David Yeung's Blog, page 11

On Mapping Systems

With respect to mapping one’s DID system, if you find it beneficial, then by all means do so.  In my psychiatric practice I neither encouraged nor discouraged my patients to map their systems. 

With my patients, it was always important to return to the fundamental point of treatment of DID, which is to allow the system to process trauma. In my experience, this happens through engaging presenting alters in a genuine, empathic and trustworthy manner. Having a schematic of their systems was not necessary to do that. 

Again, based only on the experience I had with my DID patients, mapping systems was not necessary to an efficient or focused therapeutic alliance. The problem is not particulary the mapping but rather that therapists who encourage mapping systems may infer, or sometimes outright claim, that you have to understand each and every part of the system before you can heal. Certainly, for systems with massive multiplicity, this runs the risk of turning therapy into a never-ending marathon.

Mapping also suggests that therapists need to have some detailed knowledge of the individual alters, almost like requiring a census of “who is who” including how they are grouped or related. Mistaking meticulousness for clarity, a therapist can be lured or distracted into trying to provide individual psychotherapy of each and every alter rather than simply engaging with alters as they present.  In the case of Ruth, described in Chapter 5 in Volume 1 of Engaging Multiple Personalities, some alters’ problems were taken care of as a by-product of other alters who engaged with me as well as by other alters who acted as co-therapists or “preachers” rather than by me as the psychiatrist.

Alters functioning as both co-therapists and preachers made perfect sense in Ruth’s context as she had decided the way to solve her problem was to convert the “evil” non-believer alters into believers (of Christianity.) As her therapist, my task was to maintain my neutrality so as to enable the therapeutic alliance to be extended to all alters, whether they were presenting as non-believers or otherwise. This individual choice by Ruth was a very positive decision in her healing journey. And, as always, I was careful to not interfere in the system as to religious or other matters unless specifically invited to do so.

Ruth had about 100 known alters when she saw me, and continued to present many, many more over time. It was instructive to see how they often had quite separate handwriting styles that remained consistent throughout and then long after therapy had ended. Years later she told me she had hundreds of alters. I was never sure if the number had grown or that she had became more comfortable in recognizing their presence. If her healing was dependent on mapping an ever-expanding system, she never would have healed to the point of going beyond the need for ongoing therapy. The fact is that after a relatively short time in therapy, for all practical purposes, her self-harming activity ceased. She was able to live independently, care for her children once again, and make a fulfilling life for herself which continues to this day, some 20 years later.

Mapping is sometimes also used to encourage the idea that integration is the appropriate goal in DID therapy. It is as if a DID system is really like humpty-dumpty and mapping would allow the therapist and patient to find all the piece so as to glue them all back together. Readers of my books and this blog already know that I don’t believe that integration is or should be the goal of therapy.  Why? Because under stress, the integrated personality will again split both out of habit and the need to protect itself from danger. In my opinion, it is far better and safer to focus on healing, on eliminating the intrusion of the past into the present while training to remain vigilant rather than hyper-vigilant. If integration takes place in whole or in part, that is fine. If not, that is fine too.

The goal is to heal from the trauma. To claim that healing from the trauma requires mapping (or integration) is a false leap of logic. The point is to eliminate the power of the past to re-traumatize you in the present. That is not based on mapping or integration. It is based on engaging alters so as to allow them to process the trauma in which they are trapped, that they are repeatedly playing out, and that they likely continue to dissociate around.

My further concern is that focusing on mapping and/or integration runs the risk of driving some alters into resisting a genuine therapeutic alliance. This can undermine another goal of helping the alters function as a team with cooperation and finely tuned coordination. It is incredibly beneficial to shift from alters as a group of mutually antagonistic individual parts to parts working harmoniously together. So long as they are not in conflict, they can have a peaceful co-existence. Otherwise, time loss, competing for time out, or even self-harm, will continue to cause tremendous stress.

Here are some simple therapeutic guidelines: 

1. Symptoms can usually be traced to alters getting triggered by repeated intrusion of past trauma into the present.  These are flash-backs which turn the patient’s life upside down again and again – just like the original repeated early childhood traumas.  So, the first goal is to stabilize the situation, to do a kind of trouble-shooting based on what alters are presenting to the therapist. It is PTSD treatment for the early childhood trauma. Essentially, it is figuring out what to do therapeuticly on a kitchen sink everyday level.

2. Once activated, alters assert their right to be, to exist, to communicate.  They can take over and cause havoc in the ordinary life of the DID individual.  For example, chunks of time loss can occur which are very disconcerting and often very frightening for the host.  At the same time, the alters who take over during those periods of time-loss for the host hold critical keys to healing. The immediate goal in treatment is directed towards quickly negotiating some kind of cooperation among the alters. It is focusing on turning the chaotic conflicted group into a disciplined team-like group with the common goal of healing. That is the ideal. While it is far more easily said than done, that is the target.

