David Yeung's Blog, page 10

Considering the Use of Drugs in DID Treatment: Part 8 – A Sales Channel Is Not Therapy

[8]  Drug companies use a particular sales technique known as “off-label” marketing to expand the sales potential market of their psychoactive medications.  

The technique of “off-label” marketing is selling the medication for a purpose that has not been approved by, in the US, the Food and Drug Administration. With this kind of marketing approach, we are being led to participate in a cold, money orientated mental health system that is not really effecting for those who need help dealing with trauma or other mental health issues.

For example, a drug may be approved for treating psychosis, but not dementia. However, that drug may be marketed for “off-label” use for individuals with dementia. This is not at all uncommon. This kind of marketing is often done at seminars that are sponsored by the pharmaceutical companies seeking to boost sales. It is based on anecdotal information they promote rather than peer reviewed studies. You can look at past drug litigation, such as around the use of Risperdal, to see the dangers in this technique. This kind of marketing made Risperdal a multi-billion dollar drug despite harming many children.

This same danger was recently highlighted in a study of Haldol, a drug that has been marketed for decades as an anti-anxiety drug but established an enormous off-label use. That use was for “treating” dementia related anxiety issues. According to the study, there were zero peer reviewed research papers indicating a positive impact of the drug for dementia patients. Here is a warning from 2007 that is instructive, given that the medication had been in used for dementia patients for decades at that point:

“Haloperidol (Haldol, Johnson & Johnson) is approved for intramuscular use, off-label intravenous use of the drug is relatively common for treating severe agitation in intensive care units. However, due to a number of case reports of QT prolongation, torsades de pointes, and sudden death thought to be associated with this practice, the FDA has issued an alert to healthcare professionals. The prescribing information for Haldol, Haldol Decanoate, and Haldol Lactate has been revised to reflect the concern and potential risk when the drug is administered intravenously or at higher doses than recommended.”

Note that this warning doesn’t say you should not continue to use it for dealing with agitation in dementia patients. It is merely an “alert” that was likely issued as a prospective litigation defense.

In short, beware of off-label use of psycho-active medications. Perhaps the anecdotal information promoted by the pharmaceutical industry is accurate, but perhaps it is not.

9) Emotional difficulties have to be approached through first understanding the emotions involved.

All aspects of the individual have to be considered in therapy; the biological, psychological, social and spiritual aspects. There is no substitution for this by prescription. Prescriptions are not time-saving if that is all you offer the patient. Why? It is because missing the underlying factors that generate the symptoms will only cause delay and suffering – often for years – as a result of the wrong treatment. Should the wrong treatment include psychoactive medication, there will likely be an even more difficult path of undoing the impact of that medication before being able to address the actual issues.

Years of pharmaceutical experiments will ensue for the patient. The hunt for another therapist will eventually follow, often many years after the original misdiagnosis and corresponding error in treatment. It breaks my heart that this is so common. It is why I continued to practice psychiatry into my 70s and why, in retirement, I wrote the Engaging Multiple Personalities Series.

The case histories in Engaging Multiple Personalities Volume 1 were all of people that came to see me after being treated to no avail by other therapists and psychiatrists for years. For those I was able to help, it was not that I was a particularly brilliant therapist. It was because I actually listened to them. Without exception, their prior therapists either did not believe in dissociation or were too callous to pay attention to the early childhood trauma these individuals experienced.

An effective therapist speaks to the heart, not to the brain. We must never forget the humanity of our patients, or our own.

This is the final section of this extended post.

 

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Considering the Use of Drugs in DID Treatment: Part 7 – Go Slowly

[6] The best we can do is to humbly accept the limitations we have in striving for a more precise description of depression that may respond to medication.

DSM 5 gives a clinical picture that defines a depressive condition that would be appropriate to treat with medication. In one example, this includes a somewhat arbitrary time limit: If grief in bereavement is prolonged more than a certain number of days, then we deem it a pathological state. And, with that diagnosis, comes the implied appropriateness of trying some pharmaceutical intervention.

