David Yeung's Blog, page 14

Anxiety – Part 2: Patterns and Recommendations

In psychiatry, just as in any other branch of medicine, the real cause of a symptom may be hidden from the patient, the doctor or both. In psychiatry, the root causes of disorders are often unintentional hidden because of internal conflicts that are submerged below one’s consciousness. We all have experienced worrying about one thing only to eventually discover that the real issue is something quite different.

1. Anxiety may be caused by a taboo subject we simply cannot or do not wish to face.For example, a young woman married to an abusive man may not consider divorce an option, will not even see it as a possibility. Sometimes that is because there are children involved, sometimes it is because of financial circumstances or religious teachings. Such a person coming to a therapist for help presenting a variety of anxieties and depressive symptoms may never mention the domestic violence – even though it is the core issue. It behooves the therapist to exercise their sensitive radar to clue in because direct questioning will often elicit a simple negative answer resulting in everyone involved heading down the garden path of deception.

2. Anxiety often creates other symptoms in order to create a distraction that can lead both the patient and therapist on a wild-goose chase. For example, a sore back, a stiff neck or a splitting headache or compulsively cleaning at a specific time late each evening may be the complaint. Focusing on the distractions soon turn the distraction into a real problem that even more strongly leads away from the root issues.

3. Anxiety is characterized by a state of helplessness, of complete loss of self-control. Typical examples include, ” I cannot breathe” in a panic attack as well as “I can’t sleep” in insomnia. Normally breathing and sleeping are part of the effortless behavior pattern of a living being. The anxiety is interrupting the basic human operating systems.

4. Anxiety leads to cognitive distortions. Even doctors have anxiety/depression. I know of a doctor, a specialist, who in the depth of his depression, without any reason, worried that no one would come to see him in his practice when in reality, the usual waiting time to see him was 6 months.

 

Key Remedies to Consider:

1. Come back to the present.

For runaway anxiety such as panic attacks, the first thing to do is to bring oneself back to the present moment. That is empowerment. In other words, don’t fight the panic in your mind: Reassert control over your physiological response to the thoughts. How to do this? Well, the most common complaint in anxiety attacks is ” I cannot breathe.” Under the circumstances, until the patient is able to do this alone, the therapist will have to strongly take over and direct the patient to breathe SLOWLY. I would reassure my patients that it is safe to regain the control by holding the breath for ten seconds. I would tell them that even at my age, I could still hold my breath for one minute without causing any harm to my body. That usually caught their attention. By seeing that it was harmless for me to hold my breath for 1 minute, they were reassured that holding their breath for 10 seconds would not hurt them. Once they had intentionally slowed down their breathing, they generally felt re-empowered, back in control of their most basic body function. This was simple, immediate, effective and within their capacity. The fact that I was willing to throw myself into their fearful experience reassured them that I was taking their concern seriously, not casually dismissing their complaints as trivial.

2. Learn how to worry constructively

Some worries are necessary while others are not. Let us call one group “constructive” and the other “destructive.” First, we need to learn to distinguish between the two. The reason we usually cannot separate one from the other, leading to the paralysis of anxiety disorder, is that we are too emotionally involved with the subject of our worry. Effectively, we are talking about correcting cognitive distortion.

Destructive worrying is worry that entraps one onto a vicious self-perpetuating cycle. The resultant worry feeds into whatever is causing the worrying making it worse, creating a sense of loss of control or “dis-empowerment.” There are usually two internally opposing voices at work. One tells you that your worrying is justified. The other says that you are just worrying too much, that you should not be worrying. Constructive worrying enables you to consider the issues without entrapping yourself in a vicious self-perpetuating cycle.

How can we determine whether or not our worry is constructive? A patient came to see me once for anxiety issues. I applied the paradoxical intention concept from Victor Frankl’s Logotherapy approach. I asked my patient to sit still for a few minutes to prepare himself, organize his thoughts and review what was bothering him, before telling me all the things that were bothering him. In other words, I was asking him to worry without trying to fight it.

As a result of my request, he gave himself permission to worry. He sat down and focused on the internal turmoil without worrying about his worrying. When he was sitting and reviewing what he was supposed to be worrying about without that self-criticism, he was able to process his situation without further outside input. After a few minutes, to my surprise, he opened his eyes and said that what he was worrying turned out to be of no real significance. He did not even need to tell me! His body language confirmed it.

Be very clear about your non-verbal language as a therapist because it carries a lot of weight – often more weight than the spoken word. It was clear to my patient both verbally and non-verbally that I took his complaint seriously and respectfully, rather than being dismissive of his worries.

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Anxiety – Part 1: Symptom and Message

In a psychiatric practice, anxiety is the most common complaint among patients. But consider how common is it that a psychiatrist facing an anxious patient immediately concludes that the patient is suffering from “Anxiety Disorder” and simply prescribes a pill for the anxiety. The same holds true with patients complaining of depression. No wonder that a consensus is slowly building everywhere but in the pharmaceutical industry that there is an alarming number of North Americans – men, women and children – are over-medicated for pain, anxiety, or depression.