3. Engage whatever alters present and work with them. Remember that all of the alters are around when you speak with one, and make sure you formally invite them to participate by listening, by watching and by speaking when they so wish. Many alters can heal as they touch in or simply follow a more principal alter’s therapeutic journey.  They do not always need to be called out or to be otherwise addressed directly.  In fact, many just feel safer watching and listening. A corollary to this is that being mapped can be frightening to them. It might be seen as telling them they need to stop hiding when they are still not feeling safe enough to be identified. And frightening an alter can make them potentially uncertain about the therapist’s motives. That uncertainty can be a recipe for therapeutic disater.

In my experience, the most important therapeutic tool is deep respectful listening. With that as the ground, inviting all alters to listen in, mapped or not, addressing their concerns and understanding them in their context becomes possible. Other tools I used were stillness on the part of the therapist, working with the practice of one safe breath at a time to connect them to the safety of each present moment, self-soothing techniques, grounding techniques and the 5% rule. Medication, if used as an adjunct to psychotherapy rather than the principal therapeutic intervention, can have clear benefits to support the patient.

 

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Encouraging Empathy Within DID Systems

Recently, I posted a two-part piece on the importance of cultivating and training therapists in empathy. I am confident that if a therapist has empathy, or even the seeds of empathy, that quality can be nourished, enhanced and cultivated which will necessarily increase their capabilities as a therapist. The distinction was made between sympathy and empathy in that piece, identifying them with compassion as critical components in therapy.

An equally important question for DID individuals is that if empathy can be taught among therapist-trainees, can we engender and help cultivate empathy in alters? In my experience, it is definitely possible and can be vital in DID therapy. Let’s examine the possibility of suggesting to patients (and to others with DID) that alters can begin to connect with other alters inside in ways that are both kind and safe.

In practice, encouraging connections among alters needs to be done slowly, gently and over time. Remember, empathy requires the ability to place oneself in the position of the other. Alters are, very correctly, scared of this. After all, it was early childhood trauma on an ongoing basis that is the general origin of DID. For an alter to fully experience and express empathy for another traumatized alter is extremely difficult. Why? Because the system actually does know how terrible the trauma was – it is not just projection and guesswork as it may be for a therapist.

Many alters are frightened of other alters, in particular those that act out internally and externally in extreme ways. They are often frightened of the intensity of the trauma other alters hold. After all, protecting the system’s parts is the reason the dissociative response often produces amnestic barriers. So, disturbing the protection established very early on with the amnestic barriers is something to be done only with the agreement of the alters, which can be gently invited but never demanded.

Some alters are dismissive of other alters, denigrating them for a perceived weakness. Some alters are angry so as to keep their armor up and attuned to potential attack. It is important when you see the myriad of presentations inside a system, even your own, to know that it is not necessary to try to speak to each and every alter about the importance of empathy.

The fact is that beginning a connection between one alter with just one other can have a fundamentally powerful impact on the relationships among all the alters. Why? Because it demonstrates the possibility of safe interaction. It demonstrates the power of simple warmth along with the ability and benefit of gently dissolving some of the amnestic barriers.

Imagine a radiator. It will have a scary quality if your first experience of a radiator is burning yourself on its hot surface. You might never get close to a radiator again out of fear. But, if you are cold, and someone shows you that staying 5 feet away from the radiator will make you feel a little warmer but not too much warmer, you can learn that the radiator isn’t always dangerous at that distance. Then, you can stay 3 feet away and see how much warmth you experience there. When it gets a little too warm, say at 1 foot away, then you have learned the boundary of safety in terms of that particular radiator.

The warm connection of empathy inside can be the same for the alter that is frightened to connect to another. That is true on both sides, the alter considering extending warmth – who may not want to get too close to the trauma material of another alter – as well as the alter considering accepting warmth – who may not want to get too close to another for fear of betrayal or of retraumatization if they open up even a little bit. Encourage the alters to express and to feel the warmth a little at a time, like being 5 feet away from the radiator, or even 10 feet. It is the intention, the aspiration to connect, which opens the gate of and to support.

Don’t suggest that any alter truly try to take on the trauma of another, or to go deep into their imagination of the trauma material held by another. The system knows what is and has gone on, even if individual alters only hold a piece of the memory. Just as with the approach I took with my patients, it is never necessary to pry into the trauma material, just be available to listen to and for what an alter might present. That is enough for empathy inside.

Pushing further increases the risk of retraumatization. So, go safely, small step by small step, while asking the protectors to watch over the process to ensure if doesn’t go too fast. Even inside, the 5% Rule is a key protective mechanism to remember. http://www.engagingmultiples.com/the-...

Many alters hold specific traumas or parts of trauma, and have done so since the trauma occurred. In so many ways that is their identity, their reason to exist. The trauma they hold was affixed to them in a dissociative experience, one that no doubt terrified the system. This resulted in the arising of that alter and perhaps others.

While memories may be walled off internally between alters, many alters know of the others, or at least some of the others. Many alters know which alters they want to stay far away from and which ones they might be willing to connect a bit closer to. You can start with encouraging an alter to simply be there to listen to another alter who may be crying, who may need the experience of a kind word inside, who may simply need the experience of not being alone. You are not trying to have one alter fix another, just to confirm a connection – like catching someone’s eye across the room and nodding to them. That connection can be a balm which sets healing in motion.