If a genuine therapeutic alliance has been established with the patient, I would have a clearer sense of the likelihood of early childhood trauma, or an assessment of potential ongoing trauma in the patient’s current life. Being able to identify trauma leads to one treatment path. Absence of trauma would lead to a different treatment path.

My approach is to look at a person’s depression. If it is there most of the time, when he wakes up, when he does not get cheered up seeing his loved ones, when he is socially withdrawn, when he cannot shake it off, that would satisfy my criterion of a form of depression where I might try antidepressant. But, that would only be as an adjunct to psychotherapy.

Depression that responds to drugs usually has a different quality than depression connected to trauma. It is more like someone who has lost interest in things that used to generate a positive experience, a positive response. A common description is of a patient that no longer enjoys his favorite foods.

Psychiatric text books describe true depressive symptoms in different ways. The term “True depressive symptoms” refers to depression as a syndrome, a disorder; in other words a mental illness that prevents one from living one’s life in a way that accommodates the ups and downs of ordinary existence.

[7] There is a dangerous pattern in psychiatry to quickly conclude that a depressed patients should be on medication.

This kind of presumption is illogical, dangerous, and based on an inflated sense of one’s insight. But, it is inflated by the promotional materials of the pharmaceutical industry and the money that flows from it. I have heard this kind of nonsense from the press as well as from many of my peers. What is missing? It is empathy that is missing. It is the warmth of genuine compassion that is missing. Both of those should be tested before anyone is given a license to be a therapist – whether it is a license as a psychiatrist, a psychologist, a clinical social worker or perhaps even just an ordinary human being that deals with other human beings in trouble.

For the sake of billions of dollars of sales, pharmaceutical companies invest heavily in propaganda and brain-washing to promote the use of drugs as the exclusive means in solving the mental health problems.

Be aware of the erroneous assumption that depression is a disease curable by antidepressants. This is, at best, a half truth. We need to be alert to identify patients with depression that is amenable to psychotherapeutic intervention.

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Considering the Use of Drugs in DID Treatment: Part 6 Determining Treatment for Depression in DID

[4] As I have said before, I am not rigidly against the use of antidepressants per se.

Some of my depressed patients did indeed respond positively to treatments other than psychotherapy, often in ways that might be seen as miraculous. My disappointment and concern is that there remains no clear protocol that confirms what kind of depression will respond to which treatments. The result was that I used my own criteria when considering options for my patients, based primarily on my clinical experience.

I used psycho-pharmaceuticals in the past. I can attest to the fact that they do help some very severely depressed patients just as I can also attest to the fact that they do not help others. To this day, for me at least, there are no studies that satisfactorily define what kinds of depression respond to which chemical interventions.

It can be an assault on the patient to give them a small manufactured pill. How is that possible? Keeping a patient on antidepressants for years while ignoring psychological factors such as early childhood trauma, or recurrent ongoing trauma as the cause of the depression, is a chemical assault. Such an approach has the quality of trying to beat down the depression rather than cure its cause. Until we have an actual proven answer in identifying which depression would be responsive to which drug, we need to be extremely careful in using these approaches.

[5] The term “Chemical Imbalance” has no real meaning.

It is a false assumption that antidepressants are generally both safe and effective. The truth is that all pharmaceuticals are substances foreign to our bodies, even when they are based on natural chemicals produced by plants for example. Pharmaceuticals are highly potent chemicals. They are specially designed to quickly alter our metabolism and interfere with it. In fact, psycho-active medications are designed to rapidly impact one’s existing brain chemistry. They are far more potent than the plants they may be derived from.

The term “Chemical Imbalance” is somewhat a sales device. The identification of the numerous serotonin-receptors in the brain has helped some, but so far has had not cured the pain and suffering of all or even most depressed patients. The truth is that psychiatry in the 21st century remains an inexact science.

