CHRONIC TRAUMATISATION AND DISSOCIATION IN NORWAY
By Arne Blindheim and Ellen K. K. Jepsen, ESTD representatives for Norway
The attention and knowledge concerning chronic traumatisation and dissociation have increased rapidly in Norway. Several courses every year are well attended in different places in Norway. Several trauma units, both outpatient and inpatient, have been developed, and many books and articles have been written. Still, as in many other countries, we have professionals who deny the impact of child abuse and neglect on mental health, and also deny the existence of dissociation.
The development over recent years is to a large extent due to the interest and engagement of professionals at different locations around the country. We will here describe some of the central aspects of this history. It is difficult to create a comprehensive overview of all those who have contributed to this effort, so regrettably some may feel overlooked, but we hope it will not be too many. Norway is a large country with few people and long distances. The development of the trauma field therefore has followed several historical lines from different professional environments. One of the pioneers who started to take an interest in, and work with, how early relationships impact children, was a psychologist working in Bergen, named Magne Raundalen. Already in the late sixties, he had TV programs about the way in which early relationships have an important impact on children’s mental health. Raundalen has been and is still doing an amazing job working with the subject of children’s upbringing in relation to abuse and neglect in Norway, as well as with children exposed to war in other countries. His engagement has been on a high political level, and he has influenced the opinions of politicians and other authorities in the society towards children. He later became astaff member of the Center for Crisis Psychology, founded in 1988 by Atle Dyregrov and Jacob Inge Kristoffersen. This centre grew to become one of the leading environments in Norway with regard to different forms of trauma. In 1993, Dyregrov wrote an article about EMDR. He introduced the method to Scandinavia, and arranged one of the first EMDR trainings in Europe. The courses in trauma that he and the centre arranged with leading capacities on trauma during the nineties became, for many professionals, an eye-opener to chronic trauma and dissociation.
As far as we know, the first people in Norway who became interested in the field of chronic trauma and dissociation (at least in modern times), were some professionals in Stavanger in Southwestern Norway. This happened by coincidence when colleagues on a psychiatric unit in 1992 (Jan Haslerud, Tor Bøe, Helge Knutsen, and Elisabeth Dramsdal) searched for literature on sexual abuse. They found an article by Suzette Boon and Nel Draijer that captured their interest. The interest spread to other dissociation specialists, and they invited Colin Ross to come to an annual conference on schizophrenia. After that, several other international leaders were invited to Stavanger. As one could expect, these colleagues met a considerable amount of skepticism both from the schizophrenia field and from the “false memory crowd”.
Another professional who became interested in this field early on was clinical psychologist Karl Yngvar Dale. He has worked with trauma and dissociation since the early nineties, as both a clinician and a researcher. He has applied and refined the hypnotherapeutic approach to the treatment of individuals with DID and other dissociative disorders. One of these, a patient with a combination of schizophrenia and DID, was presented in a case study published in 1996. Dale moved on to launch a comprehensive study into the clinical and psychophysiological characteristics of DID, the results of which were outlined in his doctoral thesis from 2008, “Out of Mind – Out of Sight”. In collaboration with an Iranian scholar, Habib Nobakht, Dale has recently performed a series of studies into various concomitant factors in the trauma/dissociation relationship. Two of these are already published – focusing on self-harm and religiosity, respectively, and two are submitted – focusing on near-death/mysticism and sleep disruptions, respectively.
Around 1995 in Oslo, a small group of five psychologists, Trine Anstorp, Kirsten Benum, Eva Axelsen, Toril Ursin Boe, Wenche Fjeldstad, and one psychiatrist Marianne Jakobsen, started to meet for peer supervision and support. Even as rather experienced therapists at that time, they were challenged by certain symptoms presented by clients that they had never seen before, today known as symptoms of complex trauma and severe dissociation. They decided to visit trauma conferences abroad and got to know colleagues who helped them understand how to treat traumatised individuals and support their healing process. A few years later “The Trauma Forum” counted 13 dedicated trauma therapists. However, they wanted to get more professionals interested in this, and therefore they decided to organise an educational program on a much larger scale. Professionals from the American, Dutch, and English trauma fields were invited to Oslo for presentations. So, ten years after the small colleague group had started to meet, around 150 therapists from all over Norway regularly attended a two-year trauma-focused course. Their aim was to strengthen the understanding and treatment of severe traumatization and make trauma knowledge and practice a part of ordinary health practice.