In my experience, once alters start helping one another, the rate of healing is tremendously accelerated.  Encouraging an alter to explore the possibility of helping has to come very slowly and very skillfully, a subtly suggested invitation. The initial response is usually a big NO. Why? Because to suggest that alters help each other goes against the foundation of dissociation. It goes against the amnestic barriers that arose originally for protection and to minimize pain.

Even just the idea that there are alters inside that will befriend or at least listen to another alter – that will listen to that sadness, anger, whatever – is extraordinarily powerful. It establishes the sense, correctly, that there is the possibility of comfort and even help 24/7 – right there within the system. It can become one of the pillars that allows for co-consciousness and for eliminating the sharp edges of internal conflict. This is self-empowerment.

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Empathy For Therapists: Part 2

The important role of empathy in a therapeutic alliance is seldom emphasized in training, particularly as the treatment focus has moved toward pharmaceutical intervention. Perhaps some teachers of psychotherapy feel it is self-evident and therefore there is no need to elaborate. However, in practice, this deficiency is often evident. It shows up immediately when there is the mistaken view that information can be gathered without paying attention to the unconscious currents displayed in how the patient presents during the initial interview, the initial contact where the therapist is gathering background data. This continues if there is the further mistaken view that therapy can be conducted in a detached, apparently scientific way, as if that appearance is, in itself, sufficient.

Novice therapists, particularly those whose training has focused on psycho-pharmaceuticals, sometimes are under the false impression that merely following a checklist will result in competent therapeutic intervention and guidance. This is foolish. To think that one can expect genuine healing of depression from merely a prescription of a drug, without awareness of the patient’s personal milieu and social background, the past and present contexts of their life, is both ludicrous and dangerous.

In the case of a cold or “too busy to listen” attitude of the therapist, relevant information is often not communicated or, if it is communicated, it fails to be identified as important. Results of intake assessment interviews can be biased if they follow a pattern of questions and answers according to what is solely the interviewer’s definition of essential data. A checklist style of interview presumes that one will end up with a complete and accurate sheet of information if only one asks the right questions.

Nothing is farther than the truth. That mode of interrogation may yield many false positive answers as well as many false negative answers. When there is a lack in empathy, communication often becomes meaningless. Novice therapist may miss the critical context of a response by becoming diverted over some minor detail. A simple and unfortunately accurate example is that missing a clue to early childhood sexual abuse is a mistake of vital significance in an assessment.

Empathy directs the therapist in the how, when and what to say in the history taking. The sensitive therapist will know when to keep silent, when to ask follow-up questions, and what to ask while remaining always tuned in to the emotional tone of the communication. This means that each and every intake assessment will be different, based on the presentation of the patient.

In other words, the therapist becomes sensitive to the voice of the individual’s unconscious. Conscious data and words are seen as only part of the picture. True reliable and meaningful data of the interview are obtained only in a positive therapeutic relationship. The foundation of that lies in the therapist’s empathic understanding. This highlights the fact that there is no clear line of demarcation between when an assessment ends and therapy begins.

Never forget that the patient is assessing the therapist during the entire assessment event. A patient that doesn’t see empathy from the therapist is not going to trust that therapist enough to make the assessment accurate. Further, without empathy, there is a very real risk that the interviewee will not return to become a patient due to that lack of trust. In other words, an improperly conducted assessment, without empathy, is already heading to a therapeutic failure.

Personally, I suspect empathy can be turned nurtured and developed in most individuals. But, there is a prevailing tendency to denigrate the importance of empathy, because it is not seen as true science. According to Carl Rogers (1977), three attributes of the therapist form the core part of the therapeutic relationship – congruence, unconditional positive regard and accurate empathic understanding. These are the only tools the therapist possesses, just as indispensable to the therapist as scalpels, anesthesia and the asepsis are to the surgeon.

Today, the individuals who are overly focused on psycho-pharmaceutical approaches may forget these critical attributes. In practice, some professionals are exclusively focused on accurate record-keeping Accurate record-keeping is extremely important for therapy, but is not so helpful if it is focused on primarily for the sake of practicing defensive psychiatry, the fear of litigation. A therapist with perfect record-keeping may have done everything in a legally impeccable way – always prescribing in accord with the manufacturers’ recommendations – but without empathy may be unable to successfully treat their patients.

In the absence of a warm “ready to listen” clinical approach, case after case can easily get misdiagnosed. How can that happen to good therapists? It can happen quite easily when therapists are exhausted and overwhelmed by their caseload. When the caseload becomes too much, those who only pay lip service to genuine psychotherapy will limit their success in helping to those who will respond to antidepressants. The very real problem with this then is that the carpenter whose only tool is a hammer will see everything like a nail to strike.

How often do psychiatrists go home to their double martini to relieve the distress caused by vicarious trauma? The burned-out therapist often unwittingly chooses turning off empathy as a way of protecting themselves from the emotional cost of providing therapy. The fact is that everyone wants to avoid pain, even if the pain belongs to the other person. However, therapist do not have that choice if they wish to truly benefit their patients.