After almost a century of sophisticated biochemistry research, we are still generally operating in a fog as to defining exactly what is the chemical imbalance in a brain that expresses pathological depression. I do not dispute that psychiatric medications have contributed to the treatment of certain psychoses. They have, in fact, led to a reduction of the number of institutionalized psychotic patients in developed countries. However, we must accept that there are some unavoidable limitations in the purely pharmaceutical approach to depression. It is a the false hope that we can trade pills for genuine psychotherapy in the name of saving time and man-power.

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Considering the Use of Drugs in DID Treatment: Part 5 – Diagnostic Bias in Files

Few people outside the psychiatric and pharmaceutical communities know how common the practice of stretching and bending the meaning of words is in medical files. That practice is influenced quite strongly by the bias of the clinician. I have personally had client files sent to me that clearly were based on a liberal and intentional misuse of words. This misuse served the purpose of identifying an otherwise understandable behavior into a symptom. I am confident in saying this because many of the files referred to me included dissociative behaviors and events. In fact, the files actually used the term dissociation but failed to include any primary or even secondary dissociative diagnosis. Further, those files usually indicated pharmaceutical treatment failures and no application of psychotherapy.

For example, patients were referred to me that were experiencing agitation related to a flashback of abuse. In the files, agitation was interpreted as “a variant of hypomanic behavior.” Such misuse of language completely shocked me. Those patients had often lost years on a wild goose chase, with therapists trying to find the right pharmaceutical agent for “a variant of hypomanic behavior.” The correct approach should all along have been trauma therapy as it was their trauma that was being displayed in the symptoms.

It is common to see patients that are kept on antidepressant for years yet remain depressed. Although they are labeled as suffering from “treatment resistant depression”, it is more appropriate that they be labeled as suffering from Antidepressant-resistant depression!

If a patient on antidepressant(s) has not improved as expected, the correct procedure is to review the diagnosis, not just to persist in trying different dosages or a newer drug. There is no logical reason or peer reviewed study that would indicate that the depression symptom is part of a disorder that justifies the exclusive use of medication. In reality, that is the common practice – to increase the dosage or change of antidepressants. Instead, try listening to the patient. Or, at least, continue with the medication and try listening to the patient.

In Volume 1 of Engaging Multiple Personalities, there are several examples of patients I had referred to me that were labeled as having treatment resistant depression who made progress in their healing journey through psychotherapy. With psychotherapy, those patients were treated. Their traumas were acknowledged and often successfully processed. During the psychotherapy, there were weaned away from antidepressants successfully and fairly quickly. I only remember a very few DID patients who required antidepressants as adjunct to being treated with psychotherapy.

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Considering the Use of Drugs in DID Treatment: Part 4 – Understanding the Clinical Presentation

[3] When a patient has made repeated suicide attempts, that patient is often labeled with the diagnosis of depression as part of a Bipolar or DID diagnosis. As we have been discussing, the correct diagnosis is critical as there are medication protocols for treating bipolar whereas there are no medication protocols for treating DID.

Bipolar Affective Disorder and DID are diagnoses based solely on their clinical presentation. Unlike malaria, they cannot be confirmed in a laboratory. In the past, before microscopes, malaria was also diagnosed by its clinical presentation, which is a specific fever pattern. But now, it is diagnosed using a microscope that enables the parasite to be seen in a blood smear.

There are no laboratory tests for these psychiatric disorders. The clinical presentation alone is used to make a diagnosis of DID or Bipolar Affective Disorder. And the evaluation of clinical presentations is subjective. It is based an interpretation of what is behind the behavior, of what is causing it. There is a risk of the clinician’s bias in that interpretation. If bias drives the decision, that can compound the risk of mistaking one diagnosis for another, perhaps correct one.

This is more common than is generally acknowledged because the same or similar clinical presentation can be seen as quite different illnesses. For example, one psychiatrist may identify something as a mood swing and decide this is a bipolar patient. Another psychiatrist might identify it instead as a dissociative event where a different alter is presenting.