As the prevalence of complex trauma in psychiatric populations is so high, healthcare workers needed more competence in the field. Therefore, ten years ago the organization of trauma educational programs was taken over by the newly established Regional Centre of Violence, Trauma and Suicide Prevention, located in Oslo and meant to serve the Eastern region of Norway (RVTS East). Since 2007, five such centres have been created and financed by the Norwegian Directorate of Health. Today several thousand specialized healthcare workers have attended intensive trauma training as wellas workshops and supervision. Both out- and inpatient services have been very enthusiastic about this program, especially encouraging leaders to participate in it.
Their slogan is “Building competence involves change in both the organisation of healthcare systems and clinical practice”. They have been careful to develop a trauma perspective in which therapists of many theoretical backgrounds feel comfortable. They all share the common language of phase-oriented treatment.
During the nineties, there was an increased interest in different forms of trauma treatment at the Center for Crisis Psychology. The interest in chronic trauma and dissociation grew from there, and Arne Blindheim, who for several years had educated himself in this field, started to teach on this topic in different settings. In 2006, he began to arrange courses and trainings with Ellert Nijenhuis and Joy Silberg in Bergen. For the first trainings with Nijenhuis, more than 100 people wanted to participate, and admissions had to end more than two months before the courses began! In following years, he organised trainings with other leaders in the field, such as Janina Fisher, Andrew Moskowitz, and Stephen Porges. Since 2009, Nijenhuis has given several 8-day basic trainings, and also several 8-day advanced trainings, and a Masterclass in Bergen. The participants from these and Joy Silberg’s trainings have come from all over Norway, as well as Sweden, Denmark, Holland, England, Scotland, and Romania. Blindheim also gives trainings and workshops, presentations and supervisions for professionals at several places in Norway. He will now in near future, together with collegue Marianne Straume be part of an eduacational program held by Nijenhuis with the goal of leading a basic 8-day courses themselves from spring 2019. Nijenhuis will still be teaching the advanced trainings in Bergen. The Modum Bad Psychiatric Clinic is in a rural district 90 km from Oslo. Since 1998, this clinic has offered a specialised inpatient treatment program for childhood sexual abuse survivors from all over Norway, with increasing awareness of dissociation. Nijenhuis came to train all staff involved with patients (as well as some clinicians from other places) from 2005 to 2008. Suzette Boon has visited Modum Bad regularly since 2007 for trainings in therapeutic as well as diagnostic skills.
A research project consisting of a naturalistic study of patients admitted to the trauma groups between 2001 and 2007 was initiated with the aim of studying changes in symptom intensity (including dissociation) and relational functioning. The assessment of dissociation with the use of the Norwegian version of SCID-D-R has been included more and more frequently in the clinical context. Thus, it was possible to compare how highly dissociative patients (with DSM-IV DDNOS-1 and DID) responded to treatment compared to child sexual abuse survivors without these conditions. This study resulted in a PhD thesis titled “Inpatient treatment of early sexually abused adults: Dissociation and outcome”, that was defended at Oslo University in 2014 by researcher Ellen K. K. Jepsen. Results from the study showed that patients with severe dissociative disorders (DDNOS and DID) had significantly higher levels of PTSD, depressive, general psychiatric and dissociative symptoms, as well as poorer interpersonal functioning than chronically traumatised individuals without a severe dissociative disorder. Furthermore, highly dissociative patients showed less improvement following treatment than patients without these conditions. This led the team to create a program for a more homogeneous diagnostic patient group with DID and DSM-IV DDNOS-1/DSM-5 OSDD, to make it possible to address dissociation more specifically in group sessions. The pre-treatment assessment of dissociative disorders has therefore become an important part of the clinic’s work.