Empathy requires the ability to handle psychological conflicts, including that of the therapist. It is much easier to turn off empathy and do one’s work mechanically, than to listen with empathy and feel the pain of the other person. But, the penalty for that is doing bad or useless psychiatry. Therapists need to protect themselves by caring for their own state of mind. In that way, they can expand their ability to care for their patients.

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Empathy For Therapists: Part 1

Empathy is something mental health professionals are assumed to have in abundance. We normally take for granted that anyone wishing to be a therapist would have that fundamental quality as it is the cornerstone of proper mental health assessment and treatment. But, while many therapists have sympathy, empathy is not quite so common, particularly in treating individuals with DID.

It is important to understand the differences between sympathy and empathy. Both are necessary to engender and cultivate a therapeutic alliance but they have separate functions and impacts on both therapists and patients. Sympathy is a feeling that engenders warmth in a connection while empathy is something far more active that provokes a much more personal and deeper understanding.

Sympathy is feeling compassion for the hardships that another person has encountered or is currently experiencing. It doesn’t require that you actually understand or can share in some way that person’s experience. It is more like you feel bad that they have had to experience something distressing.

Empathy is actually imagining yourself in the shoes of another person, getting a sense of what their pain might really be by imagining yourself in their circumstances. It is a deeper understanding because, to a greater or lesser extent, you are touching the feelings of another person – not just witnessing them. Sympathy is like seeing the other person’s experience from the outside whereas empathy is like touching the person’s experience from the inside.

While a therapist cannot truly experience the early childhood abuse of their patient, the therapist can seek to truly imagine themselves in the circumstances of their patient at the time of the original traumas. One has to consider as deeply as possible what the terror and pain was for the patient. To do this, you cannot imagine yourself now, as an adult, but rather imagine being a small child under attack by an abuser who is 10 times your size and controls every aspect of your being. Imagine that attacker threatening you or your siblings if you were to say anything about the abuse. Imagine that the attacker is the person who is supposed to be caring for you, the person everyone in the outside world assumes is protecting you. Imagining yourself like that, having only a small child’s limited verbal and physical development, and in that set of circumstances, is one way to generate empathy, to appreciate the intensity of the traumatic experience of a patient.

Doing this on an ongoing basis is a way to cultivate direct empathy for the patient. It is critical to being able to develop the capacity to communicate safety and understanding to the patient in the present. It is this capacity that enables the patient to begin to trust the therapeutic alliance that is so necessary for effective treatment.

In practice, empathy involves sympathy and compassion. So, it is important to enhance those qualities as well. It is not possible to have true empathy for someone injured in a car accident without feeling sympathetic towards their pain as well as feeling the desire to lend a helping hand. Many people, therapists and otherwise, can relate to car accidents and injuries that result from them.

Not so many people, therapists and otherwise, can relate to the circumstances that result in DID – which are much more terrifying. It is the terrifying nature of the abuse experience, happening in early childhood, that sometimes keeps therapists from being willing to fully empathize with their patients. For therapists, one has to be careful with these kinds of empathy exercises because there is a risk of vicarious trauma. I have discussed this further in Volume 2 of Engaging Multiple Personalities as I believe it is a real issue therapists must deal with in their own lives.

Remember that while empathy is the ability to understand another individual’s experience by putting oneself into the other’s place, the therapist must retain their own objectivity. Therapists must be introspective and assess their own reactions to what their patient may have survived. This includes being aware of the therapist’s own fears of vicarious trauma and perhaps fears as to how they themselves might have reacted had they been subjected to that abuse.

As therapists, empathy is perhaps the most crucial quality needed in the establishment of rapport, of a therapeutic alliance. Deep empathy helps our patients to be open to experiencing the therapeutic milieu as safe, as trust-worthy and as having integrity. This is the prerequisite for effective helping relationships, enabling the patients to share their innermost concerns with their therapist to begin and continue in the process of healing.

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Inviting Alters to Therapy

A reader asked about working with alters that were afraid to present themselves authentically in therapy, even though at least some of them viewed their therapist as amazing. It seems that because they were fearful and wanted to remain safe, they were prevented from presenting by what was likely a protector. At least part of the system was afraid of “losing control.” It seems that there was at least one part that “filled with rage and seems to need to come out but can’t.”

Internal conflicts like this a common phenomenon. With any such internal conflict, it is important to respect all the participants and, with that respect, to engage their different perspectives. Using the 5% rule as an approach may give some level of comfort to the protector that things will not get out of hand (http://www.engagingmultiples.com/the-5-rule/). That same approach may allow for an alter that is enraged to express a small piece of anger at a time and feel safer doing it that way.

The healing journey is actually quicker and deeper when one goes small step by small step. Anything more runs the risk of retraumatization. The protector is likely aware of and concerned about the risk of potential betrayal and/or abandonment. The risk of retraumatization is something perhaps the protector is also aware of and concerned about. Both are important functions of protectors. For healing, creating a path that protects from the retraumatization while allowing for engagement is best.

