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Video: Bessel van der Kolk

The way psychiatry deals with the effects and clients with often chronic child abuse should and must change as in diagnosis and in treatment.

Why screen - DES - for dissociative problems.

Unfortunately, it is not yet a good practice in psychiatry to screen for dissociative problems. Still, and that may now be known, having dissociative problems correlates with having experienced traumatic events. Another correlation is that dissociative problems correlate with the later development of PTSD. The degree or severity of the dissociative problems can also be an indication of the age of the client on whom the abuse started. Young children under the age of about 6 use dissociation primarily as a way to cope with nasty or traumatic experiences, as if 

it were able to protect itself against the very disturbing emotions by splitting off the event in his / her mind or mind. That is why it should become a good practice to use the DES checklist or other screening methods, among other things. The mental health care will also have to develop questionnaires of dissociative complaints specially adapted for young children or young adolescents. The severity and form of the dissociative symptoms then correlates with the severity of child abuse and age of onset abuse / abuse.

"Psychiatry often subtly say: you are sick, disturbed, having a brain abnormality instead of you are a victim and we understand your problems derived from childabuse"

"In the past and present I  thought and acted out of inability, I was in pain, I deny that pain, I had no close bond with alcoholic sadistic pedophile father and mother, no confidence, no bond, no inner security, I dissociated, I numb my feelings, the inability to feel, to be safe, is the guiding principle in my life, I was not allowed to be a child who wanted and wished, Gentleness and trust is the way, comfort and cry, mourn what was never there and reach for loving become poor and the person I am in confidence, reach out for an inner bond with myself and the child, orphaned and abandoned to embrace and see that you did not deserve it and how I should let go of what was not and now I am open to inner change and a meaningful life."

For many the above was not their experience"

       A relationship of trust with social workers is of vital importance to them with early childhood traumatization and a prerequisite. Without a good bond and trust, in which an effort should be made to teach the client to express his feelings, to learn to give words and to pay attention to someone's needs and ignored feelings and to deal with peace and calm there, therapy has no or little progress. It takes time to teach the client to express what it feels and to give words to his inner self. It requires faith in recovery and giving back one's ability to learn to influence their environment and wishes. Unfortunately, especially in chronic mental mental health care, the tendency is to be distant and directive / pedagogical, to deal with these clients in an advisory capacity and to learn to ignore pur sec behavior. Yet it is and must be assumed that, in essence the clients core is healthy and that should be the focus and not the assumption that one is inherently ill. As a result, there is no bond - something that many in psychiatry regard as undesirable and is soon afraid of created dependency - and as soon as the client is open and experiences an active and trusted bond, the counselor quickly changes the idea that there is dependence and therefore trust has grown.

       Many workers and especially nurses call this therapy or work for specialists and prefer to keep the boat off visually and mentally to develop a different and healthier attitude for the experienced traumas and the desomatization of stress and tension that is maintained by poor emotional coping or acting. People often dare not to be real or to show or express feelings and to expect that other behavior is required and that the worker thinks this is desirable from the client's solution. The point is that clients come into contact with their real feelings, learn to give words to them and that we understand how these people tend to ignore, numb and despise their desires and feelings. Therapy or help is not just analyzing, wanting to understand and rationalize, but a path from the inside to the outside, learning to trust feelings and daring to feel and mentalizing experienced traumas in a different way. The biggest cause in behavioral modeling and therefore the unimportant consideration of inner motives or feelings, memories, needs is behavioral theory. With pedagogical methods you cannot get there and only learn an attitude. The core must be to learn to express feelings with confidence and experience that one can be oneself, even if it hurts and feels sad. It is to teach the client to comfort themselves and to understand.

"Dissociative disorders have hardly the attention as a diagnostic criteria in the psychiatry"

Dissociative disorders, such as depersonalization, derealization (distinct from psychosis), dissociative fuque, DID and some others hardly have as a diagnostic component the attention of clinicians and researchers, such as psychiatrists and psychologists. This while it is fundamental part of traumatization or (complex)PTSD. How the consciousness can lead to dissociation is hardly part of scientific or neurological research and more is known about the phenomenon "forgetting" or unconscious mind than about dissociation. Yet Piere Janet has formed a good theory about trauma and dissociation, which is hardly known. Forgetting and dissociation are both processes that we can see as emotion regulation or how consciousness does not come to processing the many traumas.

regulation or how conscious mind can not process the trauma in such a way that it is helpful for the client. There is hardly any  scientific interest in a neurological explanation at all. Yet forgetting and being unconscious and dissociation work hand in hand to survive. Many life in their heads, feeling numbed efied emotionally and the unconscious traumas express themselves through a dissociative consciousness in the person. DID is often seen as a result of an imaginative personality and often as part of schizophrenia, if they also hear voices (could be that of a identity) or psychosis. There are believers and not believers. But one really does not come to an investigation of dissociative processes.