The Trauma Unit at Modum Bad inpatient clinic now has four treatment groups (of eight patients) for patients with early relational trauma and complex PTSD. The four programs have a common theoretical foundation and offer phase-oriented treatment, with a main focus on stabilisation, but also exposure if and to the degree the patient can tolerate it. Besides the group for highly dissociativepatients, another group includes complex PTSD patients with indications of severe dissociation but not clear diagnoses of a complex dissociative disorder (yet?), and the other two groups include complex PTSD patients. The two latter groups are involved in a newly started research project by researcher Peter Sele. This project is a planned RCT study comparing three suggested treatments for complex post-traumatic stress disorder in an inpatient treatment setting; a) exposure, b) stabilisation, and c) phase-oriented treatment (stabilisation followed by exposure). The study sample consists of patients with complex PTSD following childhood trauma (sexual abuse, violence and neglect). Patients with suspected dissociative disorders involving fragmented identity states and/or severe daily life amnesia are excluded from the sample. The two main study aims are: 1) to learn more about the applicability of the three treatment options for this patient group; and 2) to gain knowledge about the process of symptom change in the treatment of complex PTSD. Symptoms (e.g., PTSD, complex PTSD, and dissociation) and theoretically derived change processes will be monitored by weekly repeated measurement throughout treatment.
The number of patients referred to the Trauma Unit is far above the capacity of the unit, resulting in very long waiting lists. Patients wait around 1,5 years to be admitted, which reflects the extreme needs of chronically traumatised patients. More and more patients with dissociative problems are now referred to Modum Bad, and more and more clinicians indicate in their referral letter that the patient has dissociative problems. This indicates that there is much more attention being paid to dissociation among clinicians than 10 or 15 years ago.
In 2008, an outpatient trauma clinic, “Traumepoliklinikken Modum Bad in Oslo”, opened. It is now an approved part of the official psychiatric services as well as part of Modum Bad. They work exclusively with complex trauma, both assessment and treatment. They work mostly with groups, but also offer individual treatment. They have about 150 assessments, 40 individual therapies and 18 groups with about 9 participants in each group each year. Since 2008, the outpatient clinic has grown from 5 to 13 therapists. The focus has been on understanding complex trauma problems, especially divided into two main groups with complex PTSD and dissociative disorders. They offer group therapy to both patient groups, and it is mainly patients with dissociative disorders that are seen individually.
The group programs focus on stabilisation. One program is for complex PTSD patients and uses the book “Tilbake til nåtiden” (“Back to the present”). A program for dissociative patients uses a Norwegian translation of the book “Coping with trauma-related disorders” by Boon, Steele, and Van der Hart, as well as self-made video recordings.
The clinic offers group courses in stabilisation for patients with substance abuse. It also offers treatment in sensorimotor psychotherapy groups and mindfulness groups (based on the book “Mindfulness and compassion” by Salvesen and Wästlund), circle of security groups for traumatised parents, and groups for patients with refugee backgrounds. Brand new is the development of traumasensitive yoga.
In 2014, a randomised study of the treatment effects of stabilisation in the two different patient groups was started. Data collection will end in late 2018/early 2019. About 150 patients are included in the study of the treatment effects on complex PTSD, and approximately 50 are involved in research on the treatment effects on dissociative disorders. Psychologist Harald Bækkelund is heading the research in the context of his PhD.
In 2016/17, Ingunn Holbæk started a qualitative research project regarding patients with newly diagnosed dissociative disorders. The goal is to investigate how dissociative symptoms are experienced from the inside. What is it that inhibits and promotes a good treatment process, and how can mental health workers contribute to this?
The trauma clinic now wants to turn its focus a little more towards phase 2 work within both patient categories. They are also working on the development of new groups, as well as tailoring help that promotes collaboration among and improves life-quality or dissociative patients.