The second part of the question flowed from the first. It concerned the experience of alters in despair specifically because they would leave therapy sessions feeling that they had not presented truly or as they needed to. The result is that they leave feeling worse than when they came to therapy, feeling once again that they had failed. I think that this is also not an uncommon experience.

Making sure that everyone – all of the alters whether they are presenting externally or not – is invited to listen is an important first step. This can be done at the beginning of each session. Then, at the end of each session, everyone should definitely be thanked for listening, whether they actively participated out loud or not.

It is important to acknowledge the bravery of alters that are willing to show up even if they are as yet unable to express what they need to say. By inviting them at the beginning and always thanking them at the end, you demonstrate your willingness to let them decide if and when they feel safe enough to participate directly. By doing so, you demonstrate your appreciation for their desire to heal.

The act of acknowledging alters is a powerful method of validating them because they have never been acknowledged before. Often, therapists are mistaken in thinking that alters should disappear, because they are seen as something pathological to be eliminated. This is a mistaken view.

This acknowledgment is critical. When a very hostile alter feels acknowledged and understood, something is going to shift. Sometimes it can be like defusing a bomb, and the DID system knows this. Remember, behind anger there is always deep hurt.

When one alter is able to engage in therapy, using the 5% Rule or otherwise, other alters will begin to feel the benefit. As one heals, the others will begin to feel safer and eventually participate in the healing process. It is a rippling effect, which often happens in DID therapy. When an alter presents and wishes to participate directly in therapy, they will do so if they are invited with genuine warmth and empathy.

Many alters will heal by witnessing the therapeutic process of other alters as they go through it. As one alter is healed, others may feel the therapeutic effect. Because of this, each alter does not need separate therapeutic intervention.

So be kind to everyone inside, be patient with them as you engage. With that kindness, with that patience, healing can take place.

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When Alters Attack Inside

TRIGGER WARNING

The following is in response to an enquiry which I think may have a general relevance to our readers. As the question involves violence within a DID multiplicity system, please note that this post comes with a trigger warning.

 

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A reader with DID spoke to her therapist about an alter who was attacking small alters inside, including sexually. The therapist told her to get over it because it didn’t really happen. I believe this is a mistaken approach to therapy that will undermine the possibility of a genuine therapeutic alliance with those alters. In my view, it perpetuates the belief in the system that no one believes them about their trauma. This experience is not particularly different from when one angry alter does physical harm to another alter, like cutting or cigarette burning. The alters experience it in the same way – they are under attack, they cannot defend themselves, and they are not being believed.

In establishing a therapeutic relationship with DID individuals, the therapist has to get over their conventional view, their own ties to the logic of a unitary consciousness. They have to accept how the alter that is communication genuinely feels rather than impose their own logic on to his/her patient. To an outsider, an individual cutting himself is hurting himself. It is visible to the therapists eyes. In the context of a DID system, this is often seen as one alter trying to cause harm and injury to another alter. When the damage is not visible to the therapist, that doesn’t mean it isn’t happening.

I remember the case of Ruth in Chapter 5 of my book. Ruth was hospitalized against her wish to keep her from bleeding to death, because of her continuing attempts to cut herself. She was forcibly kept in a general hospital for 5 continuous months.  She was discharged with the case-note indicating that she was still alive. Despite the clear dissociative symptoms, she was not given a dissociative diagnosis.

So, how was she able to survive and heal? Most important, she wanted to heal. She interviewed me as a potential psychiatrist to help her. Treatment was quickly instigated through weekly psycho-therapeutic sessions, and by inviting her alters to air their complaints. For Ruth, it took the form of therapy through journaling and discussing the written material she brought to the therapy sessions.  While she never responded to anti-depressant medication, involving years on heavy dosages including in the hospital, her “depression” responded to psychotherapy.  Her cutting was quickly reduced as a result and did not pose any more danger to her life.   So long as she felt hopeful, I never worried that she would succeed in killing herself.

Therapists have to get over the hurdle of understanding that the experience of a DID individual is based on understanding the context in which alters engage each other and the outside world. The most effective way to do this, in my experience, was to engage the alters as they presented. In considering this seemingly “illogical” proposition of one alter sexually abusing another, it could be seen quite straightforwardly as one alter angry enough to want to cause physical and psychological harm to another alter.  

The therapeutic task with the angry alter is then to engage that angry alter to understand what function the rage and conduct is serving, why they feel it is necessary to do this. It is no doubt related to that alter’s own trauma and the seeds of healing will be found in that engagement. The therapeutic task with the abused alter is, as always, to engage that alter to allow them to process their trauma. While there is no “one size fits all” approach in helping alters process their trauma, engaging each alter as they present their feelings, their experience, opens the gate for healing. In my practice, I would often suggest that other alters engage with the angry alter, to listen to that one as well as to intervene as a friend just as I would suggest that other alters engage with the abused alter to listen as well as intervene as a friend.