In an ordinary medical practice, pain is the most common complaint among patients seeing their family doctor. For example, when hearing a complaint of pain in the stomach area, the doctor first tries to find out a little more about the pain before making a diagnosis. The doctor will ask if the pain is acute, chronic, triggered by a particular movement or food, whether it hurts when it is pressed here rather than there, and so on. Only after the analysis concerning the source of the pain is made would a diagnosis be made and an analgesic (a pain killer) be prescribed.

Just as many cases of pain can be traced to bad posture, lack of exercise, and lack of mobility in the elderly, many cases of anxiety and depression can be traced to very real experiences of deep trauma.

Life is filled with mixtures of joy and sadness, carefree laughter and deep worries. Joy and laughter are seldom experienced as a problem. But when something in the environment triggers your internal alarm system, you will start worrying. Worrying is not per se a bad thing. It can be helpful in deciding to focus your energy in preparation for a task at hand, for problem solving or securing a level of certainty. However, when worry becomes one’s normal state of being, it becomes difficult to control. It can result in persistent anxiety, loss of sleep and/or raising blood pressure. When worry becomes ongoing anxiety, inappropriate or disproportionate to the object of concern, it is no longer helpful.

Clearly, not all worrying is pathological. For instance, if your teenage son is going out for a casual ride but you suspect that the driver has had a couple of beers, then your worry is perfectly justified. It is an alarm bell going off that is to be taken seriously. But once we have done the necessary scrutinizing of a situation, and ensured that reasonable actions have been taken, worrying is a waste of energy. If that worrying continues to the point of paralysis, it then fits into the psychiatric category of an Anxiety Disorder.

The next question needs to be asked though, “Does that mean that drugs are necessarily the best treatment?” One argument against pharmacological treatment is that while drugs can ease your mental tension, they may also take away the ability to encourage yourself to practice self-regulation while potentially leading you down the path of chemical dependency. Being trained to deal with tension via a quick chemical fix is not particularly that far from the entryway of addiction. In the long run, is this beneficial for you? It is my view that as therapists, we should be encouraging patients to engage in correcting and refining the balance of their internal alarm system through therapy that may include medication as an adjunct but not the sole treatment.

Life is full of obstacles past, present and future. One must beware of relying solely on drugs to protect you. Relying on a drug that helps, without embarking on the necessary internal re-calibration work of psychotherapy, is a mistake. Why? Because you have not used the situation to learn about the root causes of your difficulties in dealing with the obstacles you face. This leads to the ongoing undermining of your own sense of self-empowerment.

If you visit your family doctor because of a pain in your right shoulder, I certainly hope the doctor does not say, “We will open up your shoulder and take out whatever is bothering you.” No, you want the doctor to ask more questions, to further examine the shoulder, and order some tests to find out the real pathology. Shoulder pain can be what is called “referred pain” which can indicate potential pathologies as diverse as abdominal, pelvic, heart and lung problems as well as, of course, a strain or tear in the shoulder muscles. In a similar way, simply treating anxiety or depression without identifying the actual illness or circumstances causing those symptoms is at best lazy medicine and, unfortunately, has the capacity to be far worse.

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When You Don’t Want to Leave Your Therapist

In general, therapist and clients have an extraordinary relationship. While therapists make their living by providing therapy services, their relationship with clients must be genuine, congruent and empathic to be effective. It is not the same as having a conventional or ordinary close friendship because the trust and power dynamics are neither conventional nor ordinary.

Naturally, some alters, particularly the young ones, want to cling on to the relationship with their therapist after termination of therapy. This is true whether it is the end of a single session or the end of therapy completely. This is an important issue in the therapeutic relationship. Expressing the confidence and willingness to be there for the next session is something a therapist commonly does to encourage and support the client in ongoing therapy. It is saying that the relationship is not over – just the session. This is quite different from ending the therapeutic relationship. This is something I dealt with in preparing my patients for my retirement a decade ago. I took a year to help prepare them for that transition.

Clients often see their therapist as a particular kind of a close friend: One willing to communicate confidentially about the client’s personal history for the sole purpose of helping them heal from trauma. It is someone with whom clients can talk about issues and histories that are not so safe for to communicate about outside of the therapeutic environment. So, even thought the therapist/client relationship is based on payment for services, it is also like the best part of a friend who gives you their undivided attention. They give that undivided attention for an hour every week or 2 weeks. This is different than an ordinary friendship, no matter how genuine.

In normal personal relationships, you choose your friends based on certain qualities that appeal to you, whether he/she is funny, handsome or smart, etc. There is an expectation of sharing information about one’s life, more or less deeply depending on the depth of the friendship. Change and growth are implicitly expected in any relationship, but in a therapeutic relationship that expectation is solely about the change, growth and healing of the client.

Therapists don’t choose patients in the same way they choose their friends, such as common interests, social circles, and the like. They treat the individuals that come into their office, whether or not they have friends, hobbies or other things in common. Unless there are exceptional circumstances, the therapist takes whoever comes into their office needing his/her service. It is important to understand that your therapist-friend has problems of his or her own, but, unlike a conventional friendship, he does not share them with you. He maintains this boundary in order to ensure that he is there solely for your needs, not his own. Your therapist has to keep his problems to himself in order to properly be there for you.