Those who have difficulty in accepting the phenomenon of dissociation often choose the diagnosis of a Bipolar disorder to fit their patients into a pigeon hole with which they, the psychiatrists, are comfortable. These disorders often include depression and instability in mood states. With the identification of a behavior as a symptom, the correct diagnosis is critical because treatment is quite different for each of these disorders. A critical distinction in the diagnoses are that identifying the behavior as a symptom of bipolar legitimizes the use of drugs. This is because there are drugs approved for use in treating bipolar disorders while there is no drug approved for use in treating DID.

We do know that diagnoses having an approved drug for treatment mean short interviews with patients that are less emotionally taxing for the therapist. This means that there is a greatly diminished risk of vicarious trauma for the psychiatrist to go along with the convenience of a prescription based treatment rather than psychotherapy.

Despite the many papers published on brain amine metabolism and depression, we do not know exactly how these are truly related. Nevertheless, using drugs as the treatment means that instead of putting out the energy of empathy, and deeply listening to the patient, there is just the checklist of questions to ask. The questions are all versions of “are you feeling better?”

The answers are then coupled with trying different kinds of antidepressants, dosages and combinations. A diagnosis that has an approved drug treatment guides the psychiatrist to focus on the relatively simple task of choosing the right pill rather than on psychological and social issues. But if that diagnosis is incorrect, the resulting treatment plan will not address the problem. It will cause more suffering to the patient and often further mask the correct diagnosis.

So, the correct diagnosis is critical.

Evaluating clinical presentations means that the symptoms and signs are documented by selecting and interpreting those presentations. The problem, to give one example, is that a psychiatrist who is biased towards a bipolar diagnosis will see a behavior as hypomania. The result is that he will give a patient the latest mood stabilizer as the first line treatment. If that psychiatrist ignores indications of early childhood trauma or even remaining open to that possibility, he will simply not identify the behavior for what it most likely is – dissociation related to flashbacks of that early childhood trauma.

For that psychiatrist, a diagnosis of bipolar affective disorder and the use of a mood stabilizer will appear to be a sound clinical practice. The doctor and the drug manufacturer are protected legally from claims of negligence. It is the essential litigation insurance. It is difficult years later to prove that the doctor was wrong.

Identifying severe agitation or panic in a patient with a history of abuse as hypomania rather than recognizing it as an episode of flashback agitation is a mistake with real and difficult consequences. Flashbacks are not a feature of hypomanic behavior. But, I have seen it described as hypomanic behavior in patient files because of a clinician’s bias favoring a diagnosis of bipolar.

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Considering the Use of Drugs in DID Treatment: Part 3 – The Widespread Prescribing of Antidepressants

According to Paul W. Andrews, an assistant professor in the Department of Psychology, Neuroscience & Behavior at McMaster University in Ontario, Canada:

Antidepressant medication is the most commonly prescribed treatment for people with depression. They are also commonly prescribed for other conditions, including bipolar depression, post-traumatic stress disorder, obsessive-compulsive disorder, chronic pain syndromes, substance abuse and anxiety and eating disorders. According to a 2011 report released by the US Centers for Disease Control and Prevention, about one out of every ten people (11%) over the age of 12 in the US is on antidepressant medications (italics added). Between 2005 and 2008, antidepressants were the third most common type of prescription drug taken by people of all ages. They were the most frequently used medication by people between the ages of 18 and 44. In other words, millions of people are prescribed antidepressants and are affected by them each year.

This information is in keeping with most of the statistics I have read, which show that the percentage of adults using antidepressants in developed countries is extraordinary. It is alarmingly high to most everyone – except for the companies that manufacture and profit from them. In short, this is a major alert. We need to re-think the rampant use of these drugs.

The narrative used to support this widespread use is simple: Suicide is the result of depression and depression is a disorder amenable to drug treatment. It is a simple but quite muddy thinking that is pushed out to both the medical and general population. It comes from misinformation coupled with aggressive advertising by drug companies to the public as well as professionals. They advertise directly to the public, and promote it through continuing medical education events for professionals. All of this is paid for and promoted by the very companies profiting from the sales. They tell the public to rely on the doctors, and they tell the doctors to rely on the pharmaceutical company sponsored literature along with other information that is not subject to outside or peer review.

