3 Hour Workshop

Shame, Negative Therapeutic Reaction, and the Phobia of Feeling Good in the Psychotherapy of Dissociative Identity Disorder

Saturday, March 24
1:30 PM - 5:00 PM
Location: Salon 3

Dissociative Identity Disorder (DID) is a severe childhood onset posttraumatic developmental disorder where the traumatized child is unable to complete development of a core sense of identity, and maintain a stable sense of self across states and contexts. Shame, trauma, posttraumatic stress disorder, and dissociation are strongly linked. Kluft has posited that DID self-states can be conceptualized as manifestations of shame scripts, using Nathanson’s model of the Compass of Shame (COS). Through case discussion, this workshop addresses the utility of this model in DID treatment, particularly with patients who appear stuck in treatment and/or report histories of severe sadistic abuse in childhood, often as part of organized groups involved in child trafficking and other criminal activities, although the model is helpful in DID treatment in general as well.  In sadistic abuse, there is a deliberate attempt to make the child’s every activity, thought, emotion, and experience a source of profound humiliation through coercive control. Sadistic abusers are intensely relationally focused on the child, and the child experiences continually being psychologically invaded and controlled. In psychotherapy, this often manifests as “mind control” transference, an extreme variant of traumatic transference that may lead to treatment stalemate, as the basic activity of psychotherapy – attempts to explore the patient’s thoughts, feelings, and memories - is experienced as profoundly dangerous. This situation is often compounded, as many of these patients also report mistreatment, boundary crossings, boundary violations, and frank abuse in previous mental health treatment, both inpatient and outpatient. These DID patients come to experience positive emotions, particularly in relationship with the therapist, as well as any positive life changes, as a signal that humiliation is imminent. They are deeply phobic of anything positive and feel that their survival depends on destroying it. More classically understood aspects of negative therapeutic reactions - such as not believing one deserves anything positive because of inherent badness - also complicates these dynamics. Apparently malevolent introject self states often act through profound internal humiliation, and frequently drive intractable safety crises based on terror of the positive, especially in relationship to the therapist. These self states can be effectively worked with when reframed as protectors that attempt to gain at least some fragment of control over anticipated mortification, since attachments – and the need for attachment - are experienced as inherently humiliating. The author’s experience is that many problems, apparent stalemates, and treatment impasses can be resolved, if only slowly, by using this conceptual model. 

Learning Objectives:

Richard J. Loewenstein

Medical Director
Sheppard Pratt Health System, Baltimore, MD
Towson, Maryland

Richard J. Loewenstein M.D. is the founder and Medical Director of The Trauma Disorders Program at Sheppard Pratt Health Systems, Baltimore, MD, ranked by U.S. News and World Report as among America’s 10 top psychiatric facilities and ranked by them as among America’s top 1 % of psychiatrists. He is Clinical Professor of Psychiatry at the University of Maryland School of Medicine. The Sheppard Pratt Trauma Disorders Program includes a 22-bed inpatient unit, an outpatient program, a fellowship program, and research, consultation and teaching components. He is the author of numerous papers and book chapters on dissociation, dissociative disorders, and trauma disorders. He is among the authors of all editions of the ISSTD and Dissociation Guidelines for the Treatment of Dissociative Identity Disorder in Adults. He has authored or co-authored standard chapters on diagnosis and treatment of dissociative disorders, including all of the most recent editions of the American Psychiatric Association Textbook, Treatment of Psychiatric Disorders, and Sadock and Sadock’s Comprehensive Textbook of Psychiatry. He is a Fellow of the ISSTD and Distinguished Life Fellow of the American Psychiatric Association. He has received numerous awards including the Lifetime Achievement Award of the International Society for the Study of Trauma and Dissociation. He is co-chair of the American Psychiatric Association (APA) Task Force on the Biopsychosocial Consequences of Childhood Trauma, and is an advisor to the APA DSM 5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group. He is co-investigator and senior advisor to the TOPDD Study.


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Shame, Negative Therapeutic Reaction, and the Phobia of Feeling Good in the Psychotherapy of Dissociative Identity Disorder

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