Deep down, the therapist treating DID is often providing a corrective parenting experience offered in the safety of a therapeutic relationship to support the client processing past trauma. What is a corrective parenting experience? It is being there for someone when they are hurt, reassuring them of their basic goodness and helping them feel better. For example, when a child falls down and scrapes their knee, a proper parental response would be picking up the child, looking at the injury, assessing it and either getting the child medical treatment or reassuring them that the injury will heal without much of a problem. In other words, providing comfort and safety.  A traumatizing parental response would be something belittling, mean. It would be using the incident as an excuse to further crush the child’s self-esteem and sense of safety by eliminating the idea that the parent will ever serve as the child’s adult protector in the world.

There is a risk that the the young alters in particular will not understand that the therapist providing a corrective parental experience is not the same as the therapist becoming a replacement parent. This is something the therapist must gently and consistently clarify for the client.

After termination of therapy, there is no legal requirement that there be a complete cessation of contact. However, for ethical and genuinely therapeutic reasons, it is risky and inappropriate for the therapist to engage in a direct relationship of friendship with a former client. The power dynamic inherent in the original relationship will not disappear. Further, and critically important, is the fact that should the client need therapeutic assistance in the future, a direct relationship of friendship will cut off that possibility.

It might be OK if the client wishes to send their former therapist an occasional greeting card. Sometimes that may be done by the client in order to leave open the possibility of returning to therapy with the original therapist. In fact, one of my patients continued for years to send the occasional brief letter to my secretary to maintain some continuity with my office. in my experience, maintaining that boundary is important for the well-being of the (former) client. It is my view that when the client finishes with therapy, it is important that he/she feels the improvement is based on their own efforts, rather than something to be credited to me. It is their successful processing of the past trauma, their survival, that is the point – not my achievement. If they can move on in life without further therapy, it is all for the better.

This is very difficult for some of the alters to understand, particularly when they remain infantile or of very young age. This does highlight another question, whether or not young alters grow and mature in their age during therapy. As is shown in some of my other writings, integration is not necessarily the goal. If the alters integrate, and their age approximates that of the body’s chronological age, that is fine. But, in my opinion, the most important mark of successful DID therapy is that the conflicts among alters are resolved so that they are working together rather than at cross-purposes based on unprocessed trauma.

This answer will not satisfy all, especially those who remain having young alters in their system. There are really no comforting words that are guaranteed to reassure a group of children (in DID – the young alters) when we take away their caregiver (in DID – the therapist) and say everything is OK. It doesn’t work for a child traumatized and separated from their loving parent as a result of worldly circumstances like illness or war, and it doesn’t work for a DID system traumatized in the past and now separating from their therapist.

However, one can give them all confidence in their ability to continue on their healing journey. That is part of the preparation work, prior to termination of therapy, that I tried to do for all of my patients. Perhaps some of the adult alters in the DID system can take over some parenting function transferred from the therapist. Perhaps the alters can become really good friends inside, supporting and mentoring each other. Perhaps the system can become more firmly established in their self-care and grounding exercises. The best reminder for the system is that all the parts are there for a reason so be kind to everyone inside, always be kind.

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Breathing

It seems a bit silly to tell someone how to breathe. After all, everyone breathes. But,”take a deep breath” is something people have been saying to others for generations when trying to help them calm down. What is the connection between breathing and healing, or potential healing in connection with DID?

Therapists have clued in on yoga and meditation as having some benefits in the psychological healing and restoration process. Many therapists encourage patients to engage in breathing exercises and “controlled” breathing. They usually connect this to mindfulness; meditation stripped of its spiritual/religious context. Previously, I posted on the risks of mindfulness meditation with DID; http://www.engagingmultiples.com/mind.... In my experience with patients, the benefits are not so automatic as some people say. And, there are risks.

Breathing is governed by the brain’s respiratory center. While you can control your breathing as a voluntary act, your brain will continue to instruct your body to breathe without you having to continually give conscious instructions to do so. Beyond that, even though one can willfully hold one’s breath, the eventual lack of oxygen and accumulation of carbon dioxide in the lungs causes the brain’s respiratory center to overwhelm your will: You breathe again whether you want to or not. The point here is that breathing is governed both involuntarily as well as voluntarily.

Breathing patterns change when a person is under stress. A person under stress, any person, is likely to automatically to hold his breath or to breathe laboriously. In a genuine panic attack, one often feels as if one has to catch their breath, or as if one cannot breathe at all. A person in a panic usually takes very shallow and very fast breaths. This comes back to the common message we all get – to “take a deep breath” in order to calm down.