It is not appropriate for an outsider, therapist or otherwise, to debate what they see as the impossibility of one alter abusing another, when they are sharing the same body.   It misses the entire point of the dissociative response.

We, as therapists, have to accept how an alter feels, which is genuine and real, no matter how “illogical” this may appear to an outsider. Without that acceptance, a genuine therapeutic alliance simply will not take root.

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Diagnostic Labels

A reader posted a question regarding the diagnostic label that might be applied to him. Apparently, his therapist read my Volume 1 of Engaging Multiple Personalities and decided the reader was not “multiple” but has “dissociative parts”. Not surprisingly, the parts see that as a statement invalidating their existence and significance. In short, it was taken as making the parts appear to be less than real – even though, as the reader put it, “we feel pretty darn real”.

This issue may be something of interest for the general DID community and its support networks.

I am not sure why, after reading Volume 1, a therapist would take the position distinguishing dissociative parts from multiples in that way. In Volumes 1 and 2, I do distinguish between parts that have executive functioning capability and those that don’t. But that distinction is useful only to identify which parts developed in ways that encouraged executive capacity and which parts developed for holding discrete pieces of trauma. This distinction has nothing to do with whether one part is more real than any other part – or any less real than any other part. If the individual has dissociative parts that feel they are not being fully acknowledged because they are not seen as “personalities” , but just as ” dissociative parts”, then I don’t see how a true therapeutic alliance can fully form between the patient and therapist. If the parts feel they are separate individual personalities, who am I or any therapist to argue that they are not sufficiently distinct and separate to be given that classification? If you feel deeply about the sense that you are a personality, just like other alters, you should be acknowledged accordingly.

Diagnostic labels are just that – labels. They are just words. They are labels used to organize ideas and facilitate communication of phenomenon or experience. They should be used to promote healing, not conflict.

For example, some readers have complained that I use the words “multiple personalities” in the title of the series. Given the change in the DSM from Multiple Personality Disorder to Dissociative Identity Disorder, why do I continue to do that? It is because many DID individuals, and certainly my patients when I was in practice, prefer the word personalities. They feel the term to be more appropriate to how they, including alters, feel. That was more important to me as a therapist than the views of many people outside the DID experience, including doctors or therapists, who vehemently object to the use of the words multiple and personality together, who insist the there cannot be more than one person in one physical body. One could have a philosophical argument about that but will it help process any trauma? No.

I do not have any problem if my patients or anyone else prefer to use the word personality instead of identity. These are just words, so use any word that you feel applies to you that communicates your experience. Of course, you have to pay attention to your immediate circumstances in choosing the appropriate words for that context. There is no problem explaining that you have 7 personalities or identities while in a therapy session but there is no point in expecting an immigration officer at the border to understand that there are 7 of you as you show your passport at the border.

In therapy, the focus is to process the past trauma that keeps on intruding into the here and now. It is to facilitate internal cooperation, communication, coordination within the system. The idea is to minimize the conflict among the alters because that conflict prevents processing the trauma and prevents you from reclaiming your life.

It is important for the therapist to concentrate on helping the alters to feel respected, validated and taken seriously, as they individually appear, so that a genuine therapeutic alliance can be established. With that, an environment of healing can be created. Everything else is of minor importance. If you have a therapist you can work with, I would not waste time fighting about a diagnostic label. It is better to simply tell them what you need. If it is too difficult for someone to say out loud, then written messages from alters that can be delivered in a therapy session may be helpful.

Diagnostic labels are created by theorists trying to describe observed phenomenon. In my psychiatric practice, the guiding principle was not theory but rather practicality – how to help someone process trauma. Processing trauma is not theory. It is hard work. Its success is based on the efforts of the patient and the application by the therapist of psycho-therapy with kindness, compassion and empathy.

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Communicating With Alters That Don’t Speak

A reader wrote to me asking my thoughts about a problem that affects many DID individuals. The question was about working with alters who are mute, perhaps too young to speak, or, in general, uncommunicative. This raised a common concern: how can we communicate when they do not speak?

The foundation of this is the understanding that communication with alters in need is essential for healing. Ignoring alters will simply make matters worse.

When we consider the possibilities of communication, it can take place directly or indirectly, verbally or non-verbally. Direct verbal communication is usually, though not always, somewhat straightforward. Indirect verbal communication can refer messages routed through a 3rd party. In the case of DID, this 3rd party routing can be very useful. I had patients that established one or more alters as the spokesperson and/or message deliverer between me and alters that for whatever reason did not wish to communicate directly. Sometimes, the communication gateways were alters that knew the silent ones inside enough to approach them, or be approached by them, to pass messages in both directions.

With respect to young alters that were pre-verbal, these had usually arisen at the time of early abuse that took place when the host was pre-verbal. For those, it seemed that alters who were just a bit older and already verbal were the best at communicating to those very young alters, and could facilitate communications.

In short, I suggest that encouraging alters to take on that role can be very helpful. Some may be willing to do so, some not. Inviting alters to try, even if they don’t succeed, is a positive step forward – like cracking open a door that has been long closed. The door won’t readily swing on hinges that have been frozen in place after so long, but the first little opening enables a second to take place and a third until eventually the hinge begins to swing more easily.

