they had their birthday party
two days ago or that they had a major conflict the previous day with their best friend at school. Some
children might also alert the therapist to the fact that they cannot recall seeing the toy that they often play
with in the therapy room or might be shocked by seeing a drawing that they have previously made or poem
that they have written during a previous session, and deny vehemently that they have ever seen it before.
Case 4: Behavioural changes/ switching

Sam was 11 years old when he was referred with attachment difficulties. Despite the adoptive parents
desperate re-parenting regime of many years in order to enable Sam to fill in the gaps of early infant
neglect, including regular rocking, singing and feeding Baby Sam, Sam continued to display the signs of
very infantile behaviour, which could very quickly move to a more adult-like, controlling presentation.
The previous attachment therapists ensured the parents that the infantile behaviour would gradually move
to more age-appropriate behaviours, but after 6 years in placement, the parents were beginning to feel some
concern. Indeed with the assessment, Sam stated that he had a baby Sam that was living in my head. It was
evident that as soon as Sam was given any responsibility that he could not cope with, baby Sam saved himself
by curling up in the foetal position and making baby noises. This attracted the kind and nurturing attention of
the adoptive parents, who through this process also soothed their own longing for a baby.
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11
In cases of children who were neglected and abused early in life and are now living with foster carers or
adoptive parents, there is often a misconception that nurturing the child with the appearance of regressed
behaviour will enable the child to move forward developmentally in order to acquire more age-appropriate
behaviour. Although this is partly true, in many cases such as Sam, there is a very young dissociative
state that is not able to ever display developmentally appropriate behaviour unless it is addressed as a
dissociative state, and this requires a different approach. Shirar (1996) refers to regressive behaviour in
children, where the child repeats similar infantile behaviours that took place at the time of the trauma that
caused helplessness and anxiety. She also states Regressive behavior (Regressive states in my opinion)
can be more difficult to detect in children than in adults, especially when the child is very young to begin
with. Reverting to behavior of a lower developmental level is often perceived by parents as just being
childish, mood changes, whining or having a bad day.
Wieland (2011) refers to this as behavioural changes where the child will suddenly act much younger or
much older than the childs chronological age or to suddenly become aggressive when normally passive
and accommodating.
The presentation of the regressed behaviour in this instance would never successfully be addressed by
nurturing this infantile dissociative state. It was functional as it enabled Sam to be protected against the
adults demands and the responsibility of reality. On other occasions, Sam would be excessively controlling
and demanding, especially in terms of types of food, times when he needed food, and who was preparing
the food. In therapy, Sam disclosed that Bossy was like a mum and was just making sure that Little Baby
Sam was looked after. This information reflected Sams early experiences as a baby and toddler when he
had experienced profound neglect and had to fend for himself to survive.
Case 5: Perpetrator Introjects

Ross was an 11-year-old girl who was referred due to her aggressive and violent behaviour at home. Ross
refused to allow the mother in the therapy room and used her time in therapy to talk about her life at school,
drew, talked about her friends, what she wants to do with her life, and denied the existence of all problems
at home on a consistent basis. As soon as she was reminded of the original problems, Ross assured the
therapist avidly that that is all gone now.
By the end of the third session, the mother pushed a note in the pocket of the therapistit described
shockingly aggressive behaviour on a daily basis at home. The mother was invited into the next session.
Ross resisted initially, but as she was previously prepared that the mother might be present at some
sessions, she complied. As usual, Ross excitedly told the therapist about school, friends, life, and so on.
When the therapist enquired about the possibility of any difficulties at home, without hesitation Ross
denied that there were any. When the therapist wanted to check this information with her mother, Ross
assured the therapist that this was not necessary as she can remember what happened. At this point the
mother sighed deeply and was allowed to explain her side of the story. Ross listened as a picture unfolded
about extreme violence and aggression on a daily basis at home, with significant damage to the house
during the past week. Ross started to sob. This was the beginning of the realisation that there were two
parts of the self. The one who had no behavioural problems at all and presented as a very endearing young
girl and the other who was holding extreme trauma that she experienced as a young child.
Ross eventually became able to explain that in her internal world there was the presence of Happy Ross
who was clearly the person who attended therapy with me when the mother was not present and then there
was the Horrible Ross who was the one who hurt family members at home and brought about significant
destruction to the home and objects. Slowly a picture unfolded where Horrible Ross was a perpetrator
introject of one of her mothers partners who was very violent when Ross was a baby. As perpetrator
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introjects are much more forceful than other dissociative states, they can be more difficult to work with as
they often resist integration (Potgieter Marks in Vogt, 2012). Perpetrator introjects often cause increased
damage to the childs self as professionals and parents alike are increasingly placing pressure on the child
to change the behaviour, pressurize the child to choose good behaviour and even threaten the child with
police and jail. It is evident that perpetrator introjects have the capacity to force the childs caregivers into
desperate measures and, left untreated, have the capacity to ruin a childs life.
Summary
In all of these cases, only one or a couple of classic signs of dissociation were present, and not always
consistently in the same area of the childs life. The common denominator was that these children all
experienced early complex trauma and were clearly living with trauma that had never been processed. At
the time of the trauma, they did not always have the presence of their attachment figure, but had to survive
the trauma and continue with life.
In their lives, all of these children were in some way disconnected from the reality of their lives and their
unacceptable behaviour, and were unable to cope with reality in the way that we would expect from a
child in an age-appropriate way. They all struggled in their attachments and social relationships and were
unable to take responsibility for their actions consistently. Most of the children were unable to attain their
academic potential.
The challenge for the therapist working with children and adolescents is that they are unable to explain
their problems or their internal world verbally. Rather, they explain it to us through their behaviour and
actions, and we as adults, and even as therapists, may fall into the trap of trying to change them. Evidence
for this can be found in the short-term structured programs or processes offered and aimed at creating
the ability to conform to societal norms and expectations, which invariably fail with the dissociative child.
The reality is that dissociation can appear in various disguises and without effective training, regular
clinical supervision or consultation, we as therapists might merely be well-meaning. By looking in the
wrong direction, we are less effective in helping the children and adolescents to heal. If we dare not ask
ourselves the question could this be dissociation?, we will miss the often subtle and varied symptoms of
dissociation. Therapists may be in danger of dissociating from the dissociation unless they move outside
of their own comfortable working models, look in the direction of the dissociation and continue on the
never-ending journey of acquiring and integrating new knowledge and understanding of the traumatized
childs and adolescents complicated world. Only if we, as therapists, are brave enough to see, be curious
about, and explore their dissociative world with them, can we become part of the solution.
REFERENCES
Putnam, FW. (1998). Dissociation in Children and Adolescents. New York/London: The Guildford Press.
Shirar, L. 1996. Dissociative Children. Bridging the Inner & Outer Worlds. `London/New York: W.W. Norton & Company.
Silberg, JL. (1986). The Dissociative Child. Diagnosis, Treatment and Management. Lutherville, The Sidran Press.
Silberg, JL. (2013). The Child Survivor. Healing Developmental Trauma and Dissociation. New York/London: Routledge
Van der Hart, O., Nijenhuis, R.S. & Steele, K. (2006). The Haunted Self. Structural Dissociation and the Treatment of Chronic
Traumatization. New York/London: W.W. Norton & Company.
Vogt, R. (2012). Perpetrator Introjects. Psychotherapeutic Diagnostics and Treatment Models. Kroning: Asanger Verlag
Wieland, S. (2011). Dissociation in Traumatised Children and Adolescents. New York/London:Routledge
ESTD Newsletter
13
CROSS THE BRIDGE

TO REDEFINE THE
PAIN
1
By Orit Badouk Epstein Attachment based psychoanalytic psychotherapist, London.