In my opinion, “take a deep breath” is the wrong phrase to use. I preferred to tell my patients to slow down their breathing. Why not tell them to take a deep breath? There are two reasons. First, I want to avoid encouraging already panicking patients to continue with their rapid breathing, just try to grab more air as you pant.. That doesn’t address the panic – the patient continues to panic. As a therapist, you are then encouraging them to experience their panic attack like a drowning person trying to suck in all the air they can. Second, and most important as a therapeutic intervention, panic attacks are about experiencing a loss of control. Fear is coupled with that sensation of the loss of control. Therapeutic intervention needs to address the physiological connection between breathing, fear and the loss of control

It is my experience that enabling a patient to reclaim control over their physiological response to fear gives them a tool for coming back to the present moment. It is often a very effective tool that opens a door to escaping the entrapment of the triggered physiological panic response. Go back to the fact that breathing is a blend of voluntary and involuntary control by the brain: It is within your power to slow down your breathing. One can start by slowing the breathing down just a little bit. With practice, a patient can utilize their voluntary control of breathing in a gentle way to slowly bring themselves back to a place of psychological safety. That is enabling a patient to connect with and rely upon their own fundamental strength. That is empowerment – the opposite of loss of control.

Slowing down the breathing, rather than fighting the gasping for air head-on, allows the brain to blend back the voluntary control back into the involuntary panic driven breathing. Going from 100% involuntary control of panicked breathing to 98% involuntary control and 2% voluntary control can happen without inducing further panic responses. Then one can slowly increase the percentage of voluntary control, perhaps to 5% voluntary control and then maybe 10%, and so on. So, for me and my patients, the key phrase was “slow down the breath.”

Once the patient is willing to try to slow down the breathing, even asserting only 2% voluntary control, they then have the direct experience of being able to assert some level of control over their breathing. That small level of control is the experience of having power over the impact of the past trauma – even just that little bit. The patient discovers the fact that it is possible, through one’s own breathing, to regain control over their body – which is taking control away from the past trauma.

Slow breathing is always associated with a sense of “equanimity and tranquility.” In slowly breathing out, one activates the parasympathetic nervous system and engenders in the body a trophotropic state – a state where the body rests and recovers its energy. It is a physical sensation that enables the distressed person to discover such feelings in the midst of chaos and fear. This is the way to redirect one’s attention from the impact of past outside trauma to the genuine sensation of inner well-being.

Phrases like “take a deep breath” or ” controlled breathing” are action-oriented. I choose to use more laid-back expressions that suggest lack of confrontation, expressions that call to mind receptivity and awareness. Encouraging a patient to slow down their breathing a little bit at a time lacks any harsh quality of an external command by the therapist. It remains as it should, a suggestion that we can tap into our strength safely. Putting it simply, all is not lost when you are still breathing.

In recent years, there is strong scientific evidence for the benefits of mindful breathing. Mindful breathing is a spiritual practice thousands of years old that is used in many religious traditions. But traditional instructions on mindful breathing are not about control, they are about letting go of the thoughts that tend to take one away from the present moment. The instructions are, effectively, to ride the breath, in and out, as the vehicle to do that letting go.

In the West , as Allen Watts pointed out, it is difficult to understand the concept of “being” as distinct from “doing.” Broadly speaking, in the Judeo-Christian Western world it is uncomfortable to “just be.” It seems that one has to be doing something at all times. The story used to explain this involves  a group of villagers debating what a man, a distant figure far away, is doing. When they approached the man, asking him exactly that. He replied, ” I was just standing here.” That’s it. One does not have to be doing something in the active sense to justify one’s existence. One can “just be.” Arriving in a new place, one can just absorb the experience of sound, sight, smell and taste of the land he is visiting.

While numerous neurological studies have concluded that prolonged practice of meditation can actually change brain structures and alter its way of reacting to stress, DID individuals must approach it slowly, gently and with protections in place. Again, in my experience, start by slowing down the breath when you panic. Practice that slow control mechanism until it becomes a habit. In that way, you are always enhancing your ability to protect your connection to safety in the present moment.

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Surprising Responses to Engaging Multiple Personalities

It has been about two years since the publication of Volume 1 of Engaging Multiple Personalities. While I have received numerous and important responses from individuals with DID and at least a few therapists, I have solicited responses from other readers from whom I had somewhat surprising feedback. I am putting up this post as it highlights some of the obstacles facing those with DID. Forewarned is forearmed, so I offer this as something to help prepare individuals with DID to deal with mistaken views on the part of therapists who should know better – and others they may encounter.

1.  “Trauma happened decades ago, surely patients can forget and move forward.” This was also expressed as “They should stop dwelling on the past and focus on the future.” This is the most common response to my book by both general (non-DID individuals) readers as well as highly learned or qualified people, including two professors in Medicine, one church minister and headmaster. I am flabbergasted! I thought that by now it would be general knowledge that after some trauma, the memory is stuck in the body, and that one cannot wipe it clear based on the strength of one’s will. The saying is “The body keeps the score.” (Van der Kolk.)