Here are a few points to consider:

[1] Suicide attempts do not necessarily result solely from depression.

For some time, it has been noted as a potential side effect that some antidepressants actually lead consumers to suicidal behavior. The term “suicidality” has been brought into somewhat common use. The U.S. Food and Drug Administration (FDA) proposed that makers of all antidepressant medications update the existing black box warning on their products’ labeling to include warnings about increased risks of suicidality, suicidal thinking and behavior, in young adults ages 18 to 24 during the initial treatment. Initial treatment generally refers to the first one to two months of medication usage. The first question I have with this warning is whether the label is primarily for prospective litigation defense rather than for any other patient centered reason.

Suicide is a complex behavior that cannot be reduced to a pseudo-scientific term like suidicality. Not all depression leads to suicidal ideation. I believe suicidal behavior is a form of anger turned inwards. I have numerous examples of patients who harbored internalized rage. By turning and maintaining that intense anger inwards, the need to express that rage was translated into suicidal behavior.

Once, a suicidal patient was referred to me who was taking an overdose of drugs every other day. She would end up in the Hospital Emergency ward for weeks on end. Finally, some of the nurses in the ER suggested sending her to me because what her then-therapists were trying was obviously not working.

I saw her a few times. She told me that she was extremely angry at one of my colleagues, a psychiatrist who had a responsible position in the hospital. She was boiling in anger but had no way to complain about his conduct. Just listening to her and acknowledging her grievances was ventilated that smoldering anger.

The ritual of repeated hospital visits was her way of expressing her anger. The simple act of listening and acknowledging her with empathy abruptly ended her repeated “suicidal overdoses.” Someone with a psychiatry degree, me, bothered to listen to her. Listening and acknowledging her was all that was needed to change her behavior. She stopped coming to see me after a few sessions, and abruptly ended her pattern of overdoses and visits to the ER.

I was later asked what I had done to stop her suicidal behavior. I hadn’t done much other than recognizing that her suicidal behavior was simply her way of protest. It was how she was trying to tell the world how angry she felt being trapped in that authority/helpless victim struggle with a perceived authoritarian psychiatrist with degrees and status. She was a single woman in her 50s feeling powerless. I was confident about the importance of listening and acknowledging her because 2 other patients had already complained to me about that psychiatrist’s abrasive manner in their own encounters with him.

This was an example of a patient who perceived that their therapist was not interested in listening to her innermost concerns. Immediately, such a patient loses his/her faith in the therapeutic relationship. If the doctor’s primary goal is choosing a pill as the mainstay of treatment, that is a direct message to the patient. That direct message is not one of empathy or compassion. The patient may and will likely feel rejected, ignored, helpless, and hopeless. Anger should be an expected response. And anger will often be redirected inward or outward.

If the patient loses hope, suicide is often seen both as a way out and a statement of protest. It is a red herring to coin a new word “suicidality”, as if that is a reasonable scientific risk of chemical side effects. It is as deceptive as implying that depressed patients will most likely have their depression alleviated with magic chemicals labeled “antidepressant” and that there is a mix of chemicals/dosages that will make the problem disappear.

[2] Antidepressant use is not an accurate reflection of the prevalence of depression.

The popularity of antidepressants in a given country is the result of a complicated mix of depression rates, stigma, wealth, health coverage, the degree of aggressive sales tactics of the pharmaceutical industry, the availability of treatment. It is also tied to the biological bias of the therapists toward chemical intervention rather than psychotherapy – most of whom are trained and marketed to by the pharmaceutical sales representatives.

Again, I want to be completely clear that I am not aganist the appropriate use of antidepressants as an adjunct to psychotherapy. I have done exactly that with some of my patients. However, the mind is not simply a box of neural circuitry where wires can cross and be uncrossed, where chemical switches can simply be toggled on or off. We must not forget our humanity. Do not ignore its powerful effect in helping to transcend despair. We must not forget the power of empathy, of compassion, and of hope in healing and recovery.