Not much has been written though about
the long term therapeutic alliance with
this client group or, more correctly, with
the most challenging parts. This is a
brief attempt to portray a move towards
intersubjectivity; a snap shot of being
in the room with the fierce protector
parts of a survivor of systemic abuse.
first place, the one who wants to better the quality

of the reduced life she has fallen into, will enter
the room casually smiling and will simply greet
me good morning. Such a wish, I grant, would
make this kind of work redundant. Instead, our
eyes meet half way, mine with a hesitant smile,
hers, hiding behind a fringe. Her dark eyes convey
nothing but relentless pain, cut-off, their existence
lies in a narrow lane between terror and isolation.
Its Monday morning, 8am sharp. Londons roads

are still frosty and the sunlight has just begun
shimmering in the sky, slowly drifting out of
last nights darkness, ready to meet a new day.
I hear the doorbell ring once, with the burden of
knowledge of the past 6 years, I open the door
gently and secretly hope that this Monday, summer
or winter she, the one who sought therapy in the
As she takes off her shoes, I usually wrap her many

parts, both the little and older ones, in a soft baby
pink blanket, and I place a hot water bottle and a
little teddy she named Professor Leopold next
to her. Tucked under the soft blanket, she often
comments how much she enjoys the smell of the
washing detergent on the blanket. We also turn
the clock away facing the window, in an attempt
1 My title is taken from a line in the song Burning by War on Drugs
ESTD Newsletter
that perhaps will help time slow down. This routine

that provides her with comforting objects, we
have found to be both grounding and soothing to
everyone inside her and help create a safe base.
This Monday, like many previous Mondays, in the
cacophony of her jarring internal world, stirred
by the pernicious terror of some anniversary, or a
coming religious date, no one is allowed near her.
Its too noisy,
We didnt want to come,
you didnt have to get up so early to get here,
we dont like therapy, empathy mean weakness
why do we need to do all this adult stuff?
We want to self-harm and just disappear into deep
sleep.
We hate people, Do not call my name!
We dont want to go to work,
You have your sheltered life with your perfect
family life, whats the point of all of this?
14
and from where no one was able to come back

whole. Her shivering naked body could not stop the
noise of her clenched teeth: she would be punished
as with every cry and tear her possessors would
own her frozen body even more. Their violations
meant that each time they appear, her brokenness
shattered further, like a prisoner from the start
whos been released and torn apart. The only way
one can come out alive is with more parts, all of
which are both divided and organized in their
adaptation to fear. Some will have to transform
into the malevolent shadows of their tormentors,
some will despise them yet be riddled with guilt and
shame., and some, like the rest of society, will just
stand by and watch this continuous horror movie,
unfolding with disbelief, playing out time and again.
In the space between me and her remarkable
ANP, Lauras cut-off parts are there to warn us
that more memories are about to emerge, more
nightmares are there to taunt her or that some
contact has been made by a frightening member
of her family. And with their pervasive dissociative
exclusion (formally known as denial) they will cause
more mayhem. She is not supposed to remember,
she is not supposed to talk, she would be killed if she
did. To convince her otherwise, reassure her that:
Its ok, you are now safe with me right here would
be to ask her to trust me.
Professor Leopold is dead, we hate everyone!

You think you know us, well you dont!
In the depth of her grief is a stranger living inside
her churning with rage, sitting in darkness. In
knowing this part, both Laura and I allow her to
fill the space between us with that despairing
dread of what feels like the pit. It is constant and
exhausting in its efforts to maintain detachment.
Out of terrorised compliance to her tormentor she
preserves the silence. After all, to speak out would
mean to be killed; to reach out, would mean to act
out and self-harm; to believe that those depravities
are not only a bad nightmare, but a memory would
mean going mad but more than anything, to attach
means to die. The pit lies at the bottom of trauma
land back in trauma time where no one was helped
Trust! Dont make us laugh; no one is to be trusted.

Why should we trust you? Trust means dependency,
are you going to adopt us? Are you going to allow
us move in with you? I didnt think so. Trust is for
gullible children who then get betrayed and hurt by
disgusting and scary adults her disconnected gaze
shows no affect.
In not fully keeping Lauras external and internal
relational world in mind, I have learnt the hard way
that to ask anything of the sort will only widen
the chasm between us as well as between all the
parts, sometimes to the point of severance and
the ending of therapy. For the cut-off parts, neither
empathy nor insights are sufficient in themselves to
affect therapeutic change. For reasons of survival
they are deeply stuck in trauma land and locked
ESTD Newsletter
in a distorted time when the now feels like then,

a time when the colour of my brown eyes look
identical to her mothers blue piercing eyes and
when my smile is just like the sinister grimace of
her abusers. In this confusion the cut-off parts are
doing their best to protect the little ones suffering
from further betrayal and abuse in the present.
Educating these parts towards benevolent trust
therefore might be misguided to us professionals.
Asking them to leave the system, change their
role, de-programme, integrate, do this or do that
would not only make us sound like her controlling
and conditioning scare-givers but is more like
asking us to abandon our survival tools all together.
For some survivors this might feel like a big ask,
a tall order that will take many years of therapy.
With some respectful boundaries, sitting there with
her, naming her, accepting her presence, finding a
language that validates her experiences, I tell her
that with time I have learnt to know her a bit better,
I can really see her seeing my many failed attempts
to try and get into her tiny soiled shoes. How could
I, how could anyone, get it? And with your relentless
crippling shame can I really make it better by saying:
its not your fault; you did nothing to deserve this?
No! She angrily nods, you cant make it better, no
one can!
Bounded by betrayal, Lauras cut-off parts are now
even more trapped unable to restrain themselves
after all dissociation is their only salvation: Do you
want us to leave ? We know that we are too much
but we cant control it, we would self-harm if we
could that would really satisfy everyone inside,
her fingers sharply roll against her stiff arm.
Sometimes, grounding techniques such as breathing
or providing this terrorised self-state with a gadget
to fiddle with , a nice smell or reading a chapter from
a book can help alleviate those states of terror for a
bit, but not completely.
Difficult as the session may be this Monday, when
some of the crevasse is still very much around, I tell
Laura how each Monday, often after a triggering
weekend, feels a bit less ferocious, a tiny bit softer
and a little more regulated than the previous one.
And the cut-off parts are slowly getting better at
15
tolerating our misgivings and staying in the room

with us. Their re-enactments in the past were
outrageously inappropriate, lashing out verbal
abuse, provoking, controlling and continuously
testing. The fight-flight responses felt so intense
that I could barely remember the session the
minute she left the room; instead my body would
just collapse with exhaustion. Yet Lauras ANP and
other parts know that I know that they know that
not everything in her present life is defined by her
abusive past. Her growing reflective functioning
increasingly allows a broader experience to live
more and survive less. Her bouts of depression,
missing 3 days of work at a time, have greatly
reduced and her intimate relationship with her
partner and close friends have gradually moved
from their polarised position to a more relational
consistent place. In this enduring process both me
and Laura are there to bear witness to this oceanic
pain, find a mutative language that can just about
shift some of it and eventually enable her to live
with less fear. But more importantly, improve her
relational world as she better understands the
cut-off parts impact on the people she loves in the
present.
As for my part in this journey, I tell Laura that as
disappointing as I may have been to her; growth
can only come out of learning to own our inherently
flawed imperfections and the efforts we make in
trying to repair it.
Lauras tears are now rolling down her youthful
looking face. At this moment of meeting, her big
wide eyes are looking through this window of
tolerance, unveiling the darkness of her past. I
notice the gentle shift in her posture, her frozen
gaze is now looking softer and her breathing is
calmer. She seems a bit more unified in herself,
slowly accepting that perhaps with time, her fierce
protectors will come to know that despite their
horrific past its never too dark to cross the bridge
and mourn their losses without a fight. Its nearly
time for us to end the session. I tell her it is possible
to feel safe, be heard, feel understood and for now
you are not alone. Ill see you on Wednesday.
Written with the clients consent.
Suzette Boon, Ph.D. was presenting the TADS Q
A CHRONICLE OF THE ESTD

TRAUMA CONFERENCE IN
ROMANIA, 2015
By Anca Sabau Child psychiatrists, psychotherapist
In April 2015, Timisoara, the city of roses
or little Vienna as it was called in the
19th century, the third city of importance
in Romania, happily held a series of ESTD
events that made trauma a much used
word.
A large number of clinicians (442), mostly young
ones, from all over Romania and also from neighbour
countries (Hungary, Serbia, and Poland) came to
listen to the speakers at the first ESTD Conference
in Romania. The conference Beyond the Trauma
Faces focused on the assessment of complex
trauma and dissociative disorders on the first day
and continued with more specific work on traumatic
memories on the morning of the second day. In the
afternoon, Romanian clinicians presented different
trauma and interdisciplinary papers (Epigenetic
aspects in PTSD, Preliminary study results on