General Dallaire of the Canadian Forces peace keeping soldiers Rwanda wrote a moving account of a flashback he had that was triggered by seeing a person chopping open a coconut shell with a cleaver. Simply seeing that image, he immediately began to re-experience watching people being killed with machetes. His ability to intervene and rescue anyone, to stop the slaughter, was blocked by the UN mandate prohibiting any intervention by him or his men.  He re-experienced the trauma of seeing what was going on, as if he was there once again.

That is the way flashbacks work, it is not a question of choice. They come back faster than a rocket, by-passing the conceptual process. They take over your mind and your body through the autonomic nervous and motor system before coming to one’s awareness. They take over your perceptions so that you are no longer grounded in the present, rather the past reaches out its hands to pull you back. People with PTSD all experience that.  DID survivors commonly experience that kind of flashback regarding early childhood trauma that might have happened decades ago

2.  Another frequent questions was, “Do they really appear like that, as a 4 year old child in the body of a 50 year old woman?” Rather than commenting on the depth of abuse that must have occurred to generate the protective mechanism of dissociation, this is the topic that generated interest. General readers, again referring to those without DID, sometimes get sidetracked by the dramatic aspect of the DID presentation, of an alter suddenly appearing. In doing so, they fail to grasp the impact of the trauma, the fear and suffering experienced the individual experienced in the past or in the present moment of a flashback, and consequent loss of function.

This is worse than unfortunate! In general, people do not want to face the ugly facts of childhood trauma. Because of how terrible the trauma must have been, people cut off their own empathy – perhaps afraid that they themselves will be overwhelmed just contemplating it. Instead, they often refer back to their own experience of a mild loss of details of events from their own childhood. But those references are to what life was like when they were 4 years old rather than imagining the trauma someone else experienced at that age that results in dissociation. It is safer for non-DID individuals to get carried away by the drama, and avoid the trauma.

3. The general reader (and society in general) simply does not grasp the immensity of the problem, the number of individuals affected, and how horrific their experience must have been. It impacts an enormous number of psychiatric patients who are looking for therapists to help treat their trauma and dissociation. It may be that this will change as the impact of foreign conflicts involving large numbers of traumatized children, just as it was not until the tidal wave of PTSD impacting military personnel returning from Vietnam forced society to at least acknowledge that it was there. And just as with the returning servicemen, the impact of the wartime trauma on children in foreign conflicts will take decades to truly unfold.

Certainly toward the end of my psychiatric practice, I repeatedly received confirmation from patients I meet suffering from depression that they were prescribed antidepressants without questions even being asked about their possible adverse childhood experience.    I am well aware that even when such questions are asked, they may not yield the correct answer in the first place – which may correctly be yes or no. However, when patients are not even given the chance to offer any information on past trauma, the therapist has failed in a fundamental way.

I encourage you to have confidence in your own experience as you proceed on your healing journey rather than be subject to the confusion and ignorance of even professionals. Find therapists who do understand DID, or train decent therapists, who simply don’t have experience, through the honesty of your journey.

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A Wonderful Use of This Blog and Engaging Multiple Personalities Volume 1 and 2

I received a personal message giving me permission to discuss how one member of a DID Facebook group used my books, Engaging Multiple Personalities. With great joy and appreciation, this is the message I received, lightly edited for clarity and anonymity:

“Yes of course you can have permission to use my words as you see fit. If it wasn’t for your blogs, I very much doubt I would be helping mental health [workers] in my tiny area make small changes. On Sept 16th 2016 we managed to get a training day on DID for all who work in mental health in our rural sleepy little town in the [UK]. Until we appeared in this little place, the psychiatrist tells me they never had a case of DID!? I suggested that they have but didn’t see them, misdiagnosed them or they are hiding still out of fear, fear they will lose their children, fear we will get that wrong label and be forced to take all sorts of unhelpfully unpleasant drugs. We weren’t accepted easily though. We were taken away from our family put on a section. We were forced to go through a forensic evaluation to assess the risk we were to the public and our youngest child, he is 14. They failed to see he is the last child at home of 6 who was never abused or made to witness our self-harm. We passed the core assessment and forensic evaluation 14 months ago but were only given the right to be alone with our child 2 days ago. We committed no crime, we hurt no one. We were just brave enough to tell our psychiatrist that we have DID. But things are changing [here now]. Another 5 clients have stepped forward to reveal their DID but was in the local [mental health] system far longer than me. It does make us smile now that every person from mental health services we have seen since the training day now knows about DID. We are kept busy with appointments to speak to more CPN’S, social workers, therapists, crisis team nurses to help them in their education about what DID looks like, sounds like and to share our experiences with them. If we didn’t stumble on your books none of this would be possible. So, if we can give a tiny bit back to you to show our appreciation we are more than willing. Thank you from all 17 of us.”

I commend this individual for her bravery and strength in first dealing with the difficulties of her local mental health system for herself and for then helping that same mental health therapist group learn about DID. I am delighted that my blog and books continue to help individuals and mental health workers far from my home! My guess is that with the DID education of the therapists, those additional 5 clients felt safe enough to then disclose their DID. This is how the DID community’s strength helps each other to heal, transforms therapists’ understanding of DID, and can continue to do so.