Every family has its own truth

Within a family as a group the groups own truth plays a important role, which actually serves in favor of the family and how it should deal with domestic problems. A family therefore has a group truth towards other important others and how it should continue as a family. Social perception and how problems are expressed externally is actually easy to explain with how group members act and deal with family problems and thus support and reinforce its members. (sometimes keep members sick) That group processes are occurring within a family, in which the victim is stigmatized and held victim by means of shame and blame about what happened and silencing the victim for years is seen through the family logic not that strange but certainly for others. This way victims often know how they sometimes had to tolerate something for years and how they were played out and used emotionally by these group processes that caused the abuse. The family is also a cornerstone with how one thinks collectively about certain problems and needs. Children who are abused or maltreated as part of a family are often emotionally isolated and imposed in such a way that their story abuse

may lead to the breaking up of the family and thus threatening the future for the family. In my case it meant: "the abuse must stay within the family, nobody must know, if you do not stop that nonsense, then your brother and sister must be put in a home, father must go to prison (who will care for you and us, etc), I'm going to put everyone against you, if you're telling others, mother will hang herself" The mental health care often treats the individual and sees it as a personal story, but it also necessary how the behavior of the victim is explained in terms of the context of the family and its family logic. Power games - however subtle - and thus emotional blackmail is not just what happens in a family, but in fact all the more happens in closed communities and isolated cultures and thus therefore the greater the importance of the group culture.  The more isolated the victims and the family the more a person can be victimized. We often do not realize how group processes and expectations play an even greater role in decision-making and that expectations about behavior and ideas of its members. Actually, nobody is really free. 

Victim role development; the power of internal blame and shame

If someone does not already have a victim role, we as a therapist or mental healthcare worker must prevent someone from developing it. But to understand what really a victim role is, it not of a complaining / pitiful attitude, but more that a survivor has allowed to be abused / used / bullyed or emotionally used or against his or her will have sex or just agrees with something against his/ her feelings. Also allowing his own children to be beaten or abused belongs to this. Bystanders often find it strange that a male victim is alowing it and therefore is not seen as a man. But that has nothing to do with it. Men have more difficulty recognizing that they were abused as a child and often they are aware of it later in life. Often due to shame, ignoring their feelings and hurt, it does seem manly to acknowledge and accept that they were abused. How verbally strong they might appear to be. We do not expect a male client to have doubts about his sexual orientation as a confusing consequence of the abuse. A inexpert or outsider might think that their client is ashamed to be homosexual. Men experience the consequences emotionally as a sign of weakness. Their confusion emotionally is of a different order than women or it is assumed that they behave in the same way, preferably snottering with a tissue provided by the counselor. It is the problem of how boys are socialized and what we expect from them. We expect decisiveness from men and a male victim can become entangled with it emotionally. There is so much misunderstanding about male victims and

many do not dare to speak out and partly I give them emotionally seen right. More than women they are afraid to be seen as a crazy person or a confused one. Trauma therapy is typically a female point of view, especially concerning the consequences and ways of treatment, not that I blame those helping women or female victims. How often I have not heard "come on ,be strong, go for it." It is time that we test our perception of what we expect from problems and behavior of male victims, as male victims see themselves or the way they experience their abuse. Too often we use our own perceptions of what is typically male and what we expect from males. It does not matter if the therapist or social worker is a man or woman. It is important to start seeing and understanding their emotional confusion. Let's face it and just acknowledge it "when we think of a victim, we think or look at it from a female point of view and thus a female victim, especially how boys should experience it in the eyes of others." This might also be the case with some experts and the vice squad. Perhaps we are surprised to hear of see the confusion of a male victim as a bystander and it might  surprise us. Perhaps I should wear a skirt the next time I talk to a counselor, but maybe they think I was already a gay person and not a consequence of my confusion. As a boy of 4 I often thought, "Does daddy do that because he thinks I'm a girl .." I'm so  confused by the frequent abuse that I do not know how to think about it, let alone I am not so pleased about what aid workers know and understand from male victims. 

