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Advance Praise for Finding Solid Ground
Finding Solid Ground is easily one of the most helpful books available on the
treatment of clinical dissociation. Based on an extended clinical research study,
this guide is highly recommended for those who seek concrete, evidence-based
guidance in this area. Equally recommended is the associated workbook, which
provides detailed and compassionate information and exercises for clients
struggling with dissociative challenges.
—John Briere, PhD, Professor Emeritus of Psychiatry, Keck School of Medicine,
University of Southern California, author, Treating Risky and Compulsive Behavior
in Trauma Survivors. NY: Guilford (2019)
Finding Solid Ground is an enormous contribution to the field of trauma: the first
book on trauma and dissociation written by authors who are both scholars and
clinicians. They build a solid ground of research evidence to support an
understanding of dissociation combined with practical applications that can be
easily integrated into psychotherapy or serve as a stand-alone treatment. Well
done!
—Janina Fisher, PhD, author of Healing the Fragmented Selves of Trauma
Survivors, Transforming the Living Legacy of Trauma, and The Living Legacy Flip
Chart
Finding Solid Ground provides invaluable resources on the treatment of
dissociative trauma-related disorders. The authors are educators par excellence
who have used their expertise as researchers and clinicians to produce a highly
readable overview of dissociation along with treatment guidelines and exercises.
Their innovative TOP DD studies offer empirical support for their approach. A
major contribution!
—Christine A. Courtois, PhD, ABPP, Licensed Psychologist, Consultant/Trainer,
Author, Co-Editor, The Treatment of Complex Traumatic Stress Disorders (2020)
Finding Solid Ground
Overcoming Obstacles in Trauma Treatment
Foreword—Frank Putnam
Preface
Acknowledgments
FRANK PUTNAM
The year 2020 marks the 40th anniversary of the third edition of the
Diagnostic and Statistical Manual of Mental Disorders, commonly
referred to as “DSM-III” (1980). Unveiled to cries of acclaim and
alarm from the establishment, the DSM-III’s atheoretical, symptom-
driven, multi-axial, descriptive approach to psychiatric diagnosis was
a significant departure from earlier nosology based on outdated
theories of personality reaction formation. The DSM-III’s delineation
of specific symptom constellations, irrespective of theory or etiology,
helped to refocus clinicians on the clients in front of them.
While acute psychological effects of combat were recognized
under labels such as WWI “shell shock” and WWII “combat
fatigue/neurosis,” there was a need for psychiatric diagnoses that
encompassed delayed and/or chronic emotional, cognitive, somatic,
and behavioral responses to past trauma. In the United States this
was, in large measure, a response to a growing awareness of the
serious mental health problems in Vietnam War veterans that often
emerged years after their return from combat. To address this
deficit, the DSM-III introduced the diagnosis of posttraumatic stress
disorder (PTSD) as well as detailing a more accurate clinical profile
of multiple personality disorder, subsequently renamed dissociative
identity disorder (DID) in DSM-IV (1994). The DSM-III’s recognition
of delayed-onset posttraumatic disorders initiated a new field of
research and clinical practice—although it would struggle to gain
legitimacy and resources for years to come.
Forty years later, however, the existence of posttraumatic
disorders is rarely questioned, although a lively debate continues
about subtypes. As additional, noncombat forms of trauma were
studied (e.g., rape, child abuse, first responders, and natural
disasters), it became clear that there is a range of posttraumatic
responses that are complexly influenced by variables such as age,
gender, type(s) and duration of trauma, and relationship to
perpetrator(s), as well as factors such as degree of social support,
synergistic interactions among different types of trauma, and
individual differences. One of the posttraumatic psychological
processes that critically influences clinical presentation and
treatment response is the client’s degree of dissociation. The recent
addition of the diagnosis, PTSD—dissociative subtype in DSM-5, for
example, reflects a growing appreciation of the importance of
dissociation in influencing clinical features of trauma-related
disorders (TRDs).
Despite an initial lack of professional awareness and widespread
skepticism about the existence of dissociative disorders, much has
been learned over the past four decades that demystifies these
conditions. Dissociation is now measured with the same
psychometric precision as depression and anxiety. Epidemiological
studies in general population and clinical samples find that the
dissociative disorders are common psychiatric conditions (see
Chapter 1 of this book). High levels of dissociation are correlated
with refractoriness to standard treatments for a variety of psychiatric
conditions, including PTSD, eating disorders, and borderline
personality disorder.
Pathological dissociation is strongly linked to a history of severe
trauma. This etiological relationship of severe trauma and
subsequently increased levels of dissociation holds for a wide range
of types of trauma across culture and time. Severe, repetitive, often
early-life traumas such as childhood sexual abuse are recognized as
a necessary—but not sufficient—cause of dissociative disorders.