It was very kind for this system to want to give back to me, to show appreciation. But, truly, this is appreciation for the hard work my own DID patients put into helping me understand how to work with DID. In many ways, my books and blogs are their messengers – their gift of healing to others with DID.

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Should Closure Be A Goal in Therapy?

Like forgiveness, discussed in an earlier blog post (http://www.engagingmultiples.com/trap...), the conventional understanding of closure is not necessarily a realistic goal in therapy. In my opinion, there should not be the presumption that is required for healing.

“Closure” or “Need for Closure” (NFC), the latter being often used interchangeably with Need for Cognitive Closure (NFCC), are psychological terms that describe an individual’s desire for a firm answer to a question and an aversion toward ambiguity. The term “need” denotes a motivated tendency to seek out information.

For my DID patients, the notion of closure was generally connected to seeking some outside confirmation that the abuse indeed happened exactly as remembered. In the therapeutic approach I took, the question of confirming the details of the abuse simply weren’t all that important for therapy. It was clear that my DID patients had been terribly traumatized. It was clear that they were, in the present, subject to tremendous fear, anger and dissociation. They all had triggers they might encounter in the present that, when activated, at any given point in time would pull them back into past trauma. The point of therapy was to limit the impact of the past trauma on the present.

To focus on getting some kind of conventional outside confirmation of the details of the abuse misses the point. The details are not something to be healed. Horrible as they were, they are historical experience.  there is no magic wand or magic pill to make them undo them. They are, simply and brutally, the traumatic experiences that resulted in DID. The problem to be addressed, and the injury to be healed, is the past trauma still affecting the patient in the present. No therapy – no closure – is going to take away the fact that traumatic events occurred. What therapy can do is support healing from the traumatic event(s) and reclaiming one’s life in the present.

It is instructive that many concentration camp survivors – even those that were liberated 70 years earlier – continue to be impacted by the intensity of their experience. Consider that society in general does not discount their experiences. Indeed, they are now usually honored as survivors beating witness to horror and holding a critical collective memory. Yet, whatever support they receive, the survivors of the Nazi concentration camps still carry their wounds. How they carry those wounds, and how it impacts their lives, may be instructive for treating survivors of child abuse – whether or not they have DID.

Those that survived the camps seemed to be able to access a critical desire – the desire to bear witness.  This bearing witness can often be linked to the anger they experienced in being tortured, in being treated as if they were not even human. It is the drive to survive and bear witness that has genuine power, but it is not based on a need for closure. From a DID perspective, I would argue that this highlights the importance of the angry alter(s), who often see fighting for survival as necessary to be able to call out, at some point, the perpetrators.

Those from the camps that continue to speak out in their nineties do not appear to be concerned with anyone outside confirming whether or not their memory is true. They have the confidence that the events happened. There is documentary evidence showing that such things happened. If anything, whether it is seen as spiritual or moral, they perceive that their obligation is to warn humanity of the danger of dehumanizing one’s perception of another person. This is quite different that conventional understandings of closure.

There are a few critical points that distinguish DID patients from concentration camp survivors. First, DID patients were usually assaulted as individuals by individuals close to them – not by others from outside their immediate community. Concentration camp survivors could see that their horror was something they experienced communally – no one denied their suffering in the camp.

Second, it was after the war, usually decades after the war, that holocaust deniers attacked survivors as liars. However, this was a minority that was confronted by the majority of outside powers. It is the opposite of the experience of DID patients where denial of their abuse history begins almost from the moment of the abuse. That denial comes from the abusers, from people they try to communicate to about it, and, based on the usually overwhelming positions of power of their abusers, the abused children themselves .

Third, concentration camp victims were of all ages while most DID patients were abused at an extremely young age – before their ordinary ego structures coalesced, before they developed conceptual defenses and abilities to process their trauma experience. Most very young children brought to concentration camps were killed quickly, as they were too young to be worked to death. This was the case unless they were singled out for use in medical experiments by the horrific Dr. Mengele.

In DID treatment, if one posits the therapeutic goal as closure, then notion of closure must be framed as something attainable. It can be likened to survival and witnessing by the concentration camp survivors but in this case it is to warn humanity of the horrific danger and consequences of child molestation and other abuse. This appears to be happening, finally, as more and more victims of child abuse become willing to talk about their trauma history.

While there is likely no “closure” for the vast majority of DID patients in terms of external confirmation of the abuse, there is the very real possibility of hope, of joy, and of liberation in reclaiming one’s life. This hope, joy and liberation is the best and genuine closure.

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Should Integration Be The Goal in Therapy?

Most standard texts consider a unitary personality, meaning the integration of alters into one single personality, as the ultimate goal and measurement of therapeutic success. I beg to differ. My criterion of success was and is measured in terms of social and relational function. If a DID individual is functioning with minimal internal conflict, like a well put together orchestra or football team, that is success in therapy.

It is not helpful to demand a unitary personality as the final criterion of success. After all, a DID individual is an expert in dissociation. For those with DID, Dissociation is strongly ingrained after being used for decades as a defense mechanism against overwhelming stress at the beginning of abuse, and potentially overwhelming stress one might encounter in the future. That habitual defense pattern will reappear as soon as the post-integration DID individual faces stress in the future that is greater than the strength of the integration.

