David Yeung's Blog, page 15

Anxiety and Panic Disorders

 

If we suddenly encounter a danger or a threat, we will fight, try to get away or be in such fear that we are immobilized and freeze. The fight, flight or freeze responses are daily experiences in the animal world. A gazelle lives its life grazing in the field and propagating for species survival, while simultaneously being on the alert for predators. Anxiety is an alarm system to keep an animal on its toes, to maintain a look-out for possible life threatening danger. The nervous system is fine-tuned to anticipate danger or threat so that there is time to escape danger.

These responses are normal in the human condition. Something may trigger our alarm system and we are thrown into the emergency alert mode. If the internal alarm goes off when there is no obvious danger or threat, how does one handle this internal warning? You really cannot completely ignore it. You will try to find an explanation to account for it. Your mind may start building up a scenario to account for such fear and anxiety. It may be a subliminal flashback of memory that is the trigger.

More fear will feed on that initial intangible fear, and perhaps a bodily sensation gets misinterpreted. The alarm system will convince you that something is wrong, that there is still danger. And then, you get into a full response mode of fight, flight or freeze. Even if we are getting a clearly false signal of impending danger, we may have already set into motion those patterns of getting ready to fight, running away, or becoming frozen with fear. This is a primitive reaction that is in our genes. It is a reaction cycle that kept our ancestors alive for tens of thousands of years.

The problem is that this kind of response behavior is usually no longer adaptive for survival in modern life. In most cases we do not have a natural predator lurking behind the tall bushes in the park to prey on us. However, as is clear from the statistics on early childhood abuse, there are predators out there, sometimes in the child’s own home. In later life, if some past trauma for which our body has been keeping the score raises its ugly head as a fragment of implicit memory, we receive the same alarm signal warning us of possible life-threatening predatory danger.

Traumatic memory does not function like narrative memory in our ordinary life, like remembering coffee yesterday with a friend. Traumatic memory is often cued by sights, smells, tastes and the feeling tone in an environment. The memory often arises in a pre-verbal way. So, not conceptually remembering the specific trauma doesn’t mean that we have not experienced it, nor does it mean that we don’t carry that trauma in our mindstream.

Therapists in clinical practice see that anxiety comes in all forms. The purest form is anxiety that emerges seemingly out of the blue, without an identifiable reason. When a person reacts to a small triggering sensation, often without even identifying the sensation, the associated traumatic memory of fear itself will emerge quickly into a full blown panic. The sensation can be as small as the tinge of an odor similar to one that was experienced in trauma, or the passing twinge of a painful sensation. The mind is brought back to a danger of the past. The entire body shifts into “battle station” mode. It is not that one is not afraid of something unknown, rather one is on the lookout for something familiarly frightening.

It is very instructive for a therapist to watch anxiety developing right in front of them. I have had the experience of watching a patient developing a panic attack right in front of me in a hospital when I was the psychiatrist on call one night. While remembering that  any physical discomfort or symptom such as chest pain may actually have a real pathological rather than psychological basis – which will be left to the Emergency staff physician to handle – but with respect to a possible psychologically based anxiety attack, there are a series of steps for the therapist to take.

1. The first thing is to convey to the patient of your empathic understanding of the magnitude of fear the patient is experiencing. The worst thing is to make light of the patient’s panic, saying that there is really nothing to worry about.

2. Once you have their confidence, you will have to ascertain that the condition is really a panic disorder, not some physical problem that mimics a panic attack.

3. The preferred treatment depends on the orientation of the physician as well as the time available. In my experience, the efficacy of medication is uncertain. I believe the effects are often largely a matter of how much the patient trusts the therapist. In purely relying on the pharmaceutical effect, one runs into the danger of having to use a colossal dose to suppress the physiological arousal of a panic attack. At best, medication is useful as a short-term temporary intervention.

Panic disorders are related to the patient feeling loss of control over his/her bodily power. I characterize it as a disorder of “dis-empowerment.” The patient is thinking, ” Why is my heart racing so fast when I am sitting down, not even walking.” He/she does not realize it is the response reaction that has spun out of control, with the mind and body setting itself up in preparation for dealing with some as yet unseen but monumental threat. Whether that threat is a present danger or artifact from the past, the physical response is entirely understandable and beyond self-control.

The test of the therapist’s skill is how to suggest or assist the patient in reversing that escalating panic response. Stopping something when it is already in motion is very hard. For example, if a car is moving at 100 miles per hour, and the driver’s foot is pressed down on the accelerator, it is exceeding difficult to stop the car. The first thing to do is to let him/her  regain confidence that the car is still controllable. It is easier to let the person continue speeding while gently steering it in a different direction, perhaps up a hill, rather than insisting to the person that they get their foot off of the accelerator and stop short. The patient is already overwhelmed by the intensity of the panic, it is impossible for them to stop doing whatever their body response dictates.

Remember the analogy of heading the speeding car uphill. Highways that run through mountains have special lanes for runaway trucks with failed brakes – they exit from the main road and head up a hill so that gravity, that invisible hand, acts as an environmental brake. How can a therapist use this analogy? Redirect the patient’s energy rather than confront it. Focus attention onto something for the patient to do that is not connected with denying the panic. There is the well known “Brown Paper Bag” method. This invites the patient to breathe in and out of a brown paper bag. I know of many patients who have successfully used this method. In fact, some carry a brown paper bag with them in case the panic returns.

The paper bag method is so simple. It is not asserting anything about the panic being correct or imaginary, therefore there is usually no obstacle to doing it. When someone is in a panic, the natural tendency is to “do something.” Just as with grounding exercises, this method fits into that protocol every well.

The reason it works is psychological, not physiological. Blowing into a paper bag is a simple task. The mind and body are engaged in a task. Through that engagement, the mind and body energies are redirected rather than suppressed.

There is another reason I like this method. It is because it is something the patient does which leads out of the panic. That is what counts. The best treatment is one that patients can do on their own, which engenders the confidence that they can control their bodily functions. This is re-empowerment.

Most psychiatrists advocate relaxation as the central focus in psychotherapy. This is difficult to apply, and generally not possible in the  midst of a panic attack. To ask a patient to try to relax during a panic attack is like saying to a drowning man, ” Relax, your body will naturally float.” It doesn’t work.

There is a proper time and place for discussion of the patient’s fears, whether they are seen as rational or irrational, but it is not during an attack. The cognitive or rational-emotive approach is appropriate only later, in the context of a supportive therapeutic relationship and environment. For example, a behavioral approach emphasizing graduated exposure to panic-inducing situations is only appropriate after the patient is taught methods of regaining self-control, that he is again the master of his body.