ADES and The role of interdisciplinarity in geneticsneuropsychiatry - psychological aspects in cases of
Rare Diseases).
The main speakers from the Conference were
well known names from ESTD: Suzette Boon, Liora
Somer and Eli Somer we all, even if we had heard
them before, were delighted by their high-class
teaching, the atmosphere of magic and communion
that they created.
Before and after the conference there were also
teaching classes: Suzette Boon was presenting
the TADS Q and Anna Gerge gave a workshop on
the Ego State Model it was a real marathon of
trauma classes as some of the participants called
this series.
ESTD Newsletter
In organizing the event, we had as partners the

main Universities from Timisoara (Victor Babes
University of Medicine and Pharmacy and the
West University, The Faculty of Sociology and
Psychology) and the City Hall of Timisoara. Four
NGOs were collaborating as partners in preparing
the event: ARSIT (The Romanian Association for
Study and Intervention in Trauma), Dianoia (The
Institute for Family Therapy and Systemic Practice),
SRGM (The Romanian Society of Medical Genetics)
and Casa Faenza, a local community centre. It
was a collaborative effort for everyone and most
importantly, we succeeded in creating a good place
for learning.
The Conference and workshops series also created
a kind and warm place for networking among
clinicians from inside Romania and also abroad.
Here is some of the feedback from participants
regarding the event.
Bogdan is a resident doctor in child psychiatry;
he had already participated in different trauma
courses but the Conference brought him new things:
I especially benefited from the video examples
given by lecturers Suzette Boon and Eli Somer that
showed us switching of self parts and also how an
integrated trauma patient looks and feels after
therapy. The huge amount of information made
17
an impact on me even though I am not new to the

field of trauma and I have attended other events
organised by ARSIT in Romania. This was by far
the best in the sense that I could actually hear first
hand the level of dedication and years of work
these patients need. Thanks especially to Suzette
Boon: I can truly say that I can now identify trauma
better and understand what it does to a person
experiencing it. The bonus was the questions from
the audience, the exchange of practices and the
ideas that the lecturers brought to our attention.
Here are some testimonials from colleagues from
Poland (Radek and Igor) who came by car through
Europe to participatein the trauma series:
It was worth driving almost 900 km form Poland
to attend both Suzette Boons workshop and the
conference. We were offered speeches delivered
by exquisite clinicians who not only covered their
chosen topics, but also gave numerous precious
clinical and therapeutical observations. What
was also important to us, was the possibility of
making contact with other clinicians and scientists
in the trauma field to develop a further fruitful
collaboration.
A very interesting team was the Hungarian one,
with very skilled clinicians who asked interesting
questions and made comments during the second
Suzette Boon, Ph.D. Eli Somer, Ph.D. and Liora Somer, Art Therapist and Psychotherapist.
ESTD Newsletter
day of the Conference.

Here are some words from Judit Havelka, the
Hungarian representative of EMDR: There was
a small group of colleagues from Hungary at the
ESTD Conference. They were therapists who work
with severely traumatized people and also members
of the Hungarian EMDR association.
The point of this conference is very important,
especially in the regions of Central and Eastern
Europe, where a several hundred-year old culture of
traumatisation (from the individual level to the level
of the whole society) and neglect are just starting
to change.
We are very pleased to see Timisoara as a very
dynamic developing progressive college town.
We very much appreciate the great efforts of the
Romanian Trauma Association (ARSIT) and we hope
it will become a close cooperation in the future
between Hungarian trauma therapists and ARSIT.
Also another colleague from the Hungarian Trauma
Therapist group: In April our four-person group
from Hungary attended the ESTD conference in
Timisoara. Three of us are clinical psychologists,
two of us teaching psychology at the University
of Debrecen, Hungary, and one of us a Ph.D.
18
student conducting research on adverse childhood

experiences. Besides the academic job, we work
in private practice with traumatized, dissociative
patients, mainly according to the concept of
the structural dissociation of the personality.
Sometimes we feel a bit isolated in this field so we
were looking forward to the conference and hoped
to gain a lot of new information about these states.
Frankly, we learned much more than we expected...
We were (and we still are) greatly impressed by
Suzette Boon's, Eli Somer's and Liora Somer's
lectures that were highly professional and gave a
lot to enhance our knowledge about dissociation
and its treatment. Furthermore, the attitude and
commitment toward patients and to our profession
that were transmitted by the lecturers were also an
uplifting experience that gave us a lot. These two
days were very confirmative and inspiring.... If we
were to summarize this conference in keywords,
we would choose: professionalism, commitment,
deep empathy - and a very fruitful integration
of academic knowledge and empirical, practical
experience. Thanks ESTD!
ESTD Newsletter
19
BOOK REVIEWS
By Henry Strick van Linschoten,
London 2015.
Psychotherapist in private practice.
THE BODY
KEEPS THE
SCORE
Author:
Bessel Van Der Kolk, MD
This is a wonderful new book (September

2014) that everyone involved with trauma
ought to read and have available. It is the
latest book about the consequences of
trauma by Professor Bessel van der Kolk,
the Dutch psychiatrist based in Boston,
Massachusetts who has devoted his life
to studying PTSD and finding ways of
treating it more effectively.
The book is so special as it manages to effectively
reach three groups, practitioners of various forms
of treatment, people with PTSD, and researchers. It
is written simply and straightforwardly, with many
examples, without sacrificing rigour. It does not
make easy reading, as books about trauma rarely
do
The book is divided into five parts, a historical
perspective, a summary of new knowledge
about brain and body, a section on children and
attachment, a discussion of memory, and a long final
part on different treatment methods.
Van der Kolk is an indefatigable learner and
researcher. He has continued from his days in
medical school to look everywhere for ways of

treating trauma more effectively, humanely and
quickly. The book stands out as he gently mixes
his own life development and seminal experiences
into the narrative. He is and remains a psychiatrist,
but he has kept a very open mind about all and any
ways of working that have some promise. And when
he finds a new approach that he takes seriously,
he is usually the first to request it being tested on
himself.
Some people may be a bit disturbed by the breadth
of the approaches he confidently recommends. Of
course as a psychiatrist he prescribes drugs - but
he has a healthy skepticism about their limitations.
He is fully trained psychotherapeutically, but
he carefully points out that many forms of
psychotherapy make no impact, and integrates in
his vignettes the frequency with which people arrive
after years of ineffective psychotherapy. However,
in these two key areas of possible treatment, he
remains open too, and shows that he continues to
prescribe drugs and refer clients (he uses patients
throughout the book) to psychotherapy, if he
believes this may help, support or give relief.
ESTD Newsletter
What is more exceptional is the range of nontraditional approaches he has tried out at the
Trauma Center he founded. Main methods that he
strongly recommends for their effectiveness are
EMDR; yoga; Richard Schwartzs Internal Family
Systems therapy (IFS); the body psychotherapy
approaches of Pesso, Ogden (sensorimotor
psychotherapy) and Levine; neurofeedback; and
theatre including improvisation. In between these
major recommendations he also shows partiality
towards EFT (or other tapping systems),
acupuncture, and mindfulness methods. While he
explains and quotes how many research studies
he has initiated, and points out how important
research evidence is for him, he freely admits that
many of his ideas have neither extensive nor even
sometimes partial formal research evidence for
their effectiveness.
In his understanding of the sequelae of trauma
Van der Kolk is of course enormously experienced.
In addition he is familiar with all the literature and
perspectives. In particular he describes dissociation
well and from different angles; in the chapter on
Internal Family Systems therapy, he describes how
IFS is designed to address Dissociative Identity
Disorder.
Van der Kolk is a practitioner, and writes for
practitioners. For him the careful practical evidence
(practice-based evidence perhaps, though he
doesnt use the expression) of having seen a number
of clients who did not improve with other methods
get better from using some unusual or even esoteric
practices is enough to put such a practice on his
list of things to try. Van der Kolk, and clearly the
Trauma Center, surely are rigorous in documenting
and reviewing what they do for each individual
client, and why they do it. But the variation seems
endless compared with most other places.
Van der Kolk is well aware that no practitioner is
going to be sufficiently trained in all of his favoured
approaches to be able to use them themselves,
apart from the question of whether this would
always work. But he assumes that it is always
possible to maintain contact after referring
someone to go and try something else that he
20
believes might work, such as a psychotherapist