I believe and maintain that the single personality ideal is a myth. In many non-DID individuals, although there are not amnestic barriers, there are clearly different parts that emerge when needed, whether it be the office personality, the romantic personality or perhaps the competitive athletic personality. So long as there is no undue internal friction, life can carry on even more in a colorful way with multiplicity.

There are many real life examples of highly successful DID individuals who are functioning in their multiplicity as a group of alters who have come to agreement of how to live together in the spirit of cooperation and collaboration within that one body.

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The Focus in Documentaries

I have been asked to participate in a pubic television documentary on DID in Hong Kong. While I think a locally produced documentary is an excellent idea for public education in a city of 7 millions in Asia, where DID is considered nonexistent by the mental health care system, I have reservations about it. There are already many MPD documentaries (and movies) in the public media, whether it be on television, YouTube or otherwise.

The effect in the past has been that the public sees DID as a curiosity, a circus show. So far, all the movies about DID continue to create the false impression that it is a rare condition. The movies and most documentaries portray it as a very curious and, for those not afflicted by it, entertaining illness. Marketing clips, for example show an adult professional women suddenly turning into a 4 year old girl so that the viewer will think, “how extraordinary – I must watch this!”

The result is that the public is impressed for the wrong reason. The DID community will never overcome the prejudicial idea that DID is very rare. The media focus is on the display of alters rather than the root cause of horrific early childhood abuse. That is where the (sometimes) bright light of documentary journalism needs to focus.

DID only appears to be rare. It is a hidden phenomenon, based on very private and confidential personal histories. It is not like a skin rash that someone on the outside immediately sees. Individuals with DID often include hosts that do not know their alters exist, or hosts that consider this kind of splitting as something private. They don’t even want their doctors to know for fear of ridicule, disbelief or being insulted.

I personally know of psychiatrists who simply “don’t believe” in DID, as if it were an issue of faith. For those psychiatrists, the sudden appearance of an alter as a 4 year old girl sitting on the floor in their consultation room is suppressed. It is met with “Go back to your chair and behave like an adult. You are not four, you are thirty-four.” But, DID is not an issue of faith. It is a diagnostic category that has been included for decades in multiple editions of the DSM.

There are several psychiatrists in apparent authority who promulgate their mistaken view. For example, there is a well-known authority, a university professor holding a chair in psychiatry, who proclaims that although he has been in his authoritative position for decades, he has never come across a genuine case of DID. Most laymen, and psychiatrists as well, do not challenge his view. They do not challenge that apparently authoritative statement. It can be scary to confront a so-called authority who has the power to belittle you, to attack you. No wonder society cannot get rid of the idea that DID is a very rare condition.

Most psychiatrists in Hong Kong have never seen even one case of DID. I would argue that the psychiatrists have almost definitely seen DID individuals because, statistically speaking, research shows it to be as common as schizophrenia – which virtually all would acknowledge having seen. What is the argument one can use with them to help them understand that it isn’t that they haven’t seen DID, that they have simply failed to recognize DID?  It is to point out that statistics don’t lie.

Busy psychiatrists looking for symptoms to a pigeonhole a patient into a particular diagnostic box of depression, bipolar disorder or perhaps borderline personality disorder, will see how they can fit the patient into their familiar basket of diagnoses. In other words, their index of suspicion – which excludes DID – will lead them to what they are most comfortable identifying and treating. As a result, DID will not be recognized and therefore not get diagnosed. When that happens, the patient will likely decide that it would be no use to let such a psychiatrist to know of the true nature of their affliction. The consequence is that there is once again no feedback and once again a psychiatrist fails to recognize the disorder.

There isn’t much to be gained in showing an adult speaking as a child on the screen. It becomes another cycle of entertainment, rather than an exposé of an extremely serious public health and social issue; the issue of early childhood trauma. This is the point to stress. It is critical that the public be educated about the widespread nature of such trauma along with its tremendous and wide-spread ramifications to the individuals traumatized and to society in general.

I understand that movies and television shows seek to show something impressive to grab viewers. Unfortunately, what they think is impressive (and more palatable to viewers) is the display of alters rather than the heart of the issue, which is abuse.

I have not yet confirmed my willingness to participate in the documentary as I am still pondering these points.

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Instilling Hope

A decade after retirement, I remain preoccupied with some basic issues pertaining to psychotherapy. I believe it is important to express some of the misgivings I have about the general training and preparation of therapists, based on the experience I gained over 40 years as a psychiatrist.

After one graduates with a basic medical degree, the training to become a psychiatrist lasts for several more years. There are usually pre-medical school studies of basic science or humanities that one takes before embarking on subjects such as anatomy, biochemistry, physiology and psychology. But, somehow, the positive factors relating to healing and restoring individuals to wholeness are not discussed. They may be implied but they are not specifically engaged. Factors that directly influence the work of a therapist are usually not mentioned, the two key ones being hope and compassion. Perhaps they are regarded as self-evident and therefore not in need of exploration but, by failing to focus on them, therapists are not guided to consider their importance or trained in how to put them into action.