I do not have confidence in the long-term benefits of the text book treatment of panic attack such as:

Carrying items such as medication, water or a cell phone
Having a companion (e.g. a family member or friend) accompany them places
Avoiding physical activities (e.g. exercising, sex) that might trigger panic-like feelings
Avoiding certain foods (e.g. spicy dishes) or beverages (e.g. caffeine, alcohol) because they might trigger panic-like symptoms
Sitting near exits of a room.

All of these may be helpful short-term supports but they generally involve increasing the dependency of the patients, confirming that they are helpless and remain unprepared for the next time onslaught of panic. These methods are not based on, nor will they result in, re-empowering the patients.

I have practiced slow breathing long enough to be able to hold my breath for about 2 minutes. Given that, I was able to show and reassure my patients that it is quite safe to not breathe for 15 seconds. Then all I asked them to do is to slow down their breaths to say 4 times a minute. Once they were willing to try to slow down their breathing, even just by counting to 10 between each inhalation and exhalation, their panic dissipated.

No one can sustain panic when the breath is slowed down. The usual difficulty is convincing a patient to slow down their breath because they all feel they are struggling for air. By having them breathe along with me, they can see that they are able to work with their own breath. Then, they do it themselves. Once this is accomplished, the panic will usually not return in that intensity, and the patient will not become dependent on medication for anxiety .

After the panic is under control, find out what else needs attention. Is there past trauma? Is the current life-situation full of difficulties? Tell your therapist. In the absence of a therapist, or if you have yet to establish a safe therapeutic relationship, tell yourself by writing into your diary. Putting your troubles into words is always better than just stewing about it. In writing, it becomes something tangible with boundaries that can be worked with. Too much thinking often becomes a fruitless exercise – like a dog chasing its own tail.

Panic disorders are not something that you need to find a magic pill to cure. Even if there is such a pill, it will only work temporarily. I am generally against giving pills for this because on the one hand, they may not work and on the other hand, they most certainly will not re-empower you. Grounding exercises are critical for a patient’s re-empowerment. Practice them regularly before a panic attack arises so that you develop a personal panic toolbox to keep you centered in the present moment.

Panic attacks are self-perpetuating, tail-chasing, vicious cycles that distract us. What do they distract us from? Usually, they keep us from getting near a deep unhealed wound. A bacterial infection needs an antibiotic for healing, but panic attackes are not caused by an external agent like a bacteria. To eliminate a panic attack, one needs an inoculation of the present moment’s safety. Grounding is that specific inoculation.

Panic may be your body telling you that there is danger or that something needs to be fixed. Take heed of its warning—use your time and energy to deal with the real issue, rather than seeking a medication to suppress the alarm signal. If you cannot yet find the reason for your fear, through grounding, you have at least found a way to control your body, to re-own it again.

A famous psychotherapist in the mid 20th century, Frieda Fromm-Reichmann, wrote about a man, probably not her patient, who was suffering from severe anxiety. He underwent in-depth psychoanalysis. In this case, there was a real yet seemingly unrecognized reason for the anxiety, even though he was then at the peak of his wealth/fame/family bliss. Soon after he was “cured”, the Nazis took over and he was taken to the concentration camp to be exterminated.

There is an important lesson in this: Anxiety, like depression, is not always a symptom to be eliminated. Don’t limit your focus in therapy to turning off the alarm. Check to make sure whether or not the alarm signal is correctly assessing a present danger.

 

The post Anxiety and Panic Disorders appeared first on Engaging Multiple Personalities.

Working with Traumatic Memory: Practically Speaking

In psychiatry, and in fact for all kinds of counseling, all procedures start with collecting data from the patient. Starting with the individual’s history, finding out what is happening with the patient and learning the psychological background as well as social context, one then attempts to comfort, counsel and heal. This information gathering involves asking some questions but more important is listening to the clients’, and sometimes others’, account of the current and the past situations. Often past trauma is an essential part of the history. Thus, understanding the dynamic of traumatic memory is fundamental to gathering history, just as it is fundamental to proper treatment.

All police officers, judges, counselors, therapists, clinical psychologists, and psychiatrists must at least have some basic knowledge of this dynamic. Without it, grave misunderstandings may arise. The individual’s veracity may be questioned and incorrectly denied. Injustice may be the result based on misunderstanding of the dynamic and demanding a narrative of non-declarative memory. Such a demand simply won’t work. Non-declarative traumatic memory is simply not expressed as a narrative. That doesn’t imply that it is false. It simply means that one has to understand it without the crutch of a conventionally presented storyline.

Often, some past trauma is not remembered. Past trauma is not something anyone really wants to remember, especially if remembering it means, in one’s body, that one re-experiences it.. However, eventually past trauma will resurface. Not too long ago, there was a great deal of furor debating on this topic. The question was posed as to whether or not such “recovered” memory, memories that eventually resurfaced, especially during psychotherapy, can be accepted at face value.

“Repressed memory” is a Freudian term referring to memory that has been unconsciously blocked, due to the memory being associated with a high level of stress or trauma. The theory postulates that even though the individual cannot recall the memory, it may still be affecting them consciously.

A more neutral term, “forgotten or lost memory”, is often used instead. Some studies have shown that forgotten memory can occur in victims of trauma, while others dispute it. According to some psychologists, forgotten memory can be recovered through therapy. Other psychologists argue that this is in fact rather a process through which false memories are created by blending actual memories and outside influences. According to the American Psychological Association, it is not possible to distinguish lost memories from false ones without corroborating evidence.

So, if a patient begins to remember traumatic memories during the process of therapy, how does one know if such memory is accurate or aetrogenic, meaning that the patient has been misled by the therapist into creating a false memory? In psychotherapy, recall of the traumatic past during the process of psychotherapy is commonplace. This includes “dissociative amnesia,” which is defined in the DSM as “an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.”

It is well-recognized that “Traumatic Memory”resulting from massive psychic trauma may be associated with amnesia, as well as, paradoxically, hypermnesia. Hypermnesia refers to the unusual power or enhancement of memory, typically under abnormal conditions such as trauma, hypnosis, or narcosis.

A person may be so overwhelmed by a traumatic experience that certain aspect of, or the whole experience may not be registered. For example, many former inmates of Nazi concentration camps could not remember anything of the first days of imprisonment because perception of reality was so overwhelming that it would lead to a mental chaos. [Read Krystal : Massive Psychic Trauma (1968)] At the same time, some part of the traumatic memory may be extremely vivid as if etched in the psyche. An example of this is when a rape victim may retain in great detail the pattern of the curtain behind the abuser at the time of the assault with only the haziest recollection of the appearance of the abuser.