Abused male clients

Men who have been abused as children tend to minimize their experiences or worse because they are afraid of being fooled therefore are reluctant to talk about their experiences. They experience far less than women than they may be victims and interpret the consequences as a sign of weakness. This is mainly due to the image of many male and female care providers with how men should deal with the problems. Their pain and sadness as well as fear are experienced by many male victims as not being manly. In most cases men who have been abused by a woman it is seen as less harmful. But that is not in accordance with how they experience it. A confusion that is more emotional and different than in women. It does not matter whether they have been abused by a woman or a man. Often we do

not ask for it or do not come up with it at all. Some get confused about their decisiveness or their perception about themselves as a victim, get doubts about their sexual orientation, think they should be strong, etc. Therefor it is important to break the imaginary band between the consequences and the male perception of it. Further more to recognize this wrong or incorrect view.  Many men who are abused by a woman do not ponder about their problems or make the abuse known for fear of being declared "crazy" or seen as a sissy. It does not have much to do with shame, many do not often feel and experience that they are victims. Male victims are more afraid not to be believed and in part I agree with them. That's why I think that a counselor should address their feelings as they felt when they were abused and not how you think it should be.

Emotional neglect & attachment

In many cases of long term child abuse, emotional neglect also plays a major role. In some families where the abuse and or maltreatment can take place for years, emotional neglect also plays a role. The parents and or perpetrators just simply do not care about the child. Emotional neglect is something other than superficial neglect when it comes to clothing or food. A child whether it is baby or toddler, does everything to be loved. Children often see themselves as the centre or cause of marital quarrels or domestic violence, but also the psychiatric problems of parents who are perpetrators. It thinks and wants to do everything to get some love. People who do not know what it is to grow up loveless, full of vengeance, reproach, etc. do not know what it is.

If your "core personality" is something you experience as bad or unloved, then it stands in the way of healing from traumatic experiences. A core personality who has not experienced love - what Freud would explain about as a neurotic character development - is susceptible to incorporate the weird thoughts or attitudes and ways of thinking of perpetrators or abusive parents. It makes it own because it feels guilty and not loved and thus susceptible. It actually very simple. "If you are only used to brown beans, then another meal is just something you can think of or fantasize about, but never experience." Clinicians might not understand this, how a core  feeling of being worthless and unloved  can be the basis for many psychiatric problems, especially if it goes hand in hand with abuse, shame, betrayal, punishment.

A better view of personality disorders;

is it borderline or Complex PTSD

If we look at borderline-, avoiding- and anti-social personality disorders, many of them report child abuse. They must survive emotionally and cognitively against against a context of often longterm abuse. Their behavior is actually no more than bad coping and thus emotion regulation. The wrong starting point that many clinicians make is to think that this has certain external characteristics and people often lack a better emotional and also cognitive understanding of their behavior. Often they are people whose behavior is triggered by the many unconscious traumatic memories. Their behavior is reminiscent of a pinball machine, whose consciousness, the ball is always flipping against all sorts of painful memories and therefore does not seem tho have a stable personality. They seem erratic and that is partly due to this unconscious triggering of the many memories - often these triggers do not reach the higher brain areas or consciousness - the emotions and thoughts and thus interpretation of their many painful memories. What psychologists and psychiatrists do not take very much into account is how the Limbic system that regulates behavior and emotions, more specifically determines how higher areas such

as thinking, awareness, planning and especially control determines. It has always been preferable to direct research more towards controlling higher areas, functions that determine thinking, intelligence and more and which seems according to new neurological insights is a wrong assumption. It is so obvious somehow and we should actually see their behavior or responses as children who do not know how to deal with their painful thoughts or unconscious memories. We need to think more about how an adults behavior is shaped and determined by being helpless in many situations  and how these experiences of being helpless and their traumatic suppressed memories motivate them and interpret situations. Since everyone has a different life history that also means that synaptic brain brain paths that are often used, leads to adjustments in brain structures. They are people who have never really solved their painful memories emotionally and cognitively. They try to survive and forget. What we often do not understand is how they come to behavior and what motivates them to do so.