Longitudinal parent–child dyad studies outline a generational
dissociative trajectory in which certain parental deficits in caretaking,
together with early-life trauma, are associated with Type D
attachment in infants. Type D attachment in infancy, in turn, predicts
increased levels of dissociation later in adolescence and early
adulthood, which is associated with emotional dysregulation and
impaired executive functions. Impaired executive functions are linked
to difficulties learning from life experiences, problems controlling
strong emotions, and failure to consolidate a unified sense of self.
Adults with high levels of dissociation are more likely to use harsh
parenting tactics associated with having Type D offspring. Thus, far
more than for many psychiatric disorders, there is an empirically
supported etiology and developmental theory for how early trauma
and impaired caregiving produce pathological dissociation and
identity fragmentation. Few other psychiatric disorders can marshal
equivalent levels of evidence for their putative etiologies and
developmental trajectories.
Research on the underlying neurobiology of TRDs in general and
dissociative disorders in particular has been remarkably productive,
despite low levels of funding. Brain imaging studies find activation
patterns that differentiate classic PTSD hyperarousal from
dissociative responses to traumatic reminders (see Chapter 3 of this
book). Multiple studies using an array of imaging technologies detect
reliable brain state differences associated with the identity states of
individual DID subjects. Research with a variety of types of trauma
finds that experimental activation of dissociative responses to recall
of past trauma is associated with decreased autonomic arousal,
especially decreased heart rate. This is consistent with theories that
analogize human dissociative reactions to the “freezing” behaviors
seen in young animals such as fawns and baby rabbits in response
to predators.
Posttraumatic effects on memory, cognitive associations, and
logical reasoning are now well documented for different forms of
trauma. Emotional dysregulation manifest by rapid shifts in affect
and mental state produces disruptions in an individual’s continuous
sense of self. Longitudinal and cross-sectional studies find that
severe early trauma alters the long-term development of adrenal
and gonadal hormonal systems as well as acute responses to
stressors. Prepubertal sexual abuse, for example, accelerates the
onset of puberty in females. Even a victim’s genes may be altered by
trauma through epigenetic mechanisms such as stress-induced DNA
methylation. These trauma-induced genetic changes may be
transmitted to future generations, providing a genetic contribution to
the tragic cycles of family violence.
Progress in the treatment and prevention of TRDs, especially the
dissociative disorders, has lagged behind developmental, cognitive,
and neurobiological scientific advances. Treatments for classic PTSD
that have been proven by randomized clinical trials (RCTs) exist,
including psychotherapies, exposure and desensitization models, and
pharmacotherapies. Until recently, however, treatment models for
DID and other dissociative disorders were, at best, limited to the
descriptive case series level, usually reflecting the experience of a
single clinician’s practice.
By systematically following the progress of hundreds of
independent client–therapist dyads with longitudinal evaluations, the
Treatment of Patients with Dissociative Disorders (TOP DD) studies
have significantly advanced our therapeutic knowledge of the
dissociative disorders. While short of gold-standard RCTs, the TOP
DD Network study findings are based on repeated, independent
client and therapist assessments with standard self- and therapist-
report measures. After viewing a set of safety-oriented videos, TOP
DD Network clients scoring in the higher ranges on dissociation
measures (previously associated with clinical failure) showed
clinically relevant improvements on behaviors such as nonsuicidal
self-injury, number of hospitalizations, and degree of emotional and
impulse control. In contrast to prior studies, clients with higher levels
of dissociation showed faster rates of improvement than subjects
with lower (but still abnormal) levels of dissociation, indicting a
specificity of TOP DD therapeutic approaches for highly dissociative
clients.
Finding Solid Ground: Overcoming Obstacles in Trauma Treatment
and the accompanying workbook distill the lessons of the TOP DD
studies into a coherent therapeutic approach. Because dissociative
clients are likely to read this text, it is sprinkled with motivational
encouragement to practice the TOP DD-tested interventions. In
addition to the TOP DD insights, the authors add their own wealth of
therapeutic expertise from years of working with patients with
dissociative TRDs. As individuals, they have all achieved recognition
for their contributions to the field. Together, the authors present an
inclusive and comprehensive therapeutic approach to dissociative
TRDs. While more remains to be learned, this volume and workbook
translate 40 years of progress into a new, evidence-informed,
generalizable approach to the treatment of dissociative TRDs
surpassing many of the limitations inherent in earlier individual
clinician-based case series.
PREFACE
Ula, 246
Unitarians, 25, 26
Usury, 45
Vaghas, Sád, 24
Valley of Mina, see “Mina”
Viands, forbidden, 32, 33
Victims, 56, 57, 58
Vitr, 36
Yazid, 71
Yemen, 71, 123, 165
Youm-ul-Arafat, Chapters IX., X., XI., Part II.
Youm-ul-Nahre, Chapter XII., Part II.
Youm-ul-Tarvih, Chapter VII., Part II.
Transcriber’s Note
Clear printer’s errors have been corrected by the transcriber; as far as possible, however,
original spelling, punctuation, and accented characters have been retained. All changes
listed in the errata have also been made.
In the printed book, images occupied whole pages. In this file, some images have been
moved from their original positions to avoid breaking paragraphs.
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