Sometimes, among all people, communication involves messages that say one thing on the surface but make another, sometimes different statement, at the same time. In DID, the internal conflict can play out in that kind of communication. For example, the communication might come from a very angry protector saying “I hate you – so stay away or else…” But that same message may be co-mingled or be an overlay of a message from a frightened very young alter testing whether or not the therapeutic alliance is genuine or just anotherj opportunity for betrayal.

Non-verbal communication takes place all the time and is a very important way of communication. Take the example of communication between species, we all know for example a dog owner and his dog can be in deep communication without use of words. Most of us have heard of dolphins being trapped in a fish net,  who express their gratitude after being cut loose by a diver. I believe all this is true— we human just get a little carried away by over-dependence on the use of words.

Non-verbal communication is powerful and often overlooked. We all have experienced hunches and “6th sense” warnings, alerting us of danger or conveying respect and positive regard from total strangers speaking in an unfamiliar language.

How does this relate to individuals with DID? Often the body language will be the communication – unadorned and straightforward. This is true whether it is rage, fear or laughter. Again, one can use that body language as a way to open another long-closed door. For example, an alter (male) of one of my patients became angry at home one afternoon and just started banging her head really hard against the floor as she grunted. It was quite frightening for the spouse.

The intensity of the anger and the head-banging didn’t make any sense. There hadn’t been any argument but something had triggered this reaction. Taking the approach of trying to engage what was obviously an alter, the spouse said that he didn’t understand why she was banging her head against the floor but really wanted to understand because it was obviously important to know the “why.”

Taking that body language and grunting as communication rather than as psychosis, allowed the spouse to ask that genuine question. The spouse asked for help to understand what the head-banging meant. Because a genuine question was asked respectfully, and because the spouse was genuinely trying to engage, the 5 year old alter answered in words that it was how he protected the system from the abuser. This didn’t make much sense to the spouse. How was it protective to be smashing your head against the floor?

The alter first glared at the spouse – pretty much indicating that the spouse was obviously too slow-witted to get it. But then, again because the spouse was genuinely trying to engage on the alter’s own terms, the alter was quite explicit that he did the head-banging because he knew it would frighten the abuser. If he frightened the abuser then he was the one in control – not the abuser. He explained that if he hurt the body’s head, they (meaning the host and the family abuser) would end up at the hospital. The abuser didn’t want that because then he would have to explain how the head injury occurred to the police or doctors at the hospital.

When the spouse remarked that it was incredibly brave and insightful to have come up with that on the spot, the alter straightened up his body – head up, shoulders back, the chest swelling with pride. Why? Because the spouse understood and appreciated the hidden message. The spouse understood that banging the head against the floor was a brilliant and sane thing to do by a five year old under the circumstances. It was not something crazy. As the alter swelled with pride, the spouse started laughing and then the alter started grinning – a gigantic grin.

A bridge was built on the spot in that way. That was the beginning of the spouse being able to successfully invite a shift in an angry protective alter and turn that alter into a support in healing.

That same patient had alters that would come out at night. Having already developed a relationship with the alter described above, the spouse was told that these were really really little ones. They would come out crying in fetal positions, wracked with sobbing. With the information from the 5 year old alter that these were likely infants, the spouse had them lay their heads on his chest so they could feel his heartbeat, his slow breathing, and his arms softly holding their back, protecting them. In holding them the way a parent would hold an injured infant, these alters would cry for awhile and then leave when they had been held enough for that moment. After a few months, they wouldn’t come out sobbing but rather would come out crying just a bit and finally would sometimes fall asleep on the spouse’s chest. Their appearance became increasing rare until they no longer seemed to need to come out. Nothing else really needed to be done but to be there for them, acknowledging that they had been hurt and needed comforting.

I think we can strive toward communication with alters who do not use verbal communication. Try to be sensitive to their needs, their unprocessed trauma. By being there, being genuine and sometimes simply being still, conveying the willingness to listen and to understand, we may be able to help those with DID accomplish quite a bit of healing.

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Engaging with Many Voices

Letters from readers applying the information contained in my books and blog are a rich reward in my retirement. Nothing is more satisfying than to learn that my humble writing efforts reach the around the Globe and offer some help to individuals with DID. Trauma and dissociation is widespread and, unfortunately, so often dismissed by professionals in the field of mental health. With blogs and social media support groups, there are now additional vehicles to bring comfort to many who continue to suffer from trauma and dissociation.

I received some kind words about my books, along with a question, from a reader who is both a DID therapist and patient. While he may post a review, the more important message was in his question. I felt his message included something in particular, a way to communicate the experience of DID, to those in the mental health field as well as to those outside of it.  I think this reader nailed perfectly his experience of dealing with many voices.

The reader described his experience as being “like an uncontrollable, undisciplined meeting where everybody is speaking at the time time” or “like listening to 15 radio stations at the same time, but being unable to understand or sort out what they say.”