The fundamental message of compassion exists in every religious tradition I have encountered. It is an essential practice for many Saints in the Christian tradition; it is one of the principal teachings of the Buddha; and it is the most used word in the Koran. Clearly, the importance of hope and compassion transcends sectarian differences. In the absence of religious traditions, most individuals express their common humanity through kindness and compassion.

It is kindness, the active component of compassion, the instills hope. Hope offers a path back to a sense of possibility in our lives when all, or almost all, seems lost. It’s about relief and restoration. There is a Chinese proverb that says, “Beyond the dark willows and bright flowers, there is another village.” A western proverb says, “A dark cloud has a silver-lining.” These can give sustenance to us going forward, strength to continue putting one foot in front of the other. They communicate the opposite of despair, the opposite of a “dead-end street.”

As a therapist, it is worth considering a few questions concerning hope: how important it is to instill or invoke hope it in your client; how does one engender and nourish hope; what might undermine hope in a patient; what does it feel like for you, as a therapist, to hope; and, crucially, what does it feel like when you, as a human being, lose hope – even briefly. While everyone’s answers are different, asking the questions are critical for one’s own understanding of the role hope plays in your work and life, as well as specifically they might apply to individual patients.

We all should, or are presumed to learn, these positive attributes of hope and compassion though the love and nurturing we receive from our primary caregivers. Generally speaking, they are learned from our parents, or perhaps our teachers in kindergarten and/or Sunday Schools. But, this is less and less the case in modern life. For patients, those positive attributes may not be accessible following trauma – particularly repeated early childhood trauma caused by primary caregivers.

All of therapy is built on a foundation of hope. Hope that things can change: habits, behaviours, emotions, outlooks, relationships and even people themselves.

For those who do not find inspiration from religious texts whether it be the Bible, the Bhagavad Gita, the Koran, the Buddhist sutras or others, let me point out that hope is associated with life itself. The organism knows best. Just as plants grow towards the light, the human organism intuitively knows a healing path back to well-being. A good therapist can point out the light to a patient, but part of therapy is getting to what is blocking this intuitive understanding. Perhaps it is our chaotic day-to-day struggles, perhaps it is confusion that is the result of early traumatic experiences.

To properly provide a therapeutic container, a place where the light can shine on a patient, the therapist must be clear about their own internal obstructions. Therapists are prone to depression and negative mind-sets, just as their patients may be. Many therapists, unconsciously, are drawn to the profession as a way to work out their own psychological issues. Some may simply become overwhelmed by the intensity of their patients’ suffering. Others may survive by becoming inured to it.

A depressed therapist tends to be bogged down by the client’s problems perhaps because they are wearing glasses with that same tint. A therapist may also become depressed as a result of vicarious re-traumatization though their empathic listening. Trauma-fatigue is common for the therapists who have neglected their own mental health in the past, and/or fail to maintain it under the stress of their profession. My training was primarily in British institutions, where professionals are expected to keep a stiff upper lip and maintain one’s dignity as a professional regardless of any internal turmoil. The risks of vicarious trauma and trauma fatigue were never mentioned in my training.

Looking through the case files of successful suicides, I have come to the conclusion that the common element was that hope was missing. There was a failure by the therapist in that critical goal of instilling a sense of hope in the patient. Hope is the predicate to reversing the suicidal path. Sometimes the right medication, or even electro-convulsive treatment, was able to slow down and perhaps reverse the progress towards self-destruction, but not always and certainly not in a majority of the cases I reviewed. If a therapist is honest in their self-reflection, consider the possibility that one if one gives a subtle signal of giving up on the patient, that can and often will be seen by the patient as a message of “permission” to end their life.

To put this in a practical context, when a therapist faces a patient who is imminently suicidal, the first response is to determine, by knowing the patient’s personal circumstances and/or through truly deep listening, how serious the risk is for that patient to act out on their suicidal ideation.

In my previous post on the importance of hope, http://www.engagingmultiples.com/the-..., I discussed briefly a particular patient who was suicidal. She was the last appointment in my day’s schedule. I know that many therapists would decide that immediate hospitalization would have been the correct response to this situation, and in many cases, if not most, they might be correct. However, this was a DID patient and I did not see hospital admission as likely being helpful to reverse that decision.

Hospitals can be a negative experience for the patient, especially when the treatment team or the ward milieu is not suitable for DID patients. One must remember some mental health professionals do not even acknowledge DID as a legitimate diagnostic mental disorder regardless of its inclusion in the DSM. Hospitalization in this particular case would have meant a cop-out for me as the therapist as it would not address the actual triggering issue or the loss of hope. So, I decided the only way to approach this was to see if I could actively instill hope in her.

The key was that I took her words of hopelessness as a simple direct statement rather than a threat of any kind; empty or genuine. Her decision to end her life was averted once hope was instilled in her. I am confident that hope was what saved her.

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