or psychiatrist referring a client to yoga or
neurofeedback. He also assumes that many people
will need several approaches simultaneously, e.g.
drugs, psychotherapy, yoga, and perhaps dancing
- but its also possible that for practical reasons
a normal approach with assessment and full
programmatic treatment will not be available, such
as for the students in the many schools that the
Trauma Center has supported in setting up student
programmes, sometimes based around dance and
nothing else.
As he says in the Prologue, I have no preferred
treatment modality, as no single approach fits
everybody. The implication of his view on trauma
is that ideally one single practitioner (perhaps an
assessor?) will know enough about a very wide
range of treatment methods to be able to follow
and recommend what a particular person may
need, and what they could try simultaneously or
in succession.This is a challenging way of seeing
things, and clearly not practical in many settings,
especially not in private insurance-funded ones, or
state systems such as Medicaid / Obamacare or the
NHS. At least this book gives a grand vision of how it
could be, and perhaps should be. And in the context
of a private practitioner working in the UK, it can
be a true inspiration to think out of the box, and
consider if some strange alternative treatment
could be tried that might lead to a breakthrough
whether they make progress with their problems.
Is the book perfect then? On its own terms it
may be - it is so beautifully, compellingly and
sweepingly written in its grand vision of integrating
medical, psychological and mixed or alternative
approaches, based on a careful reading of the
client and a holistic mind-body view. Single-schoolpractitioners wouldnt like it, as it does not privilege
any single method. Scientific purists might dislike
Van der Kolks preparedness to recommend and use
methods that have not been fully signed off with
Randomised Controlled Trials. But given how much
high-quality research Van der Kolk personally has
done and initiated, more than most practitioners
would ever consider, this would seem almost ironic.
The choices made amongst neuroscience findings
ESTD Newsletter
are comprehensive but perhaps remain a bit

traditional (e.g. left-right brain; MacLeans triune
brain; mirror neurons; attachment theory), but
they are state-of-the-art as far as integration with
practical work is concerned.
Early in the book Van der Kolk refers to the late
Elvin Semrad, one of Harvards great teachers, as
an enormous inspiration for him. He uses Semrad
as the authority for approaching the client with an
as much as possible open mind, without theoretical
preconceptions, and listen and observe to the
wisdom that they as client have about their own
life. The book clearly is as a whole a tribute to this
way of seeing things.
In the Epilogue Van der Kolk goes even further
than in the main body of the book. He points out
the importance of the sociopolitical context, and
that there is much wrong with todays society. He
also emphasises the enormous importance of
protecting children, and of education and what
could ideally be improved there to give all children
equal chances, and protection against abuse. This
is a dignified and fully appropriate ending.
After a lifetime of working with people bearing
the scars of the trauma they have experienced,
this is Van der Kolks grand synthesis of a lifetime
of dedication. I believe we can only admire the
book, and use if for ourselves, and in some cases
directly for our clients, as a source of wisdom and
practical ideas. There are very few practitioners
who could not learn from this book and become
more effective, as well as inspired, by reading and
studying it.
21
ESTD Newsletter
22
BOOK REVIEWS
By Julia Bueno
UKCP registered Integrative Psychotherapist.
Not My Secret To
Keep: A Memoir
of Healing From
Childhood Sexual
Abuse
Authors:
Digene Farrar with Cynthia Hurn
Portage Bay Press
In Not My Secret to Keep, we first

meet Digene Farrar in her early 40s, at
the cusp of realising her professional
dream. Nursing and running a business
had been an occupation over the years,
but modelling was a career she had really
wanted to pursue. Against stiff competition,
she wins a magazine contest that takes her to New
York with a years contract. Life had never seemed so
good.But not long after settling into her Manhatten
apartment, a jet crashes into the North Tower of the
World Trade Center. Her nursing training kicks in, and
she runs to the scene to offer help, only to become
a part of the trail of destruction. In the wake of this
indescribable tragedy, Digene begins to fall apart
processing not only the horrors of that day, but
those of sustained sexual and physical abuse shed
experienced growing up.
Digene tells her powerful story through a series of
diary extracts, bringing us close to her mind as she
fell apart and put herself back together again. She

begins in May of 2001 and chronicles events over the
best part of a decade, which include the agonising
processing of early trauma she experienced as a
young child and infant. We learn very little about
her adult life prior to her early 40s, only references
to how her defences got her through her years
up until then: those of self-reliance, avoidance of
intimacy, denial and self-recrimination. The trauma
of 9/11 seemed to puncture these well honed
survival tactics, and we journey with her through
the painstaking process of making sense of all that
she was defending against.
Trapped in New York City after the Towers fell,
and unable to return to her possessions in her
apartment, Digene desperately tries to find a secure
base. It is hard to find and she walks for hours
around the chaos, disoriented and not knowing
quite who to turn to just as she felt when young.
Her husband Jack is miles away in their marital home
in Seattle and when eventually she makes it back,
ESTD Newsletter
she notes Now that Im home, I know Im safe, but

nothing seems real anymore. As the literal dust
settles in New York, and the collective mourning
begins, Digene begins to experience flashbacks,
nightmares and high anxiety, and understandably
sinks deeper and deeper into a depression. When
Jack begins to despair, she realises she needs help.
So Digene seeks therapy unfortunately her first
therapist she meets isnt a good fit. Her awkward
questions prompt my retelling the story of that
painful day, but my emotions have flatlined like the
heart monitor of someone whose pulse has stopped.
I feel as if part of me is sealed in a cocoon, and the
result is total numbness. I may as well be talking
about someone on another planet; Im so devoid of
feelings.Unfortunately, this therapist fails to see
the dissociation in front of her and inaccurately
reflects, You seem to be doing remarkably well.
Fortunately, Digene is swiftly re-allocated to a more
experienced therapist, Janet, who clearly attunes to
Digenes level of trauma far better. We meet other
therapists later on, although her relationship with
Janet is particularly important and longest lasting,
and obviously the one that contains the greatest
psychological work and contributes to healing her
severe attachment trauma. We learn about their
long journey to make the unthinkable thinkable not
just the horrors of the terrorism, but the horrors of
her repeated sexual and physical abuse.
This isnt swift work, as we know. After nearly
five years with Janet, in a chapter Facing Reality
Digene notes I understand I need to talk and feel
in order to heal; I just cant seem to tolerate the
feelings. This leads into a year of exposure therapy
where although tedious, excruciatingly painful and
exhausting, Digene concludes that I truly believe
exposure therapy is what saved me....providing
me with a tool to relanguage the experiences at
my core and to connect the memories with the
disassociated feelings. Im now able to face them
instead of running away from them or numbing
myself.
I wondered about Digenes relationship with her
body during all of this her work with Janet seemed
23
to be processing through talking rather than

bodywork, although Janet did encourage Digene
to write her feelings down when things became
too intense. But while often dissociating from her
sense of self and embodiment, Digene meanwhile
maintains and builds upon a successful professional
persona as a fashion model her functioning part
gains contracts through her innate good looks,
but also her confidence and some sense of I am
beautiful. The irony is another part of her feels
so deeply I am not beautiful that it has, at times,
become annhiliatory.
This tension between liking/not liking her body
and her struggle to integrate the past and present
manifests strikingly around the years of efforts
Digene makes to replace a false tooth with an
implant. Knocked out as a child by an abuser, she
is determined to have the smile she (sometimes
feels she) deserves, but the implant doesnt take
and she ends up having repeated painful, expensive
and unsuccessful procedures. Getting there in the
end ties up with her integration as if the implanted
tooth couldnt settle until she got there.
Digenes relationship with her body is attended to
in a different way at the Miravel Resort in Arizona,
where she signs up for five days of personal
challenges including leaping off a high platform and
spending time with a much feared horse. Her brief
but powerful retreat ends with a moving letter to
her younger self, conveying the unconditional love,
acceptance and self-compassion she so needed
during her early years.
In the chapter Hands On, towards the end of the
book, we learn about Digenes year of massage
therapy all the successful psychological work she
had made eventually allowed for her to open herself
to touch -something she had struggled with over the
years. I wasnt sure what it would feel like to allow
someone to touch me or hug me and remain present
with the feeling. Unsurprisingly, one massage
triggers flashbacks its like my bodys key unlocked
the doors to stored memories at a cellular level, one
after another. However, trust in the skilled massage
therapist and a stock of new resources allow Digene
ESTD Newsletter
to experience the flashback with greater ease.