Therapists, police officers and other professionals, unfamiliar with this paradoxical phenomenon, may question the veracity of the victim if the recall of the trauma contains both amnesia and hypermnesia. They presume that, “If the woman was beaten and raped, surely she should remember correctly the color of the car that drove the assailant away.” It is dangerous to use our own ability to access non-traumatic memories as a standard against which we judge a trauma victim’s response.

Fundamentally, there are two kinds of memory: the narrative (explicit memory), and the non-declarative (procedural) memory. The former is involved in the straightforward narrative of an event while the latter is involved in memory that is often unconscious, sub-conscious or simply beyond verbalization. For example, this can refer to recalling an experience such as riding a bicycle (pertaining to motor skill), an emotional response, or a reflex action.

The conversion of the raw data of experience into memory is sifted through different neurological structures such as the amygdala and the hippocampus in the brain. Memory retention is often related to the valence of the emotion associated. Moderate to high activation of the amygdala enhances the long-term potentiation of narrative memory mediated by the hippocampus, while extreme overwhelming arousal disrupts hippocampal functioning, leaving the memories to be stored as affective states or sensori-motor modalities such as somatic sensations or visual images but as not narratives.

One tends to remember something very special, such as the phone number of a person with whom one is very much infatuated. But, in the immediate aftermath of a car accident, the color of the other vehicle may not be registered in one’s narrative memory because of the psychological shock experienced at the time. This is where the therapist (or police officer), in taking a history related to extreme trauma, may find patches of amnesia. One must never jump to hasty conclusions declaring such memory as false just because it has amnestic holes in the narrative. The paradox is that due to the overwhelming arousal, what would ordinarily be stored as narrative memory is instead stored as non-declarative memory.

The above is a gross simplification of the activity of some of the neurological structures that relate to trauma and memory. Because many people are not able to understand or even recognize this complex phenomenon of the impact of trauma on memory, victims are often disbelieved. They are challenged based on their “inadequate” narrative memory of the traumatic experience. But the narrative component of traumatic memory is typically like Swiss cheese, full of holes. It is adding insult to injury to demand a survivor prove his/her case of having been abused in early childhood as a narrative, after they have finally pulled together the courage to come forward to bear witness to their abusive experience. The victim, and their non-declarative memory, are not to blame.

Practical guidelines to follow when one suspects a patient history that includes trauma:

1. Avoid obsessive digging at the past. Do not interrogate a patient before a therapeutic relationship has been established. Even after establishing such a relationship, avoid demanding details. Remember that every question telegraph’s the questioner’s bias to the patient. By the choice of words and the affect associated with the question, one’s bias is revealed in the tone of voice, in body language, etc. Limit your presentation of bias to the extent you can. It takes special effort to phrase a question – including one’s own body language – in a neutral way. Make the effort. The goal is to permit the patient to allow traumatic memories, if they do exist, to arise in their own time and in their own manner of presentation. If you do this and such memories arise, they will arise with authenticity and be far more available to healing.

2. The less interrogation, the easier to establish a therapeutic alliance. In the absence of interrogation, in a container of stable warmth, it is far more likely that trust can be rapidly established. With that trust, trauma information will be forthcoming when and as needed. Usually, it is presented by the patient without any need for prodding by the therapist.

3. It not important to know all the details. The task of the therapist is to help patients deal with the psychological and the physiological effects of past trauma. For example, is the patient able to bring her mind and body back to the here and now, or is she stuck in the past? Successful therapy doesn’t mean the patient must learn and acknowledges all the details of the past trauma. Success is demonstrated when the patient is able to live in the present experiencing safety unencumbered by the past trauma. The patient’s ability to control the disturbance of the memory of the past, to be able come back to enjoy the present moment of safety and peace, is the hallmark of recovery. The patient will tell you what is important to work on.

4. You are not preparing a police report. The central issue is whether the patient is able to develop some detachment and objectivity of the experience. This means that the patient no longer experiences retraumatization, no longer becoming overwhelmed and re-living the trauma when the memory arises. As a therapist, the goal is healing – not building a court case. Neither you as the therapist nor the patient needs to prove the dotting of every “i” and the crossing of every “t”.

5. Understand Traumatic Memory. Traumatic memory consists of images, sensorial and affective states, and behaviors that are invariably consistent over time. These memories are highly state-dependent and cannot be evoked at will. They are not condensed to fit social expectations. Narrative memory is social and adaptable to the needs of both the narrator and the listener. As such, it can be expanded or contracted according to social demands.

Survivors of early childhood trauma are usually left with non-declarative memories of horrific past experiences that are locked in somatic and sensorial memories. These are usually terrifying as they survivors lack a narrative memory to help conceptualize frightening visual imageries. It is common that people are unable to accept these thoughts and feelings.

Once people become conscious of the intrusive qualities of the trauma memory, they are likely to try to fill in the blanks and complete the picture. The stories that people tell about their trauma are as vulnerable to distortion as are people’s stories about anything else. As a result, trauma history may be distorted when it is subjected to misguided leading questions from the therapist. However, just because trauma history may be distortable by its lack of narrative memory or by leading questions, does not mean that trauma did not occur. Let me reiterate the point – human memories are simply not 100% accurate. We are not computers or digital cameras playing back a recording.

6. Truth and Non-Declarative Memory. With non-declarative memory, accuracy to a third party’s conceptual (narrative) understanding of “truth” is not the point. Just as the host in a DID system may simply refuse to believe the truth of the non-declarative memory, that memory is accurate in its context. As I have mentioned repeatedly, the details are not necessary to the therapy. Once the therapist has determined that trauma did occur, let the patient assess the right time to disclose an abusive history in a form and context of their choosing. This is far more likely to produce benefits in therapy as compared to an interrogation based data collection that seeks to determine “exactly” what happened. For the therapist, it is preferable to simply accept the truth that when trauma occurs, details of the traumatic experience may not be recalled in exactly accurate narrative detail.

It is more important for the therapist (and the patient) to know whether or not trauma did occur, rather than the details of who did what when and to whom. There are some specific instances where some of the details may be critical, for example when the abuser is a primary caretaker of the patient and remains in a position to further abuse the patient or others.