Part of educating non-DID individuals as to the experience and truth of DID is figuring out how to communicate the DID experience. The analogy given by the correspondant, that it is like turning on 15 radios set on different stations simultaneously, is accurate and instructive to non-DID individuals. If your friends or therapist doesn’t understand or appreciate the experience, bringing in 15 radios tuned to different stations might be incredibly helpful. Perhaps this is something that should be done at each and every meeting of therapists who deny DID because they simply cannot connect with the experience.

The questions had to do with dealing with that experience of so many voices clamoring for attention at the same time. I suggested to begin journaling. My patient Ruth, presented in Chapter 5 , volume 1, had hundreds of alters all trying to communicate at the same time. We sorted that out fairly quickly. I asked her to invite the alters who wished to introduce themselves and write about their grievances to allow Ruth to bring in a few pages of messages to therapy sessions, according to degree of urgency or severity. The alters very quickly realized they all had a chance to get their problems addressed. They became very cooperative and took turns to be “heard.”

Reading out the messages and responding to the specific alters directly, it became a method to quickly engage them individually. The approach was problem orientated, rather than alter orientated.

Journal writing can be very effective, both as a form of self-therapy or incorporated into the therapy session. Writing has a calming effect in organizing what appears to be chaotic and confusing thoughts.

As a child, I learned that most of the time, if I could put my problem or question clearly in words, I have often come close to the answer myself. That is because the process of writing helps organize ideas and thoughts. If, having organized the ideas and thoughts by writing, with your therapist’s support you can begin to come close to the answer –  which is the beginning of processing the trauma. Once Ruth’s alters were assured that they were being taken seriously, they would take turns to present their concerns. I did not try to go through a checklist of all the alters but only listened to those with the most urgent messages. Not all the alters needed to go through individual therapy. I encouraged communication among the alters, and the breaking down of memory barriers. In that way, when one was helped, others felt that their problems is helped as well because many do have similar problems and issues.

As readers of my books and blog know, I think it is very important to connect to one’s sense perceptions in order to understand the here and now experience. Grounding exercises, using the 5% rule and one-breath meditation are all techniques that can be helpful to address the concerns of all parts of the system.

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The Meaning of Forgiveness – Part 2

The reason to consider forgiveness in the way described in Part 1 of this 2 part post, to consider letting go, is that non-forgiveness carries its own deep penalties. Intense and completely appropriate deep resentment, the deep sense of betrayal, and the other conflicted emotions that all go along with those are harmful to your own well-being, both spiritually and physically. But, do not ever forget that it was those same intense emotions that saved you as a young child.

Those same intense emotions may manifest as alters that you have difficulties with because of their intensity. By engaging those alters and acknowledging the truth of both your pain and their protective intentions, you can transform the intensity from conflict with alters to mutual cooperative support. In that way, you can forgive but not forget. In that way you honor those alters and your own survival. In that way, you protect yourself from falling into the trap of mistaken conventional understandings of forgiveness.

Persistent anger and resentment, feeling oppressed and being hyper-vigilant are mental states that are harmful to the those who do not forgive in a safe and protective way. It tinges their way of seeing the world. They are quick to look for, project out and only see the faults of others. They color their direct perceptions and adopt a negative way of seeing the world around around them. They are likely to miss the birds singing or the sun shining. They miss all the good stuff of being alive.

Their hyper-vigilance make them paranoid and mistrustful. They handicap themselves and put up roadblocks to all potentially healthy relationships. In the extreme cases, they are chronically depressed, often drowning themselves with chemical addictions. They miss out on so many of the good things in life. So work on dialing down the hyper-vigilance. Let go into ordinary appropriate vigilance. It is safer and respectful to your protectors. They are still and will always be needed.

Physically, failing to let go results in chronically raised levels of cortisol, the so-called “stress hormone.” Scientists have clearly determined that elevated cortisol levels interfere with learning and memory, lower immune function and bone density, increase weight gain, blood pressure, cholesterol, heart disease. Letting go allows us to care enough about our bodies to get rid of negative hormones circulating in our system.

Again, we must be honest. Healing is a journey, a path. It is difficult to let go and forgive. One must pay attention to the part (whether it is a fragment of the person that appears momentarily, or an alter with the capacity for ongoing executive function) who is too hurt to let go of that anger and pain. One has to pay attention to these parts. One cannot just rush in and tell a part to forget the past and move on, so to speak. If you are a DID, ask who cannot or is unwilling to forgive, then gently allow that part to process getting over the negative experience he/she is stuck with. It will help to reinforce that the goal in forgiving does not, absolutely does not, include forgetting. It does not, absolutely does not, include allowing a perpetrator close once again.

Notice how much hurt the “alter” is still feeling. Work on consoling that part. If you are a partner of the one with DID, you can still work on a part that is unwilling and unable to let go of the hurt. Treat that part as deeply real as that part perceives itself to be. Work on consoling it to allow healing from the wound.

It takes time, but the goal is eventually arriving at the stage that you will be safely released from the negative emotions of anger and bitterness. Learn to be kind to yourself, or that specific part of yourself. Then you can truly be free.

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