The book is not just a courageous and inspiring
memoir. The shorter second section explores the
unhappy reality that childhood sexual abuse is far
from unique to Digene. Just as Van Der Kolk flags
this up as an issue of (US) national importance,
so does Digene, and she shares suggestions to
survivors and those supporting survivors around
seeking support and healing. And as her memoir
testifies, the journey can be long, arduous, and
may involve different ways of working at different
times as the healing unfolds. I imagine this book to
a tremendous resource to clients and therapists
alike.
24
ESTD Newsletter
25
HOT OFF THE PRESS

By Winja Lutz
Introducing the latest research
Dear Readers, again, here comes the latest research on trauma and dissociation and related fields for your science-hungry brains
and hearts... As is true for all research: regard these studies with great care and a critical mind they deserve it!
Childhood Adversity Narratives

Putnam, F., Harris, W., Lieberman, A., Putnam, K. & Amaya-Jackson, L. (2015). Childhood Adversity Narratives. Online [retrieved
May.3.2015]: http://www.canarratives.org/s/CAN_Narrative_4-26-15-v2L4.pptx
Frank Putnam MD and colleagues created one of the most powerful presentations on adverse childhood experiences and their
effects in the hope that it will be widely disseminated and used to educate the public as well as researchers and clinicians about
the prevalence, impact, treatment, and prevention of child abuse and neglect.
The authors encourage everyone to use and share it.The slides are available on the website http://www.canarratives.org/
Report questioning shaken baby syndrome seriously unbalanced

Dubowitz, H. & Alden, E.R. (2015). Report questioning shaken baby syndrome seriously unbalanced. AAP NEWS, 36(5):1. Online
[retrieved May.3.2015]: http://aapnews.aappublications.org/content/36/5/1.2.full
Abstract
For a long time, child abuse stories made for important news. Now, suggesting that parents have been falsely accused makes
for a far more compelling story, as is the case of a recently published article in the Washington Post, www.washingtonpost.com/
graphics/investigations/shaken-baby-syndrome.
But like the back-and-forth over childhood immunizations, this is a false debate. The truth is that child abuse, including abusive
head trauma, is a real problem that terribly injures and sometimes kills children. The Posts report on the disputed diagnosis of
shaken baby syndrome is disturbing. Indeed, the science has been shaken but only by the media and a small number of physicians.
Adverse Childhood Experiences: Informing Best Practices

Corwin, D.L., Alexander, R., Bair-Merritt, M. Block, R., Davis, M., James, L., Keeshin, B., Ismailji, T., Lewis-OConnor, A. & Schneider,
D. (2015). Adverse Childhood Experiences: Informing Best Practices. Online Collaborative Living Document - Online Collaborative
Living Document Version 1.0 3/14/15. Online [retrieved May.3.2015]: http://www.avahealth.org/aces_best_practices/appendix.html
Abstract
This document is the product of an ongoing collaboration between the Academy on Violence and Abuse (AVA) and the National
Health Collaborative on Violence and Abuse (NHCVA). It is intended to assist healthcare professionals and others who wish to
integrate knowledge of adverse childhood experiences into patient care and other activities (e.g., education, human services,
and justice).
ESTD Newsletter
26
Epigenetics of Inflammation, Maternal Infection, and Nutrition

Claycombe, K.J., Brissette, C.A. & Ghribi, O. (2015). Epigenetics of Inflammation, Maternal Infection, and
Nutrition. The Journal of Nutrition, 145(5). Online [retrieved May.3.2015]: http://jn.nutrition.org/content/
early/2015/04/01/jn.114.194639.abstract
Abstract
Studies have demonstrated that epigenetic changes such as DNA methylation, histone modification, and
chromatin remodeling are linked to an increased inflammatory response as well as increased risk of chronic
disease development. A few studies have begun to investigate whether dietary nutrients play a beneficial
role by modifying or reversing epigenetically induced inflammation. Results of these studies show that
nutrients modify epigenetic pathways. However, little is known about how nutrients modulate inflammation
by regulating immune cell function and/or immune cell differentiation via epigenetic pathways. This
overview will provide information about the current understanding of the role of nutrients in the epigenetic
control mechanisms of immune function.
Inflammation and neuronal plasticity: a link between childhood trauma and

depression pathogenesis
Cattaneo, A., Macchi, F., Plazzotta, G., Veronica, B., Bocchio-Chiavetto, L., Riva, M.A. & Pariante, C.M. (2015).
Inflammation and neuronal plasticity: a link between childhood trauma and depression pathogenesis.
Frontiers in Cellular Neuroscience, 9(40). Online [retrieved May.3.2015]: http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4379909/
Abstract
During the past two decades, there has been increasing interest in understanding and characterizing
the role of inflammation in major depressive disorder (MDD). Indeed, several are the evidences linking
alterations in the inflammatory system to Major Depression, including the presence of elevated levels of
pro-inflammatory cytokines, together with other mediators of inflammation. However, it is still not clear
whether inflammation represents a cause or whether other factors related to depression result in these
immunological effects. Regardless, exposure to early life stressful events, which represent a vulnerability
factor for the development of psychiatric disorders, act through the modulation of inflammatory
responses, but also of neuroplastic mechanisms over the entire life span. Indeed, early life stressful events
can cause, possibly through epigenetic changes that persist over time, up to adulthood. Such alterations
may concur to increase the vulnerability to develop psychopathologies. In this review we will discuss the
role of inflammation and neuronal plasticity as relevant processes underlying depression development.
Moreover, we will discuss the role of epigenetics in inducing alterations in inflammation-immune systems
as well as dysfunction in neuronal plasticity, thus contributing to the long-lasting negative effects of
stressful life events early in life and the consequent enhanced risk for depression. Finally we will provide
an overview on the potential role of inflammatory system to aid diagnosis, predict treatment response,
enhance treatment matching, and prevent the onset or relapse of Major Depression.
ESTD Newsletter
27
Alterations of Mitochondrial DNA Copy Number and Telomere Length with Early
Adversity and Psychopathology
Tyrka, A.R., Parade, S.H., Price, L.H., Kao, H.-T., Porton, B., Philip, N.S., Welch, E.S. & Carpenter, L.L.
(2015). Alterations of Mitochondrial DNA Copy Number and Telomere Length with Early Adversity and
Psychopathology. Biological Psychiatry [Epub ahead of print]. Online [retrieved May.3.2015]: http://www.
ncbi.nlm.nih.gov/pubmed/25749099
Abstract
Background
Telomere shortening and alterations of mitochondrial biogenesis are involved in cellular aging. Childhood
adversity is associated with telomere shortening, and several investigations have shown short telomeres
in psychiatric disorders. Recent studies have examined whether mitochondria might be involved in
neuropsychiatric conditions; findings are limited and no prior work has examined this in relation to stress
exposure.
Methods
Two-hundred ninety healthy adults provided information on childhood parental loss and maltreatment and
completed diagnostic interviews. Participants were categorized into four groups based upon the presence
or absence of childhood adversity and the presence or absence of lifetime psychopathology (depressive,
anxiety, and substance use disorders). Telomere length and mitochondrial DNA (mtDNA) copy number were
measured from leukocyte DNA by quantitative polymerase chain reaction.
Results
Childhood adversity and lifetime psychopathology were each associated with shorter telomeres (p <
.01) and higher mtDNA copy numbers (p < .001). Significantly higher mtDNA copy numbers and shorter
telomeres were seen in individuals with major depression, depressive disorders, and anxiety disorders, as
well as those with parental loss and childhood maltreatment. A history of substance disorders was also
associated with significantly higher mtDNA copy numbers.
Conclusions
This study provides the first evidence of an alteration of mitochondrial biogenesis with early life stress and
with anxiety and substance use disorders. We replicate prior work on telomere length and psychopathology
and show that this effect is not secondary to medication use or comorbid medical illness. Finally, we show
that early life stress and psychopathology are each associated with these markers of cellular aging.
ESTD Newsletter
28
The Maltreatment and Abuse Chronology of Exposure (MACE) Scale for the
Retrospective Assessment of Abuse and Neglect During Development
Teicher M.H. & Parigger A. (2015). The Maltreatment and Abuse Chronology of Exposure (MACE) Scale
for the Retrospective Assessment of Abuse and Neglect During Development. PLoS ONE 10(2): e0117423.
doi:10.1371/journal.pone.0117423. Online [retrieved May.3.2015]: http://journals.plos.org/plosone/
article?id=10.1371/journal.pone.0117423
Abstract
There is increasing interest in childhood maltreatment as a potent stimulus that may alter trajectories of
brain development, induce epigenetic modifications and enhance risk for medical and psychiatric disorders.
Although a number of useful scales exist for retrospective assessment of abuse and neglect they have
significant limitations. Moreover, they fail to provide detailed information on timing of exposure, which is
critical for delineation of sensitive periods. The Maltreatment and Abuse Chronology of Exposure (MACE)
scale was developed in a sample of 1051 participants using item response theory to gauge severity of
exposure to ten types of maltreatment (emotional neglect, non-verbal emotional abuse, parental physical
maltreatment, parental verbal abuse, peer emotional abuse, peer physical bullying, physical neglect, sexual
abuse, witnessing interparental violence and witnessing violence to siblings) during each year of childhood.
Items included in the subscales had acceptable psychometric properties based on infit and outfit mean
square statistics, and each subscale passed Andersens Likelihood ratio test. The MACE provides an overall
severity score and multiplicity score (number of types of maltreatment experienced) with excellent testretest reliability. Each type of maltreatment showed good reliability as did severity of exposure across
each year of childhood. MACE Severity correlated 0.738 with Childhood Trauma Questionnaire (CTQ) score
and MACE Multiplicity correlated 0.698 with the Adverse Childhood Experiences scale (ACE). However,
MACE accounted for 2.00- and 2.07-fold more of the variance, on average, in psychiatric symptom ratings
than CTQ or ACE, respectively, based on variance decomposition. Different types of maltreatment had
distinct and often unique developmental patterns. The 52-item MACE, a simpler Maltreatment Abuse and
Exposure Scale (MAES) that only assesses overall exposure and the original test instrument (MACE-X)
with several additional items plus spreadsheets and R code for scoring are provided to facilitate use and
to spur further development.
Perceptions of clinicians treating young people with first-episode psychosis for