"How treatment is determined by the context of traumatization

Where victims of traumatization suffer from and how the consequences are and therefore the framework of therapy should be depends very much on the method of traumatization. For example, political prisoners and those who have been tortured have other problems (political persecution by agencies and intelligence services) than those who are victims of child abuse. War victims also have a different context. A politically persecuted or tortured victim may have the idea that although he is safe now someone behind a tree is shadowing and chasing him.

Then you might see as a paranoid trait, especially when psychoses are involved. Some perpetrators of child abuse want to keep a watchful eye on the child, curious and anxious with whom it is talking with and might tell others about being molested. The child is therefore being watched, sometimes isolated, to prevent being exposed. Again every trauma has a context within which the complaints and problems and adjustment disorders must be understood.

Create a caring/ comforting ego

Many victims tend to regulate, suppress or ignore their feelings of sadness, fear and anger. You could call this emotion regulation. Child abuse often go hand in hand with neglect or worse punishment for rightful resistance or anger. It is important that victims learn to comfort themselves and to 

feel their feelings of sadness and anger. One tries to forget or ignore their memories. This can result in a non-assertive and non-caring ego. One is surviving. Shame for the events or abuse can also lead to be ashamed of almost everything of her/ himself.

Creating trust

Attachment problems can lead to behavior which look symptomatic for the person when untreated. It is a pity that many health workers opt for an emotionally distant professional attitude that is considered a professional attitude. In exaggerated form a cool or intellectual relationship, in which one prevents the client from experiencing a bond. F.i. the the relationship of the therapist in a pure psycho analysis. The reason for this is fear that the client becomes to attached or dependent. Just experiencing a positive and warm relationship can be healing. Yet many prefer a professional and more intellectual distant or purely cognitive attitude. Attachment problems and the resulting interaction of the client must be distinguished from behavior associated with a personality disorder. Many do not trust men or women in contact - which is logical in view of their experiences of abuse and often more if the person holds a dominant position or (non-verbally). Like a therapist or nurse. Many

abused people think "what does he want from me ..." with some distrust, many do not  tolerate to be close. This behavior of avoiding essential emotional contact, which is emotionally threatening to the client, sometimes also has to be seen as a response fearing to be involved in a embarrassing situation again. I have often noticed that many professionals think that their profession automatically means that they can be trusted, without realizing how often they think working on a safe emotional relationship is important. The rejecting or avoiding attitude may have to do with an attachment problem, but it must also be seen as a protection against situations that can be experienced as embarrassing. Attachment problems can lead to behavior that becomes characteristic in adulthood. But as therapist S. Boon describes, someone who is anxious attached can be save attached by therapy

Working towards a more positive self-image/ future

In addition to treating the trauma(s), it is also important to name and strengthen the client's self-confidence and positive qualities. Many victims often have low self-esteem and little self-confidence. This is partly due to stigmatization by perpetrators and the environment. But shame for themselves, ignoring anger, fear, grief and shame and who they are makes them often doubt themselves. Experiencing positive qualities and how life can also be, can form a good counterbalance against the negative experiences. The contact between client and therapist can give the client a better impression, through role-modeling, of how a parent-mother / father role should actually be. It should be noted that the therapist himself needs to know well how his/ her own

thoughts about upbringing or sexuality are themselves formed through socialization. The interaction between client and therapist can be interpreted on the basis of psychodynamic concepts such as transference, counter transference, acting-out etc and thus create a better understanding of the cognition of the client. The importance of strengthening and emphasizing positive qualities and powers in the client itself is also important, because many have come to think in and believe in fate or what they have experienced and thus the consequences should be their life path, they have internalized the perpetrators believe of points of view and often deny them self from a more pleasant life.

"Structured interview; child abuse"

As clinicians, we all know how important it is to form a good diagnosis on the basis of  complaints. An experienced clinician familiar with childhood traumas will also agree that it is important to have a good understanding of the experienced youth traumas, in other words, when did it start, how long did it last, how did the child defend or protect it self, etc. But also the context ( other forms of abuse), who were the perpetrators, what did the child do to stop or denounce the abuse, was he/she believed when it told others, how did the environment respond, there are indications (hospital admissions, behavior, school performance, etc) ) Only an experienced clinician will distinguish between personality problems and complex PTSD or  coping problems. We must always keep in mind, however, that it is necessary to ask and be aware of other symptoms thus addressing other disorders. Taking time for this anamnesis perhaps different conversations, because at this stage it is stressful for the client, besides rust has to grow and therefore leads to revelations. Also there may be a lot of forgotten. It is so obvious that the periods in life which have more difficulty remembering it or seems to be forgotten, it is more likely that that is the period in which happened the most of the trauma. Questionnaires should not be used in a cookbook-like manner. During these spread conversations also gives a better insight into the many problems that are sometimes not mentioned at the beginning. It is therefore the time to occasionally make clear what the therapy will look like. In this phase, other problems that are important such as finances, sleep and housing / safety must also be considered.