7. Memories Held by Alters. Joan, my patient mentioned in Chapter 1 of my book Engaging Multiple Personalities, Volume 1, came to see me complaining of visual imageries and memories of her father abusing her – even though she did not believe it had ever happened. She was afraid she was going out of her mind, that she might be locked up as a crazy person for having such thoughts. Such amnesia, which in this case included the refusal to accept that abuse had happened, is typical of abuse memories when they are being held and expressed only by an alter. The inaccessibility of such memories to the host is exactly the safety dynamic that enabled the individual to survive the abuse at the time it was happening.

The function of such an alter is to spare other parts of the personality the burden/pain of the abuse. This is an example of true dissociated memory. Despite many papers which have argued against “repressed memory,” I have seen it vividly during direct interactions with patients. People who have been traumatized as young children will almost never be able to tell you about it when they first come to see you as your patient. Information gathered through some compulsory interrogation on the first patient’s first visit must be viewed with caution.

8. Genuine Therapeutic Alliance is Key. Those who deny repressed memory claim that to do otherwise invites false positives, abuse memories being presented because the patient thinks that is what you want to hear or that you have “implanted” such memories because of your own confused issues as a therapist. In other words, you have not established a genuine therapeutic alliance and therefore the idea of repressed memories is a vehicle for mutual delusion. The real issue to be concerned with is that one runs a far greater risk of getting false negatives because the patient simply cannot access the non-declarative memories in front of a stranger – which is what you are until a genuine therapeutic alliance has been established.

[This post contains paraphrased material from Bessel A.van der Kolk’s book (1996)]

 

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Is Depression Just a Chemical Imbalance?

For decades, in trying to persuade patients to take drugs for depression, psychiatrists have given them the rationale that the medication was to “correct a chemical imbalance in the brain.”

What is the evidence supporting that rationale? It started many years ago, when Pfizer, manufacturer of the antidepressant Sertraline (Zoloft), wrote that “while the cause [of depression] is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription Zoloft works to correct this imbalance”

Because Sertraline (Zoloft) was known to be a serotonin re-uptake inhibitor, it was widely assumed that it by increasing the serotonin level in the synapses, or gaps, between neurons. This was predicated on the further assumption that depression was related to a low level of serotonin in this synaptic space. The term chemical imbalance then became a “go to” cliché in the psycho-pharmaceutical view of psychiatry. While this is presented as an assumption, in fact some patients genuinely responded in a positive way. But, not all do.

However, in the subsequent frantic race to produce other kinds of antidepressant, it was found that Bupropion (Wellbutrin) also works in the treatment of depression.  This medication works by  inhibiting nor-epinephrine and dopamine re-uptake. This antidepressant is devoid of clinically significant serotonergic effects. It has no direct effect on postsynaptic receptors as does sertaline. Again, some patients genuinely responded in a positive way. But, not all do.

The general idea is that a deficiency of certain neurotransmitters (chemical messengers) at synapses between neurons interferes with the transmission of nerve impulses, causing or contributing to depression. According to this view, it remains unclear whether either one or more of the monoamine neurotransmitters are responsible for depression.

The problem with this view is the failure to acknowledge the fact that while a drug reduces particular symptoms, that does not mean the symptom is caused by a chemical problem the drug corrects. Aspirin will bring down a fever, but it is too much a jump in logic to conclude that Aspirin is correcting a chemical imbalance in the body.

Similarly, one cannot loosely use the term chemical imbalance to explain a gonorrhea infection when the infection responds to a dose of penicillin. In fact, bacterial diseases such as gonorrhea develop resistance to medications. I point out the example of gonorrhea because some strains of that STD are known to be drug resistant. It is instructive to know that such drug resistance is not labelled “treatment resistant.” When anti-depressants fail to work, the depression is deemed treatment resistant. More helpful and more accurate would be to use that same label of the depression being “drug resistant.” Just as a drug resistant STD would send the physician looking for a different treatment, when a myriad of anti-depressants fail to alleviate depression the psychiatrist needs to see that their patient is not simply a chemical soup to experiment with. There are most likely other causes of depression for that patient that playing with chemistry will not overcome.

Further evidence throwing doubt to the hypothesis of depression as simply a chemical imbalance comes from the efficacy of a newly developed antidepressant, Stablon (Tianeptine), which decreases levels of serotonin at synapses. The fact is that many depressed people simply are not helped by these serotonin re-uptake inhibitors.  In a 2009 study, Michael Gitlin of the University of California, reported that one third of those treated with antidepressants do not improve. Further, he reported that a significant percentage of the balance get somewhat better but remain depressed.  If a chemical imbalance is the underlying cause of depression, and antidepressants correct that chemical imbalance, all or most depressed people should get better after taking them.

Neuro-imaging studies have revealed that the amygdala, hypothalamus and anterior cingulate cortex (specific parts of the brain) are often less active in depressed people. Some areas of the prefrontal cortex also show diminished activity, whereas other regions display the opposite pattern.   When someone is under recurrent stress, a hormone called cortisol is released into the bloodstream by the adrenal glands. Long-term elevated cortisol levels can harm some bodily systems. It is well known that in animals, excess cortisol reduces the volume of the hippocampus.

Smaller hippocampus volume is also associated with people with severe childhood trauma. In PTSD studies of pairs of twins (not focused on early childhood trauma), where one had been exposed to trauma and the other has not, there is a significantly smaller hippocampi in the twins with trauma exposure when compared to their twins without trauma exposure. It is noteworthy that depression is almost always present in those with severe childhood trauma and it is almost always a part of the Chronic PTSD picture.

Thus far, there has not been established a clear or direct cause-and-effect relation between brain chemistry and depression. Chemical Imbalance is just a vague term to suggest that there seems to be some chemical disturbance associated with depression, and that certain drugs are known to alleviate depression in some of these depressed patients.   The explanation is speculative and the proof is far from conclusive. It is not known if the depression generated the chemistry or if the chemistry generated the depression. Depression almost certainly does not result from just one change in the brain chemistry. A focus on any one single piece of the depression puzzle—be it brain chemistry, neural networks or socio-psychological stress (for example a recent or remote past stressor) is gross simplification.

From a clinical point of view, depression as a symptom began to assume the status of a disease.  It is akin to classifying a fever as a disease, rather than as a body reaction to a stressor.  Internal medicine has not gone taken that step: We still limit ourselves to documenting fever for investigation to look for its root cause. In psychiatry, that limitation of distinguishing symptoms from disease has gradually eroded to the point where we are bending the diagnostic criteria for making diagnoses. We can now “diagnose” the illness as “Major depression” or “Bipolar affective depression.” In short, we have selected a bunch of symptoms, put them together and call it a syndrome, a disease.