post-traumatic stress disorder
Gairns, S., Alvarez-Jimenez, M., Hulbert, C., McGorry, P. & Bendall, S. (2015). Perceptions of clinicians
treating young people with first-episode psychosis for post-traumatic stress disorder. Early Intervention in
Psychiatry, 9(1): 1220. Online [retrieved May.3.2015]: http://onlinelibrary.wiley.com/doi/10.1111/eip.12065/full
Abstract
Aim
Evidence shows that approximately half of young people with first-episode psychosis have post-traumatic
stress disorder. Yet, post-traumatic stress disorder is often left untreated in the presence of psychosis.
To support the development of a post-traumatic stress disorder intervention for young people with firstepisode psychosis, clinicians' perceptions of trauma-focused interventions were sought. Two research
questions were explored: What treatment barriers were associated with treating young people with
first-episode psychosis? What supports would be useful to implement post-traumatic stress disorder
ESTD Newsletter
29
intervention?
Methods
A mixed-methods design incorporated quantitative and qualitative data from a questionnaire with
qualitative data from two focus groups. Sixteen (of 20) case managers from an early psychosis intervention
centre participated in the study (16 completed a questionnaire, eight participated in focus groups).
Descriptive statistics were generated for quantitative data and qualitative material was examined using
a grounded theory approach.
Results
The results showed that perceived barriers to delivering trauma-focused intervention were increased
mental health risks for clients with psychosis, workload pressures and poor client engagement.
Targeted training and formal professional guidance were thought to best scaffold an intervention.
Conclusions
Post-traumatic stress disorder intervention for first-episode psychosis clients should address engagement,
make safeguarded provisions for family involvement and be sufficiently paced and flexible. Traumafocused intervention is perceived with a degree of caution, is often not prioritized, lacks institutional
support and requires more targeted training. It is important to conduct further research regarding the
safety of trauma interventions alongside psychosis in order to address widespread concerns.
Behind the closed doors of mentalizing. A commentary on Another step closer to

measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective
Functioning Scale
Schimmenti, A. (2015). Behind the closed doors of mentalizing. A commentary on Another step closer to
measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale.
Frontiers in Psychology, 6: 380. Online [retrieved May.3.2015]: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4381487/
In his Clinical Diary, Ferenczi (1932/1988) suggested that an organizing life instinct allows the individual to
survive child abuse. He called this instinct Orpha, and described it as a guardian angel who anesthetizes the
consciousness and sensitivity against sensations as they become unbearable (p. 9). Ferenczi argued that a
fragmentation however occurs in personality as a consequence of the abuse: the personality is split into a
capable part as a regulated mechanism dealing with daily life and activities, secret parts that struggle
in despair because they experience the fire of suffering, and another part containing this suffering itself
as a separate mass of affect, without contents and unconscious, the remains of the actual person (p. 10).
Ferenczi's concept of Orpha tends to correspond to our current understanding of dissociation. In fact, child
abuse and neglect (CA&N) in the context of attachment relationship can generate a severe impairment
in the individual's ability to integrate mental states and their related affective contents into a consistent
structure of meaning (Allen, 2013). The psychological cost of dissociation is high: dissociation may involve
either a loss of continuity in subjective experience, and/or an inability to access information or control
mental functions, and/or a sense of experiential disconnectedness (Cardea and Carlson, 2011). How do
these considerations relate to the ghosts in the nursery (Fraiberg et al., 1975), the haunting internal
presences that lead parents to re-enact their own traumatic past by victimizing their child?
ESTD Newsletter
30
Trauma changes everything: Examining the relationship between adverse childhood

experiences and serious, violent and chronic juvenile offenders
Hahn Fox, B., Perez, N., Cass, E., Baglivio, M.T. & Epps, N. (2015). Trauma changes everything: Examining the
relationship between adverse childhood experiences and serious, violent and chronic juvenile offenders.
Child Abuse & Neglect [Epub ahead of print]. Online [retrieved May.3.2015]: http://www.ncbi.nlm.nih.gov/
pubmed/25703485
Abstract
Among juvenile offenders, those who commit the greatest number and the most violent offenses are
referred to as serious, violent, and chronic (SVC) offenders. However, current practices typically identify
SVC offenders only after they have committed their prolific and costly offenses. While several studies
have examined risk factors of SVCs, no screening tool has been developed to identify children at risk of
SVC offending. This study aims to examine how effective the adverse childhood experiences index, a
childhood trauma-based screening tool developed in the medical field, is at identifying children at higher
risk of SVC offending. Data on the history of childhood trauma, abuse, neglect, criminal behavior, and other
criminological risk factors for offending among 22,575 delinquent youth referred to the Florida Department
of Juvenile Justice are analyzed, with results suggesting that each additional adverse experience a child
experiences increases the risk of becoming a serious, violent, and chronic juvenile offender by 35, when
controlling for other risk factors for criminal behavior. These findings suggest that the ACE score could
be used by practitioners as a first-line screening tool to identify children at risk of SVC offending before
significant downstream wreckage occurs.
Childhood trauma and eating psychopathology: A mediating role for dissociation

and emotion dysregulation?
Moulton, S.J., Newman, E., Power, K., Swanson, V. & Day, K. (2015). Childhood trauma and eating
psychopathology: A mediating role for dissociation and emotion dysregulation? Child Abuse & Neglect,
39, pp. 167174. Online [retrieved May.3.2015]: http://www.ncbi.nlm.nih.gov/pubmed/25124050
Abstract
The present study examined the relationship between different forms of childhood trauma and eating
psychopathology using a multiple mediation model that included emotion dysregulation and dissociation
as hypothesised mediators. 142 female undergraduate psychology students studying at two British
Universities participated in this cross-sectional study. Participants completed measures of childhood
trauma (emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect), eating
psychopathology, dissociation and emotion dysregulation. Multiple mediation analysis was conducted to
investigate the study's proposed model. Results revealed that the multiple mediation model significantly
predicted eating psychopathology. Additionally, both emotion dysregulation and dissociation were found
to be significant mediators between childhood trauma and eating psychopathology. A specific indirect
effect was observed between childhood emotional abuse and eating psychopathology through emotion
dysregulation. Findings support previous research linking childhood trauma to eating psychopathology.
They indicate that multiple forms of childhood trauma should be assessed for individuals with eating
disorders. The possible maintaining role of emotion regulation processes should also be considered in the
treatment of eating disorders.
ESTD Newsletter
31
Trauma-focused therapy for refugees: Meta-analytic findings