 

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Considering the Use of Drugs in DID Treatment: Part 2 – Depression and Antidepressants

We often find these 2 words, depression and antidepressants, spoken in the same breath. Why is this a problem? Because always coupling them together erroneously implies that depression is a disease and antidepressants are the cure. It is dangerous to see them together so often because they begin to appear to be naturally identified as a pathology and its treatment.

Depression is not necessarily a pathology. It can also refer to a very ordinary state of mind triggered by some kind of loss, whether it be material or emotional. Depression is often part of the ordinary ups and downs of life.

Depression is a term used when a patient expresses particular feelings. It can be used for a psychiatrist’s observation in referring to the inner world of the patient. It is also the term used for a mental illness, a pathological disorder which is a clinical state.

It is easy for us to become sloppy with words. We use the same words in different circumstances without necessarily clarifying the different nuances we mean to communicate. We lump words together in ways that blur their meanings. These result in false logics that can do a great deal of harm. It has affected many people and created much suffering for patients.

In a casual conversation recently, a well-established psychiatrist shared the sad news of a mutual friend who lost a family member through suicide. He then commented that 1) young people today do indeed tragically commit suicide, and 2) they are notoriously resistant to taking antidepressants.

I was shocked. Why did he immediately associate the suicide to depression that would respond to drug treatment in such a linear way? The thought arose in my mind that the troubled young man perhaps might have been helped if he had someone to speak with at that difficult moment in his life, someone that would listen to him with understanding and empathy.

Medication would certainly not be the first thought that comes to my mind in such circumstances. To know a person is feeling badly and to then help him requires more than prescribing a pill. It is an inappropriate leap in logic to so completely associate prevention of suicide with a pill. Surely some mental health professionals are missing the point, the basic importance of listening deeply and always being kind.

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Considering the Use of Drugs in DID Treatment – Part 1

This is the first of a series of posts discussing pharmaceuticals and DID treatment. The purpose is to encourage those with DID to avoid psychiatrists that have already made any kind of diagnosis before they have established any safe rapport with you. Hopefully, it will also provide some clarification in the somewhat muddy field of psycho-active pharmacology and its place in treatment of mental health issues.

I am not against the use of all psychiatric medications. I am very grateful for what modern pharmaceutical science has achieved in relieving suffering, including medication for mental health issues. But I do not believe we will ever solve all mental health problems with pills alone.

My general advice to dissociative individuals, is not to blindly go along with pills alone. Medication alone, without actual psychotherapy, won’t address underlying trauma. Pills may temporarily put out the surface fire so to speak, the symptoms, but they don’t put out the embers burning underneath, which is the unprocessed trauma. Without a doubt, the trauma and the symptoms will reappear so long as the trauma itself is not treated.

If your mental health professional recommends taking an antidepressant, set agreed-upon boundaries for tracking its impact. For example, you might agree that it is being used tentatively. That way you can get a sense of what happens as a result and whether or not it is beneficial. It may indeed help you and often does function as a temporary fix. If it is helpful, use the stability that results so as to take the necessary steps in psycho-therapy to process the trauma. But, don’t accept it as the exclusive approach for your psychiatric problem. Instead,

You have the right, and the responsibility to yourself – including all parts of any DID system, to assess your therapist. A therapist should be interested in you as a person. A chemical cannot express an interest in you as a person.

Assessing your therapist is the first step toward establishing a genuine therapeutic alliance with that therapist. It is that therapeutic alliance that enables your therapist to help and guide you in processing trauma. You can make a therapeutic alliance with a person, you cannot make a therapeutic alliance with a drug.

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Why Ordinary People Deny Testimony of Abuse

Weeks of heated debate concerning the appointment of a US supreme court judge, has come to an end and a decision was made – a decision by the Republican majority that was not swayed by the bravery of Dr. Blasey Ford. This hearing reminded people of a previous confirmation hearing in 1991, that also revolved around alleged sexual misconduct. The latest hearing went beyond simply bringing the issue of sexual harassment into the public eye. It went beyond that earlier hearing involving workplace sexual harassment, and forced the issue of sexual assault into the light of public scrutiny.