The psychiatrist may be eager to find a disorder that comes with a textbook protocol of pharmaceutical remedies.  In fact, to make a diagnosis of either major depression or bipolar, the symptoms have to satisfy a stringent list as laid down in DSM 5.  Often anxiety and agitation may be interpreted as hyperactivity mimicking hypomania.  Bipolar is easier to “treat”, as there is a standardized algorithm to follow.   Once diagnosed as bipolar, the main treatment approach is pharmaceutical.

Arriving at a DSM 5 psychiatric diagnosis does not and should not make therapists feel satisfied and over-confident to the point of ignoring other complicating and contributing factors influencing the clinical features. The danger today is the false confidence a therapist has once a bipolar label is established, the entire attention is focused on an exclusively pharmaceutical approach. One then has the protocol of waiting for the medication to work, which usually takes weeks. If the medication in adequate dosages fails to work after a few weeks, should one double the dose and wait again? That is certainly one part of the protocol promoted by the pharmaceutical companies’ guidance.

If the patient starts self-destructive behavior, does it mean her depression is worse, or she is feeling hopeless. Perhaps her children are being taken away for adoption because she is considered to be an unfit mother. Would that not be a reasonable, non-chemical imbalance based cause to be depressed?   I have seen numerous examples of cases where once the focus is placed on pharmaceutical treatment, it is as if all socio-psychological factors impinging on the life of the patient can be and are ignored.

We know quite little about depression on a molecular level. Given the multiple reasons for the etiology of depression, to call depression a chemical imbalance in the brain is reminiscent of the classic story in which a group of blind men each touch just one part of an elephant to learn what the animal looks like. If one man happens to have touched the tusk of an elephant, he would swear that the elephant is like a cylinder of polished hard wood while another touching the elephant’s stomach would swear it was like a wall. The catchphrase “chemical imbalance” suggests a phenomenon associated with depression. But, association does not necessarily mean causation.

We really know very little about depression as a disorder. What we do know is that in patients with depression, less than half (roughly speaking) may have their symptoms alleviated by taking an antidepressant.

I am not against the use of antidepressants in treatment.  I have witnessed effective and even dramatic responses to antidepressants in some patients.  However, I am totally against mechanistically calling a symptom a disease and blindly prescribing a pill for that symptom – especially when the symptom is often a normal emotional response to real life circumstances.  Such a course of action can keep a person dysfunctional for years. With that mechanistic view, treatment will be fundamentally limited to finding the magical antidepressant that works, or, at best, one that produces the least harmful side-effects.

While common sense and the history of psychiatry dictates that psychotherapy should be the first line of treatment when someone displays mental health issues, in their eagerness to expedite recovery, psychiatrists starting treatment with pscho-active drugs may lead them to ignore psychological factors for depression, such as severe childhood or other trauma.

Ultimately, which patient should be prescribed drugs as a priority is a matter that should be determined by an experienced and compassionate psychiatrist. To understand the causes of depression, we have to see the entire person, rather than just looking for a chemical disorder called depression.  We have to maintain a strong index of suspicion for hidden or affirmatively ignored childhood trauma.  It is imperative that we therapists always look at the patient as a person, with mind, body and spirit. Only deep listening and empathy can help to bring to awareness, in both therapist and patient, those significant factors that can manifest as depression. We should not attend to just the brain chemistry in a patient with depression. Just as when a car is by the side of the road, we do not just assume that the battery has died. It may be that the driver has run out of gas or is taking a nap!

Anyone can practice medicine if all he does is to prescribe aspirin for fever, a broad spectrum antibiotic for infection, a pain-killer for pain and a steroid as an anti-inflammatory.   These are standard non-specific medications for common symptoms in general practice. Such a practitioner will help some people with some illnesses that those non-specific medications can benefit. He will cause harm to virtually all others due to this lack of insight and lack of a proper index of suspicion for the many diseases that actually affect people.

Depression is a common symptom for almost all patients coming for the first time to see a psychiatrist.  Prescribing an antidepressant as soon as one sees depression in a patients is a cop-out that can have enormously bad consequences. Psychiatry must be on guard against the brain-washing influence of both the pharmaceutical industry and the insurance companies as the payees of the health care providers. We must not embrace “chemical imbalance in the brain” as the answer to the question of depression.   Far too many working in the Mental Health field have fallen into that way of thinking. We need to wake up and re-examine our basic understanding of human beings again.   The obligation to our patients is their well being. Our depressed patients are not just simply pools of chemicals that are not in balance!

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Imagery and Imagination in Healing

This is posted in response to a question from a reader. I think it is an important question with much relevance to the individuals with DID as well as others with trauma in their personal history. Again, as always, I am retired and cannot give therapeutic advice for individual cases. My thoughts on this and other topics are intended to be suggestions that are generally applicable and something to perhaps discuss with your therapists.

In therapy for healing past trauma, it is often suggested that one use “imagery” or “imagination” to create a safe place “inside” for the alters. These can be visual, auditory (hearing), tactile (touch), temperature and kinesthetic (sensations that inform us of our position in space). In my experience the most effective cues leading to relaxation are using the temperature, touch, and kinesthetic modalities. In most cases, the least effective is the visual modality. Generally, we do not need hearing in imagination because we can produce sound, such as raindrops falling on a rooftop, from a music player – whether it comes from a record, CD or audiotape.

Instead of imagining oneself laying on the beach of a tropical island safely enjoying a protected holiday by utilizing visual cues of the white sand and the distant sails in the horizon, I would suggest that the person to imagine lying on the warm sandy beach (feeling the warmth on one’s back), and feeling the heaviness in the limbs and the backside as one is lying down after a long swim. It is my view that in seeing, one places oneself in the position of an observer watching something happening to another person. In concentrating on the sensation of touch, you become the person who is experiencing it.

I often sought to fully utilize the kinesthetic sense in imagery to produce better result. One way is to imagine oneself lying on a mattress which made of a huge bag full of little balloons. Imagine that the balloons are full of helium which is lighter than air, so that it is gently lifting you up in the air. Then imagine your legs are gently bending, flexing and extending all while being supported by the mattress holding you up. In your expansive imagination, you now are capable of doing simple yoga postures in the air because you are lighter than air, floating in the air. When you are imaging that, it is pretty difficult to remain tense. Fully using your imagination, give yourself the magical power to do whatever acrobatics in the air that you wish.

One can consider that two different aspects to the sense of touch: external and internal. Externally, we have our touch through our skin. Internally, through our muscles and joints, we can tell if our legs are straight or bent, if we are bending backwards or curling forwards into a ball. We do not need our sight to tell us that.