The staff of the outpatient trauma clinic teaches and guides professionals in specialist health services, municipal health services, child welfare services, emergency centres, and institutions in the field of drugabuse. They also teach abroad.
In 2016, Modum Bad outside of Oslo opened a department, “Kildehuset”, that offer trainings to professionals in the healthcare services and related areas such as child protection services, educational institutions, etc. These trainings include seminars and workshops in trauma theory and treatment. The lecturers are mainly national (including specialists from Modum Bad), but also include international speakers such as Suzette Boon, Onno van der Hart, Bethany Brand, and Ruth Lanius.
Several of the professionals who attended the first training with Ellert Nijenhuis in Bergen, and his trainings at Modum Bad (2006-2008), came from one of the cities in northern Norway, Bodø. Northern Norway is characterised by covering a large area with few people, and hence requires long distances to be travelled for those who need help. These professionals therefore managed to create a separate trauma department at Nordland Hospital, which eventually gained high reputation. Unfortunately, this department was closed for economic and political reasons a couple of years ago.
Ten years ago, the Viken Center in Northern Norway was developed with a similar foundation and style to those of Modum Bad. This center has its own dedicated trauma unit. The trauma unit at Viken Center gives inpatient treatment to people who have experienced relational and early trauma. They start with three weeks’ assessment, and then nine weeks of phase one treatment, with a focus on stabilisation. The focus is to help patients understand their own reactions and symptoms, and find strategies to handle these symptoms. The treatment is psychoeducation in groups, creative groups, physical activity, and individual psychotherapy. The recommendation is that the patients have local therapists both before and after treatment at Viken.
In recent years, several other specialised outpatient trauma units have been created, such as in Kristiansand in the south of Norway, and a trauma outpatient clinic for children and young people in Trondheim in the middle of Norway.
Sørlandet Sykehus, a local hospital in Southern Norway, has implemented a strong trauma perspective in their Mental Health Department, by establishing a specialised unit for treating traumarelated and dissociative conditions. The Clinic for Psychosomatics and Trauma offers clinical individual treatment and educational support, supervision and consultations with healthcare professionals in the hospital. The goal is to support the whole hospital in applying knowledge in traumarelated dissociation, personality disorders, and complex PTSD, and offer supervision of treatment models and methods. The unit represents a variety of theoretic and treatment approaches, within the framework of phase-oriented treatment.
A few years ago, Kjersti Karlsen from the psychosis field and Arne Blindheim came up with the idea of arranging a trauma, dissociation, and psychosis conference to try to bring these fields closer to each other and improve understanding of the dynamics regarding the similarities between complex dissociation and psychosis. Kjersti introduced the idea to the hospital in Kristiansand in the South of Norway, who agreed to arrange such a conference in Kristiansand. Kjersti and Arne established a team of 6 people, and together with the hospital organised the conference in 2015. The conference included international leaders in the field, and became a success with 530 participants. Most of the participants came from Norway, but there were also participants from abroad. Therefore, it was decided to make the conference a biannual event, and the second conference was held in 2017, again with over 500 participants. This conference is, as far as we know, the first of its kind.
We who work in this field see that it is an increasing interest in trauma and dissociation spreading over many parts of Norway. However, we also see that a lack of knowledge and prejudices are to a large extent still present in various academic environments, and unfortunately also at universities. Our colleagues regularly experienceskepticism, distrust, and often unreasonable criticism, and some get so frustrated that they put an end to their work in the public healthcare sector and go on to work privately, where they can only work to a limited extent with these patients for economic reasons. Fortunately, the situation is moving forward, and it is exciting to watch its progression and to be part of it. Major developments have occurred, especially during the last decade.
We would like to take this opportunity to thank our teachers and those who have made all these developments possible. Many have contributed, but in particular, we will mention: Onno van der Hart, Ellert Nijenhuis, Suzette Boon, Joy Silberg, Janina Fisher, and Andrew Moskowitz