The #Me Too movement has been critical in raising public awareness on the issue of sexual assault. But there remains, in general, serious misunderstandings on the question, function and qualities of traumatic memory. Until the public is better educated about how trauma impacts memory, victims’ statement will always be doubted and misunderstood. In that way, victims of sexual assault will be retraumatized.

This dynamic played out in these hearings where many Senators affirmatively ignored the depth of research into how sexual abuse events are remembered by victims. The logic used by deniers of Dr. Blasey Ford’s testimony relied on their so-called “common sense.” Senators expressed their denial based on the questions people that have as anyone else might raise that has no genuine understanding of sexual trauma:

[1] If something so terrible as sexual assault or rape did happen, why does she not even remember the time/place/persons involved, with some clarity? The subtext of that question is barely hidden: If it was me, I would remember.

[2] It something so devastating did happen, why did she not make a formal complaint right afterwards? This also extends into the scenario pointing out, perhaps, that the victim repeatedly saw (or returned to) the abuser and acted as if nothing serious had happen. The subtext of that question is similarly barely hidden: She kept seeing him to wait in ambush to make a complaint decades later.

The public, and certainly elected officials, need to be better educated about the unique phenomenon of traumatic memory and behaviour. When judges, or other people in high position, fail to understand the nature of traumatic memory and phenomenon of victimization, all victims of sexual assault are subject to retraumatization. Unfortunately, one can simply refer to President Trump’s mocking of Dr. Ford – attacking her memory of being sexually assaulted. 

Once again, we must go back to distinguishing the different kinds of memory. We can easily access non-traumatic memory. This ordinary explicit memory, which is termed declarative memory, can be expressed in narrative form. An example of this is recalling what you had for lunch, when you had it and with whom you were eating; at around 1 pm, sitting at a corner of such and such eatery, hastily downing soup and a sandwich with my friend John. This is ordinary explicit, or declarative memory.

In contrast to explicit memory, there is implicit or non-declarative memory. This kind of memory is usually without verbal references. Generally speaking, it is vague, all jumbled up non-verbal memory. It often manifests in the body as somatic sensations and visual imageries.

It is in this kind of non-declarative memory that trauma is processed and stored. It is challenged and often disbelieved by people evaluating the memories of victims of abuse. Those who deny this kind of memory misjudge it. They make the mistake of comparing their own explicit memory to a victim’s implicit memory. In other words, as was seen in the analysis of people denying Dr. Ford’s testimony, their erroneous logic is, “If I can clearly remember what I had for lunch with John yesterday, why can’t you remember clearly where, how and when XX attacked you?” They make that error in judgment because implicit memory related to trauma and explicit memory related to everyday experience is processed very differently in our brain. 

When an experience is encoded in fragmented, non-declarative memory, only raw emotions and physical sensations are accessible in one’s consciousness. These may manifest in hyper-vigilance, sudden and overwhelming feelings of panic or dread. They usually include intense feelings of alienation, rage, and helplessness as well as terror at loss of control. 

Instead of precisely expressive words, victims of assault (such as my patients when I was actively practicing psychiatry) may speak of “wanting to throw up,” or an intensely “yucky feeling.” Often they have intrusions of bizarre visual images. The inability to translate what is so strongly felt into something expressible in words leaves them frustrated, bewildered, angry, and hopeless. Their dilemma is perhaps best expressed by John Harvey (1990): “Trauma victims have symptoms instead of memories.”

Working with patients in therapy, a psychiatrist must translate this body of knowledge into appropriate therapeutic processes. While therapy is quite a different process than a hearing involving an assault victim’s statement of recollection, it does not excuse the misjudgment of those denying someone’s traumatic memories.

The second issue raised in such misjudgments is why a victim would remain in some kind of relationship with an abuser or fail to make a complaint within the “right” time frame. Once again, one has to understand the dynamics of the victim/abuser relationship. Suffice to say that I have encountered a victim of incest who continued to allow the abuse to take place even after she reached the age of 30 and had gotten married.