So, I suggest that you fully utilize your sense of touch/temperature/kinesthics with imagery; whether it is imagining that your body is feeling cool in a hot day under the shade of a tree or floating in the air. Pay attention to the bodily sensations of your breathing, the feel of the air moving in and out of your nose, the rising and falling of your chest. Bringing in a sense of relaxation, and most important of all, a sense of being in a safe place, you can re-learn what is it like feeling safe and enjoying the present moment.

 

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On Calling Out Alters

Controlling the appearance of alters, how they seem to be switched on or off in a system, is a complex matter. I do not claim to know all the ways this plays out, but I suspect there are many different considerations that govern the appearance of any particular alter. It is likely that specific triggers govern certain appearances, but the overall control is based on an internal system of vigilance that is constantly evaluating the total environment.

The appearance of any particular alter likely depends on the system’s assessment as to whether an alter should come out to fulfill a function or, alternatively, is triggered to jump out in reaction to a situation. In the absence of specific triggers, there is sometimes an alter, often called the gate keeper or having that specific function, with almost complete power to decide who may come out and when.

During the course of therapy, the therapist may eventually learn specific ways to invite out the appearance of particular alters. But, we should not take lightly the ability to “press the button” as it were, to call out an alter for therapy. This should not be done in the absence of extreme circumstances, such as the immediate risk of serious self-injury. Instead, let the system present the alters needing therapy in its own time based on its own assessment. Sometimes the presenting will be direct, as in an alter coming out and speaking to you about their issue in a session. Sometimes it will be indirect, when one alter starts talking about the difficulties of another alter or bringing in notes another alter has written down for the therapist to read.

I give an example of a mistaken approach I once took with the hope that other therapists will not repeat this mistake. I had a patient with one severely depressed alter.  At the suggestion of the patient’s very supportive husband, I wanted to bring out this alter for therapy. He said that the specific alter was triggered to come out by the touching of her hair. Because the suggestion and encouragement came from her genuinely caring husband, I thought there was an implicit consent to this by the patient. That was not a correct assumption. Looking back, the touching of her hair was likely experienced by the patient, specifically that alter, as a kind of violation. I learned from that mistake, but it was a bitter lesson.

It is far more preferable to allow the system to choose, at any particular moment during therapy, to self-initiate therapy with a specific alter. In other words, it is for the system to control the appearance of an alter in need, not the therapist. Giving that power back to the patient is consistent with good psycho-therapeutic practice for patients suffering from early trauma and dissociation. I learned later in my practice that empowering the patient is essential. It is a foundational approach in therapy for survivors of early childhood abuse.

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Co-consciousness

Among DID individuals, the sharing of conscious awareness between alters exists in varying degrees. I have seen cases where there has appeared to be no amnestic barriers between individual alters, where the host and alters appeared to be fully cognizant of each other. On the other hand, I have seen cases where the host was absolutely unaware of any alters despite clear evidence of their presence. In those cases, while the host was not aware of the alters, there were alters with an awareness of the host as well as having some limited awareness of at least a few other alters. So, according to my experience, there is a spectrum of shared consciousness in DID patients. From a therapeutic point of view, while treatment of patients without amnestic barriers differs in some ways from treatment of those with such barriers, the fundamental goal of therapy is the same: to support the healing of the early childhood trauma that gave rise to the dissociation and its attendant alters.

Good DID therapy involves promoting co­-consciousness. With co-­consciousness, it is possible to begin teaching the patient’s system the value of cooperation among the alters. Enjoin them to emulate the spirit of a champion football team, with each member utilizing their full potential and working together to achieve a common goal.

Returning to the patients that seemed to lack amnestic barriers, it is important to understand that such co-consciousness did not mean that the host and alters were well-­coordinated or living in harmony. If they were all in harmony, there would be no “dis­ease.” There would be little likelihood of a need or even desire for psychiatric intervention. It is when there is conflict between the host and/or among alters that treatment is needed.

Conflict in DID patients is usually quite evident. A system full of clashes is usually playing out a power struggle internally that is manifesting externally. In some cases, dictatorial alters may have an iron­clad control over the information flow and behavior of the system as a whole. In addition, because of their strong individualistic feelings, some alters may appear to behave in a callous or selfish way with no regard for the needs of the host and the other alters. This can result in one alter hijacking control of the body for a time, short or extended, for the pleasure/intentions/wishes of that one alter alone. The result is usually the host’s experience of time-­loss, one of the key markers for DID and one of the primary causes for seeking therapy.

Such a hijacking alter may think, “I don’t care that others in the system are tired and may need to sleep. It is my time, and I want to go out. I want to have a good time at the bar.” For example, I had a patient with one alter who regularly took off to have fun cruising around with motor­cycle gangs. She totally disregarded the safety of the system, the boundaries of her support network, and the host’s appointments to see me. I would note that this kind of conflict can occur even in the context of a patient with some level of co­-consciousness.

It is not uncommon for a patient’s host or front to vehemently deny the presence of alters despite clear evidence in diaries, letters, and even recorded messages of alters talking. This is the opposite of co-consciousness – at least with respect to the host. It must be terrifying, not merely disconcerting, for an individual to realize that an alter, another inside part of that same individual, can so completely take over the executive functions of the system to the point that they establish a functioning separate life in the outside world. In fact, I have had patients whose alters would, on occasion, establish a completely separate existence for a few months at a time using that alter’s name. In one case, the alter established her own residence in a different apartment, connected with a different social milieu, and, in that case, earned money as a sex trade worker.

I know hosts who have staunchly fought against such recognition of alters and even the idea of co-consciousness. One cannot blame them. The fear is so intense that I sometimes had patients leave therapy rather than work with the recognition. As a result of those experiences, I learned to sometimes withhold revealing or confirming a DID diagnosis so as to avoid scaring the patient into abruptly terminating therapy. In my judgment, it was occasionally justified to delay confirmation of the diagnosis at least until the foundation of a genuine therapeutic alliance was established.

With respect to cases where the alters are completely hidden from one another, one must tread gently. When the presence of alters is pointed out, some DID individuals may take a long time to be convinced that there are indeed other alters co­existing in that same physical body. As a therapist, do not push the point about alters or co-consciousness as a path to healing. It is not a debate to win or lose. Again, if there weren’t problems, then the patient wouldn’t be in therapy.