The diagnosis rolls itself out of these conversations. Finally, if you are smart as a therapist you need to invite the parent also who likes to complain and deny, how bad or negative your client was as a child, also for a conversation. In that case, you are mainly concerned with his / her negative statements about your client. You confirm "yes I can imagine that as a parent if your child reacted like that" Then you ask about the behavior, how difficult he / she was and ten against one you have a clear picture of the consequences. You should not confront the perpetrators, because they deny in all colars and thus lie as if it were printed. Feed and praise a little bit. Not too much, because then it is too thick on top. Questions such as "your child must have been like that at a young age, or not, that must have been very difficult for you .." and then from the mouth of the complain(er) star all facts are thus presented and so you know as a therapist how early the abuse has started. Questions such as "he / she will not have done his / her best at school or anyway ..", which in turn leads to clues. Drawing a line with years, behaviors and facts presented by the client makes it very clear. In experts often call trauma problems a "cesspool", which evokes thoughts of hopeless misery that only leads to more complaints. It is counter-intuitive to reinforce resilience in the right way, combat victim role development and extinguish the chains of anxiety around the trauma that can lead to life instead of surviving with all sorts of complaints, despair and experiencing the past every day. now.

Separate (C)PTSD units in psychiatric clinics

Here in the province we have separate units in a local clinic for depression and psychosis. It is time to pay attention to the prevalence of (chronic) childabuse among 50-70% of all clients with various consequences that there shoud be separate emotionally safe units for those who often need temporary care during a crisis. We can name it (C)PTSD wards. This may concern women who have to deal with domestic violence, rape and psychiatric complaints, but also clients who can be referred by a therapist who has embarked on a treatment course with them. It is important that the head is a psychologist who is familiar with the background and consequences of child abuse and thus trauma. Upon admission, a neurological examination must also take place as a medical one. Many victims cut themselves and many often have an eating disorder or addiction. Medical research can also bring this to light. The supervising psychologist maintains contact with

referrers, therapists and will try as much as possible to continue the treatment initiated by the referrers as quickly as possible. Nurses are all trained in recognizing behavior and expressions of signs of early childhood traumatization. It is important to take into account:

- suicide hazard
- psychosis (is it DID / consequence?)
- addiction
- eating disorders
- auto mutilation
- real safety and protection

As a manager, she provides training / education and an emotionally safe living environment for the patients, in which it is common to be able to express what trauma is doing to you and how the resilience of the client can be strengthened.

Chairs at universities

It is time that chairs would be available at universities, in which developmental psychology, neurology, evidence-based treatment, signaling childabuse and impact on personal development and of course clinical psychology and last but not least epigenetics are combined. Perhaps I have forgotten a few other fields, but if we connect these chairs in relation other universities, more can also be exchanged and psychologists, psychiatrists and clinicians and many other academics can be better equipped. These chairs also have a task in guiding research and recommendation

to policymakers, after all, child abuse in general terms trauma and the consequences is something that, in view of the many traumas and threats in the world, will continue to have an impact. Developmental psychology must also clarify how the impact is on the healthy development as a result of negative environmental factors,  - and therefore also epigenetics -  which in turn can be a supplement to clinical psychology. Perhaps we must collectively overcome the fear, that we are all vulnerable and enough adversity can make us ill.

Individual therapy:

I can be short and long, why group therapy and therapeutic communities are not done. Do not start with it. For clients who are in group therapy, a therapist can simply not overlook the many individual defenses of the participants, reactions of disbelief, dissociation and other mechanisms that are negative to the speaker and group members. It is already a difficult task for a therapist to treat someone with a severe.

dissociation and thus psychological mechanisms. Finally, if you are not supported by a team and you treat victims on your own, sooner or later you will go down emotionally  and also your client. Psychodynamics offers excellent explanatory models for transfer/ countertransference and other mechanisms that play a role in trauma treatment