Lambert, J.E. & Alhassoon, O.M. (2015). Trauma-focused therapy for refugees: Meta-analytic findings.
Journal of Counseling Psychology, 62(1): 28-37. Online [retrieved May.3.2015]: http://psycnet.apa.org/
journals/cou/62/1/28/
High levels of trauma-related psychological distress have been documented among ethnically diverse
refugees. As the number of refugees worldwide continues to grow, determining the efficacy of established
methods of trauma-focused therapy for this population is crucial. This meta-analysis examined the
results of randomized controlled trials of psychotherapeutic intervention for traumatized adult refugees.
Comparisons of 13 trauma-focused therapies to control groups from 12 studies were included in the
analysis. The aggregate effect size for the primary outcome, posttraumatic stress disorder (PTSD), was
large in magnitude, Hedges g = .91, p < .001, 95% CI [.56, 1.52]. The aggregate effect size for depression,
assessed in 9 studies, was also large g = .63, p < .001, 95% CI [.35, .92]. We used metaregression to evaluate
potential moderators of the PTSD effect size. Number of sessions significantly predicted magnitude of the
effect size, and studies that utilized an active control group (e.g., supportive counseling) had significantly
smaller effect size than those with a passive control group. There was no difference in outcome for studies
where an interpreter was used to facilitate sessions and those where no interpreter was used. There also
was no difference in outcome based on type of PTSD assessment. Results provide evidence in the efficacy
of trauma-focused models for treating refugees, and also shed light on important areas for future research.
(PsycINFO Database Record (c) 2015 APA, all rights reserved)
Oxytocin receptor and vasopressin receptor 1a genes are respectively associated

with emotional and cognitive empathy
Uzefovsky, F., Shalev, I., Israel, S., Edelman, S., Raz, Y., Mankuta, D. Knafo-Noam, A. & Ebstein, R.P. (2015).
Oxytocin receptor and vasopressin receptor 1a genes are respectively associated with emotional and
cognitive empathy. Hormones and Behavior 67, pp. 6065. Online [retrieved May.3.2015]: http://www.ncbi.
nlm.nih.gov/pubmed/25476609
Abstract
Empathy is the ability to recognize and share in the emotions of others. It can be considered a multifaceted
concept with cognitive and emotional aspects. Little is known regarding the underlying neurochemistry
of empathy and in the current study we used a neurogenetic approach to explore possible brain
neurotransmitter pathways contributing to cognitive and emotional empathy. Both the oxytocin receptor
(OXTR) and the arginine vasopressin receptor 1a (AVPR1a) genes contribute to social cognition in both
animals and humans and hence are prominent candidates for contributing to empathy. The following
research examined the associations between polymorphisms in these two genes and individual differences
in emotional and cognitive empathy in a sample of 367 young adults. Intriguingly, we found that emotional
empathy was associated solely with OXTR, whereas cognitive empathy was associated solely with AVPR1a.
Moreover, no interaction was observed between the two genes and measures of empathy. The current
findings contribute to our understanding of the distinct neurogenetic pathways involved in cognitive and
emotional empathy and underscore the pervasive role of both oxytocin and vasopressin in modulating
human emotions.
ESTD Newsletter
32
Couple Therapy with Adult Survivors of Child Abuse: Gender, Power, and Trust
Wells, M.A. & Kuhn, V.P. (2015). Couple Therapy with Adult Survivors of Child Abuse: Gender, Power, and
Trust. Socio-Emotional Relationship Therapy AFTA SpringerBriefs in Family Therapy pp 107-119. Online
[retrieved May.3.2015]: http://link.springer.com/chapter/10.1007%2F978-3-319-13398-0_9

Abstract
Many couples in therapy have a history of childhood abuse. Sensitivity to power and difficulty with trusting
ones intimate partner are key concerns for these couples. This chapter presents the relational trust
theory, which describes how gendered power imbalances in couple interactions can trigger distrustful
emotional power responses from the adult-survivor partner(s). Drawing upon Socio-Emotional Relationship
Therapy (SERT) approaches, the clinical processes described attend to gender, power, and emotions in
couple interactions in order to help partners disentangle these dual influences of power and move from
defensiveness with each other toward a more trusting position. Case examples show the problems
generated by the intermingling of gendered power dynamics and adult-survivor partner. As partners
become better able to engage in processes of mutuality, distrustful adult-survivor power responses
typically recede as a result of the adult survivors perception of the partner as trustworthy, thereby
enhancing relational trust and couple intimacy.
Epigenetic modification of the oxytocin receptor gene influences the perception of

anger and fear in the human brain
Puglia, M.H., Lillard, T.S., Morris, J.P. & Connelly, J.J. (2015). Epigenetic modification of the oxytocin receptor
gene influences the perception of anger and fear in the human brain. PNAS 112(11): 3308-3313. Online
[retrieved May.3.2015]: http://www.pnas.org/content/112/11/3308.short
Abstract
In humans, the neuropeptide oxytocin plays a critical role in social and emotional behavior. The actions
of this molecule are dependent on a protein that acts as its receptor, which is encoded by the oxytocin
receptor gene (OXTR). DNA methylation of OXTR, an epigenetic modification, directly influences gene
transcription and is variable in humans. However, the impact of this variability on specific social behaviors
is unknown. We hypothesized that variability in OXTR methylation impacts social perceptual processes
often linked with oxytocin, such as perception of facial emotions. Using an imaging epigenetic approach,
we established a relationship between OXTR methylation and neural activity in response to emotional
face processing. Specifically, high levels of OXTR methylation were associated with greater amounts of
activity in regions associated with face and emotion processing including amygdala, fusiform, and insula.
Importantly, we found that these higher levels of OXTR methylation were also associated with decreased
functional coupling of amygdala with regions involved in affect appraisal and emotion regulation. These
data indicate that the human endogenous oxytocin system is involved in attenuation of the fear response,
corroborating research implicating intranasal oxytocin in the same processes. Our findings highlight the
importance of including epigenetic mechanisms in the description of the endogenous oxytocin system
and further support a central role for oxytocin in social cognition. This approach linking epigenetic
variability with neural endophenotypes may broadly explain individual differences in phenotype including
susceptibility or resilience to disease.
ESTD Newsletter
33
Secure-Base Caregiving and Adult Attachment: Development Within the ClientPsychotherapist Relationship
Weeks, D.A. (2015). Secure-Base Caregiving and Adult Attachment: Development Within the ClientPsychotherapist Relationship. Dissertation, Walden University. Online [retrieved May.3.2015]: http://
scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=1334&context=dissertations
Abstract
Recent studies have shown significant improvements in the attachment security of adult therapy clients
during therapy, supporting Bowlbys theory that such improvement can be influenced by secure-base
caregiving provided by mentors such as therapists. However, because these studies did not measure the
secure-base variable, its relationship to client attachment development remains unknown. The present
study is the first to evaluate that relationship by measuring clients pre and posttherapy attachment
security using the Relationship Scales Questionnaire and therapists secure-base caregiving using the
Client Attachment to Therapist and Working Alliance Inventory, Short Form. Of 21 initially insecure client
participants, 17 experienced high levels of secure-base caregiving from their therapists (the SBC-High
group) while 4 experienced low levels (the SBC-Low group). Comparison of pre and posttherapy group mean
attachment scores, using the Wilcoxon Signed Ranks Test, found a statistically significant improvement
(a = .01) in attachment security for the SBC-High group with no statistical change in attachment security
for the SBC-Low group. These findings suggest that therapists and other mentors can positively influence
the attachment development of their insecure mentees. Purposeful incorporation of this knowledge into
the design and goals of existing graduate and professional mentoring programs can positively influence
regenerative social change by promoting the attachment security of approximately one third of mentees
expected to be insecurely attached, based on demographic studies. Improving their attachments can equip
them to positively influence the attachments of all their future insecure clients who, like them, might then
realize the multiple benefits associated with attachment security.
ESTD Newsletter
34
DATES FOR YOUR DIARY IN 2015

2015: Training In Finland. Assessment and treatment of complex trauma and dissociative disorders- training 2014/2015
18 lecture days by Onno van der Hart, Suzette Boon, Kathy Steele, Ellert Nijenhuis and Sandra Wieland.
More information : www.traumaterapiakeskus.com
See all trainings here: www.traumaterapiakeskus.com
June 3-5, 2015: "Trauma, Dissociation and Psychosis", an international conference that will take place in Kristiansand,
Norway.
Keynote speakers: Andrew Moskowitz, Colin Ross, Anthony Morrison, Ellert Nijenhuis, Inez Myin-Germeys, and Eleanor Longden.
Pre-conference workshop: Dolores Mosquera
Website: traumaconference.no
June 10-13, 2015: Vilnius, Lithuania XIV Conference of European Society for Traumatic Stress Studies. Trauma in
changing societies: social context and clinical practice.
http://estss2015.eu/
June 11-13, 2015: Group Therapy, Perpetrator Attachment & Social Neurobiology, Leipzig, Germany
Confirmed speakers are: Dr. Stephen W. Porges, Dr. Sue Carter, Dr. Andrew Moskowitz,
Dr. Luise Reddemann, Dr. Bernhard Strau, Dr. Adah Sachs, Dr. Michael Hayne, Dr. Ruth Blizard and many more. German-English
interpretations for all presentations!
http://www.traumapotenziale.de/veranstaltungen15_en.html
July 7-10, 2015: 14th European Congress of Psychology, Milan, Italy.