The question for the therapist is how to gently promote co­-consciousness. First, one must prepare the patient to hear the news that there are alters inside. You must wait until you have confidence that the message is not going to create uncontrollable panic in the host. Establishing a therapeutic alliance with the host is absolutely critical to this. As the therapist, you may or may not have met some or all of the alters directly. Establishing a therapeutic alliance with alters that you have met, or with whom you can otherwise communicate, can strengthen the host’s ability to hear the news.

Remember that the amnestic barriers arose for very good reasons. Breaking them down without permission invites further trauma. So, make sure the news is given in a way that makes clear that as a therapist you can help bridge the amnestic barriers when the different parts are ready. One helpful analogy for promoting co­-consciousness might be to note that you, the therapist, might be frightened to walk down a dark street alone but would feel much safer walking that same street if you had a friend (or two or three) with you. Even if that friend was also scared, the companionship would be helpful to both you and your friend. Please use the analogy with respect to your own fears about walking down dark streets, not theirs. They will understand the point.

This analogy was quite helpful to some of my patients that had very young alters with similar but not identical trauma memories. The point was not to encourage or even suggest integration. Instead it was to allow each of those alters to know that they were not alone, that there were others inside that could truly understand. That can be the beginning of a friendship within the community of alters. Once that first companionship among alters arises, it can be referenced when talking to other alters that are stil blocked by amnestic barriers.

In this way, you can encourage the direct experience of feeling safer through the experience of co-consciousness. It is a step­-by­-step process. The patient may feel like they are treading on thin ice in terms of their fear and panic. The simple answer is to encourage them to go very slowly, just as you would when walking on thin ice. When you walk on thin ice, you do not know for certain if it is strong enough to hold you. You go inch by inch, testing and seeing what happens. It is the same here.

A not uncommon experience of one alter starting to consider the possibility of companionship with another alter (though not yet safety) is when they become aware that their traumas had strong similarities to the traumas of another alter or perhaps several alters. This is akin to the analogy of walking a dark street together rather than alone. In addition, when there is the experience of a frightened alter witnessing the emergence of a protective alter in the outside world, both alters can begin to appreciate their respective roles in the system. In this case, it might be the frightened alter identifying a danger and the protective alter reacting to that identification and fulfilling its function. This is again a prelude to developing a sense of safety and can occur more easily when the alters begin to become aware of each other. When this takes place without re-traumatization, this is the beginning of seeing the possibility of healthy teamwork that is a mark of healing.

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Christianity and Forgiveness – Part 2

Forgiveness, Christian or otherwise, does not mean condoning or giving excuses to wrongdoing. Sanity may be defined as the ability to tell right from wrong. So here it is: Sexual abuse is wrong. Traumatizing young children is wrong. There is no way to twist logic that makes such abhorrent conduct acceptable. But it is important to remember that the prerequisite to genuine forgiveness is that the victim no longer feels the pain, that the past ceases to intrude into the present.

There are two aspects to an abuser’s wrongdoing: his intention and his action. In other words, he might perform despicable acts based on self-serving so-called “reasoning.” Many child molesters proceed with rationales they know to be false such as, “ It is really quite harmless. She is only 2 years old. She will not remember this when she grows up. After all, I don’t remember what happened to me when I was 2 years old.”

It is likely that with the addition of alcohol and/or rage, the abuser may think that he was justified in his conduct or have forgotten it because it was not a particularly significant event to him. If the victim believes that the original infliction of the trauma is unintentional, they may believe that it will be easier to forgive. In fact, abusers may play on that but it reeks of shifting the blame to the patient along the lines of “It never would have happened if you weren’t such a bad child” or “I was drunk so I am not really responsible.” With respect to the latter, I have colleagues that have studied the Bible and wonder how Lot’s daughter’s might feel about being blamed for their father’s incestuous conduct.

One cannot advise a patient to forgive beyond their own heart if there is even the remotest possibility that the abuser might get a feeling of pathological pleasure, knowing that what he once did decades ago continues having a powerful effect on his victim. The therapist’s task is to lead the patient to understanding that holding on to the bitterness about this past experience continues the entrapment by the abuser. The patient’s task in therapy is to work through this, to process this part of their past experience so as to be liberated from the retraumatization power of the past.

If you are holding something tightly in your hand, it will fall as soon as you loosen your grip. It is the same with processing trauma. Letting go of a painful memory’s strength is possible after you genuinely feel you have shared the experience with a significant person, like your therapist, and that you have finished the task of bearing witness to the crime – the series of childhood traumas. This process of successful therapy is often accomplished by deep listening and empathetic sharing of the pain on the part of the therapist.

Know that forgiveness does not mean forgetting. You need to remember it as part of your experience in life. You need to maintain a certain vigilance, not hyper-vigilance but still vigilant awareness, to make sure you are not preyed upon in the future. If and after you forgive, you have a choice as to whether or not to include the past abuser in your life.

By forgiving, you are accepting the reality of what happened and are able to free yourself from the past’s interference with your current life. This is a gradual process—and it doesn’t necessarily have to include the abuser. Forgiveness isn’t something you do for the person who wronged you; it’s something you do for yourself.

As I and others have said many times, the trauma that leads to DID is so overwhelming that ordinary individuals cannot truly imagine the experience. To presume that one will eventually be able to forgive their abuser in any conventional understanding of forgiveness is, in my opinion and for practical purposes, a fantasy. The aim of treatment should focus on the task at hand, teaching the patient to experience and hold on to the safety of the present. It is to teach the patient that skill so that they can experience the safety of the present when memories of the past arise. When memories are just memories, and are no longer the involuntary reliving of pain, that is what it means by healing.

Here are some therapeutic goals I consider to be realistic for patients. They are practical applications of forgiveness in one’s own heart.

1. On the social side, measures that limit and circumscribe interactions with the abuser must be monitored. For example, patients may not be able to say “no” in daily life if they are still in contact with the abuser. Therapeutically, the first step is to establish a firm base of a pain-free and safe present. The patient needs to learn the real meaning of the present, which is the immediate experience of breathing this very breath. Forgiveness in this context is being non-judgmental towards oneself. There are usually alters that are in conflict and angry with others who participate in any way, shape, or form with an abuser. Introducing each conflicted alter to the possibility of forgiving alters with a different point of view is a very positive start. It is not telling them to go along with that other alter’s view. Rather, it is explaining how that other alter feels. In essence, it is teaching the foundation of empathy. This is not easy, nor is it something that happens quickly. In my experience, it is best introduced talking about how the alter might wish to comfort a confused child – not by yelling but by holding them with warmth. Then, within that warmth, clarifying the present danger rather than re-working the past.