Even for someone without experience in dealing with trauma, one should consider the following question: “If I let someone abuse me and have complete power over me at age 3, how could I suddenly have the strength to rebel and stop the abuse at age 3 plus 1 day?” It is easy to answer that question. Of course one wouldn’t have that strength at 3 years plus 1 day. But if the power hierarchy is maintained for decades, when does one day finally become different from the previous day? If it happened at age 30, could I have the strength to stop it at age 30 plus 1 day?

When we make an informed judgment, we must make sure we understand the various dynamic factors. We should not jump to conclusions when we have insufficient information or, just as important, insufficient empathy. Empathy, the ability to put ourselves in the other person’s shoes and try to think and feel as they might, is the real key.

The leadership in society should be willing to be educated in matters related to post-traumatic stress disorder (PTSD) and Complex PTSD. Many women suffered and continue to suffer in the prevailing culture of male entitlement. This cultural view accommodates men taking what they want, treating women as sex objects, and treating women simply as objects over which they can assert power.

This entitlement culture is simply wrong, it opens the door to potential horrors. We only need to open our eyes to cultures that advocate female circumcision, cultures where gang rape is the norm rather than an isolated incident, and cultures where families sell their young girls (and boys) for sex slaves. The President openly admitted to what he called “locker room talk”, of how he could easily grope women’s genitals. We have a long way to go before we can arrive at a better world – for our daughters, sisters and our mothers. Such a world would be far better for our sons, brothers and fathers as well. Dr. Ford’s bravery is a poignant marker on this journey.

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On Using the 3 Engaging Multiple Personalities Volumes

I want to express my thoughts on how best to use the 3 Volumes of the Engaging Multiple Personalities Series.

For those with DID, If you have a therapist, then Volume 1 may be very helpful to clarify issues you might be working on with your therapist. Given that DID manifests in many ways, some of the case histories might be useful by way of saying “this is somewhat similar to my experience” or “this is not what I experience.”  The therapeutic keys can also be good points to bring forward with your therapist to the extent they ring true to your experience.

For therapists, and for individuals with DID who may have found a therapist willing to work with them but who has little to no experience with DID, Volume 2 will be most helpful for the therapist while Volume 1 can be a bridge through which you can work toward a positive therapeutic journey.

For those with DID who do not yet have a therapist, Volume 3 was written specifically for you. It can help you understand that there is a definite context to your experience. That in fact, dissociation is a critical response to enable you to survive abuse rather than something crazy. Dissociation is not insanity, far from it. While Volume 3 is not self-therapy, it may give you a strong foundation, self-empowerment if you will, upon which you can build a therapeutic alliance that will work for both you and a therapist in the future.

I find it very interesting that while the books get a very positive response from those with DID as well as from therapists that have read them as a result of patients’ suggestions. I find it painful to have to repeat so often that the mainstream psychiatric community, and most therapists, still do not appreciate the impact of early childhood abuse that results in DID.

There are very few reviews on Amazon, where the series is sold. So, the outreach for these volumes is limited to those in the DID Facebook groups in which I post, and to which those members share. If people do find the different volumes helpful, and you feel safe enough to do so, please post a review on Amazon. I think it is likely best to do it anonymously or under a pseudonym. In that way, perhaps a wider audience of therapists, and those with DID that do not connect with the Facebook groups, may encounter the books.

Finally, I also learned recently that one of the libraries that purchased Volume 1 no longer has it on the shelves. Why? Because it has been read so much that it has fallen apart. If you contact your local library, perhaps they will purchase a hard copy which would then be a resource in that community.  But, at the same time, I know that the ebook version will not fall apart when it is used – no matter how many times! So, I am happy to donate the ebook to any library that wishes to have a copy regardless of whether or not they purchase a hard copy. There are certainly more libraries in the world than I can afford to do this with, but I am happy to start with 100. If your library is interested, please have them email me at engagingmultiples@gmail.com.

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