More information: http://www.ecp2015.it
September 19-20, 2015: An International Conference in Celebration

of John Bowlbys Work: Attachment Theory How John Bowlby Revolutionised Our Understanding of Human Relationships,
London, UK
http://thebowlbycentre.org.uk/cpd/
October 9-11, 2015: 14th International Attachment Conference. Munich.

http://www.bindungskonferenz-muenchen.de/index.php?article_id=1&clang=1
October 17-18, 2015: Utilisation of EMDR in the Treatment of Complex Trauma and Dissociation one-day workshop
with Roger Solomon. In English with French translation.
Website : www.ietsp.fr
November 17-18, 2015: EMDR & Dissociation conference, Metz, France.

Translations in English and French. Speakers : Andrew Moskowitz, Eva Zimmermann, Helga Matthess, Michel
Silvestre, Marco Pagani, Joanna Smith, Eric Binet, Dolores Mosquera, Hlne Dellucci, Giovanni Liotti.
Website: http://www.emdr-dissociation-metz2015.fr/
November 27th-29th, 2015, International Society for the Study of Trauma and Dissociation's Australia & New Zealand
regional conference, Sydney. Featuring Richard Kluft, MD, Bethany Brand, PhD, Joyanna Silberg, PhD, Warwick Middleton,
MD, Russell Meares, MD, Lynette Danylchuk, PhD, Phil Kinsler, PhD, and the Chief Royal Commissioner of the Australian Royal
Commission into Institutional Responses to Child Sexual Abuse, Justice Peter McClellan.
ESTD Newsletter
ESTD CONTACTS IN YOUR REGION

Country Contact person E-mail
Austria Sonja Laure sonja.laure@nadua.at

Belgium
Manolle Hopchet manhopchet@scarlet.be
Serge Goffinet sergegoffinetpsy@msn.com
Czech Republik Jan Soukup honzasoukup@yahoo.com

Denmark Helle Spindler hellesp@psy.au.dk
Andrew Moskowitz andrew@psy.au.dk
Estonia
Maire Riis maire@lastekriis.ee
Finland Pivi Saarinen paivi.saarinen@traumaterapiasarastus.fi

Elisabeth Helling
elisabeth.helling@gmail.com
France Bernard Gente bernard.gente@gmail.com

Joanne Smith smith@psylegale.com
Isabelle Saillot institut@pierre-janet.com
Bernard Mayer mayer@ietsp.fr
Georgia Manana Sharashidze manana@gamh.org.ge

Germany Bettina Overkamp bettina.overkamp@web.de
Ursula Gast Ursula_Gast@web.de
Greece Niki Nearchou fnearcho@psy.auth.gr

Iceland Sjfn Evertsdottir sjofn@asm.is
Ireland Eileen Noonan eileennoonan165@gmail.com
Susan Cahill cahillsm@eircom.net
Toni Doherty tony.doherty@yahoo.co.uk
Isral Eli Somer somer@research.haifa.ac.il
35
ESTD Newsletter
Italy Fabio Furlani fabio.furlani@infinito.it

Gaia Polloni gaiapolloni@hotmail.com
Costanzo Frau costa8306@libero.it

Latvia Ilze Damberga lze.gerharde@lu.lv

Lithunia
Jonas Mikaliunas
jonas.mikaliunas@gmail.com
Netherlands Marika Engel engel@cphogeweg.nl

Astrid Steenhuisen steenhuisen@cphogeweg.nl
Norway Ellen Jepsen ellen.jepsen@modum-bad.no

Arne Blindheim ar-blind@online.no
Poland
Agnieszka Widera-Wysoczanska
instytut@psychoterapia.wroclaw.pl
Igor Pietkewicz ipietkowicz@swps.edu.pl
Radoslaw Tomalski radektomalski@poczta.onet.pl
Romania Anca Sabau ancavsabau@yahoo.com

Monica Petcana monicapetcana@yahoo.com
Serbia Vesna Bogdanovic vesnabgd@virgilio.it

Slovak Republic Hana Vojtova hanavojtova@gmail.com
Slovenia
Tjasa Stepinsnik tjasa@addictiva.si
Spain Anabel Gonzalez anabel_gonzalezv@hotmail.com

Dolores Mosquera doloresmosquera@gmail.com
Sweden Doris Nilsson doris.nilsson@liu.se

Anna Gerge anna@insidan.se
36
ESTD Newsletter
37
Switzerland Eva Zimmermann eva.zimmermann@bluewin.ch

Jan Gysi jan.gysi@rs-e.ch
Turkey Vedat Sar vsar@ttmail.com

Ukraine Oleh Romanchuk olerom@ukr.net

UK Scotland Colin Howard colin@harrishoward.com
Mike Lloyd mike.lloyd@cwp.nhs.uk
Christopher Findlay christopher.findlay@btinternet.com
European Society for Trauma and Dissociation

E.S.T.D.
1ste Hogeweg 16-a
3701 HK Zeist
The Netherlands
Email: info@estd.org
Website: www.estd.org

Newsletter Volume 4 Number 1 June 2015 English-V1

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Newsletter Volume 4 Number 1 June 2015 English-V1

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EDITORIAL BOARD/

JUNE ISSUE 2015

Volume 4 Number 2, June 2015

EUROPEAN SOCIETY FOR TRAUMA AND DISSOCIATION

Volume 4, Number 2, June 2015

Volume 4, Number 2, June 2015

Though [the self] is a unit, it is not unitary [...]

Volume 4, Number 2, June 2015

LETTER FROM THE PRESIDENT

Dear ESTD members,

Shall we meet? The aim of ESTD is to promote and increase

Volume 4, Number 2, June 2015

of the complexity of dissociative

Volume 4, Number 2, June 2015

Volume 4, Number 2, June 2015

Volume 4, Number 2, June 2015

Volume 4, Number 2, June 2015

Case 2: Derealisation and Depersonalisation

Volume 4, Number 2, June 2015

Case 3: Amnesia and somatoform dissociation

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Case 4: Behavioural changes/ switching

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Case 5: Perpetrator Introjects

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Volume 4 Number 2, June 2015

CROSS THE BRIDGE

By Orit Badouk Epstein Attachment based psychoanalytic psychotherapist, London.

first place, the one who wants to better the quality

Its Monday morning, 8am sharp. Londons roads

As she takes off her shoes, I usually wrap her many

1 My title is taken from a line in the song Burning by War on Drugs

that perhaps will help time slow down. This routine

Volume 4 Number 2, June 2015

and from where no one was able to come back

Professor Leopold is dead, we hate everyone!

Trust! Dont make us laugh; no one is to be trusted.

in a distorted time when the now feels like then,

Volume 4 Number 2, June 2015

tolerating our misgivings and staying in the room

Suzette Boon, Ph.D. was presenting the TADS Q

A CHRONICLE OF THE ESTD

aspects in PTSD, Preliminary study results on

In organizing the event, we had as partners the

Volume 4, Number 2, June 2015

an impact on me even though I am not new to the

day of the Conference.

Volume 4, Number 2, June 2015

student conducting research on adverse childhood

Volume 4, Number 2, June 2015

This is a wonderful new book (September

medical school to look everywhere for ways of

Volume 4, Number 2, June 2015

believes might work, such as a psychotherapist

are comprehensive but perhaps remain a bit

Volume 4, Number 2, June 2015

Volume 4, Number 2, June 2015

In Not My Secret to Keep, we first

fell apart and put herself back together again. She

she notes Now that Im home, I know Im safe, but

Volume 4, Number 2, June 2015

to be processing through talking rather than

to experience the flashback with greater ease.

Volume 4, Number 2, June 2015