2. In order to forgive oneself, a therapist introduces exercises that teach the patient how to find a physical/psychological safe place in the present. Patients are taught how to put put themselves in a physically relaxed and psychologically comfortable state. The immediate goal is for the patient to make sure that he/she is in a safe distance from the abuser. Within that experience of safety, one can develop the understanding that abusers are both dangerous and usually survivors of abuse themselves. In other words, through the physical and psychological experience of safety in the present, one can remain vigilantly awake, without being hyper-vigilant, and see that abusers are likely acting out the impact of their own history of having been abused. This is training on extending forgiveness without permitting further abuse.

3. Teach the patient to go back and process the past trauma in a titrated/controlled manner. In that way, the patient can eventually experience the arising of that memory without their present consciousness being flooded with sympathetic fight-flight-freeze reactions. Various techniques such as “the 5% rule” have already been explained elsewhere. See: http://www.engagingmultiples.com/the-...

4. Eventually the patient will develop the ability to separate the emotions associated with past trauma from the present recall of that past in a manner which avoids retraumatization. A commonly observed sign of progress is the patient’s increasing ability to spontaneously bring back some detail of the past trauma with less panic and more ease. She will speak in a calm voice, without being entrapped in fear or horror. This is usually accompanied with a sense of sadness – which is completely appropriate. That sadness is another gateway to developing further forgiveness towards oneself and the alters in conflict about the abuser.

5. Sometimes there is a wish to understand why the abuse happened. There is the hope that if one can understand the why, then forgiveness will follow because there is a context for the abuse. As a therapist, one must be very clear that there is no acceptable context that permits abuse. One can understand what drives an abuser may have, but that does not grant the abuser permission to abuse. Sometimes there is a ready understanding of abuse – such as a clear trans-generational abuse pattern. It is important that such a connection is discovered spontaneously by the patient. This is not something to be brought up by the therapist. The patient may show the beginning of understanding by replacing fear or anger with sadness. This means that the patient is developing empathy that is being extended to the abuser. Whether or not genuine forgiveness flows out of this should be left to the natural course of events for that patient. I think it is risking an inappropriate imposition of one’s own religious ideas on the patient to bring up forgiveness to the patient as applied to the abuser. It is positive to encourage internally generating forgiveness by the patient for the patient. But, forgiveness is a heavily loaded term in Christian dogma. One must be extremely careful so that the burden of that loaded term is not imposed, intentionally or unintentionally, on the patient.

6. There may come practical real life situations that are difficult, such as whether the patient is obliged to visit, support, help, or nurse the abusive parent who may or may not be incapacitated but desires the patient’s help in one form or another. My view is that a biological parent, having abused the patient, forfeits their parental status. He has disqualified himself as a parent just as a a physician can be struck off the registry because of misconduct involving a patient. The patient has no obligation towards the abuser as a parent, just as a physician is no longer a physician when his conduct has been found to be unbecoming of that position.

If the patient insists on offering forgiveness, complete or otherwise, then the prerequisite should be that he/she is healed and recovered from the ill-effects of that abusive experience, to the point that they are truly no longer subject to retraumatization. The way he/she speaks of the past abusive experience will make it quite clear whether or not full recovery has been effected. While engaging the abuser as part of one’s expression of forgiveness may be seen as a laudable goal from a religious point of view, for an abused individual it is unrealistic. It is not the appropriate goal for DID therapy.

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Roots of Psychiatry: The Reality of Childhood Trauma

The first thing that often comes to mind for a patient as well as for the therapist is whether memories of early childhood abuse are truth or fantasy. Often such memories are dismissed automatically as being untrue – even by the adult who had been abused as a child. I believe that the reason for this is that people don’t want to believe that horrific abuse of a child can or has happened – to themselves or to others. This societal issue played out in the earliest history of Psychiatry. It may be helpful to examine the background for the use of the term “fantasy”in psychiatry.

Human communication presupposes that people, in general, present themselves and are taken pretty much at face value. In ordinary conversation, one generally does not assume that what one hears is fantasy. The only time one considers something spoken to be fantasy is when it is explicitly stated to be so or when the content is simply beyond the belief of the listener. The crux of childhood trauma is connected most definitely to the latter.

The use of the word fantasy in psychiatry is tied to Freud’s “seduction theory”of hysteria. But it is important and instructive to note that at the beginning of his work, prior to propounding the seduction theory, he used various words interchangeably in an 1896 paper entitled “The Aetiology of Hysteria” to describe “infantile sexual scenes”: Vergewaltigung (rape), Missbrauch (abuse), Verführung (seduction), Angriff (attack), Attentat (a French term, meaning an assault), Aggression, and Traumen (traumas).” All these words explicitly characterize sexual violence directed against the child by an adult. The infantile sex scenes were not characterized as fantasy according to that original work.

Many of Freud’s patients were suffering from what was then termed “hysteria.” Those working with DID, as patient or therapist, will recognize that the common denominator in all kinds of hysteria discussed at that time in psychiatry is dissociation. Freud’s patients were often daughters of prominent men in society, or even of his colleagues. It may or may not have been beyond his imagination to believe that the sexual misconduct of his own upper class community was factual, although clearly in “The Aetiology of Hysteria” he did not doubt that the molestation memories his patients presented were truth. Nowhere in that paper does he raise the question of the memories being fantasy.

However, having formulated his theory of neurosis at the end of the 19th century in Vienna, he had to find an explanation for the sexual memories that was acceptable to his colleagues, the Viennese circle of eminent neurologists and neuropsychiatrists who dismissed his early work.

The result was the “seduction theory.” My understanding is that Freud used the word seduction to soften the tone describing sexual abuse. Using the word seduction implied a consent by the infant, that the infant consented to have sex in the context of seduction. Even that partial blaming of the infant was too close to accusing adults of abuse, so it was rejected by his peers. Freud ended up repudiating the seduction theory, characterizing the expressed memories of his patients as wishful thinking. In other words, there had been no actual sexual conduct. The fault was in the patient, having fantasized a sexual relationship with their father.

In this way, he made the expressing of memories of early sexual experiences with their fathers acceptable in the context of therapy because there was no actual accusation of molestation. In my opinion, the case histories described genuine examples of incest, rape and gross sexual abuse – not fantasy. The explanation given by the seduction theory was that such molestation never actually happened but rather came from patients’ wishful thinking. In this explanation, Freud chose to use the word seduction and fantasy instead of the explicitly violent terms “sexual assault” and “rape” that he used in 1896.

With Freud having characterized the memories as “fantasy,” the word became embedded in the roots of psychoanalytic thinking about early childhood sexual trauma that has dominated American psychiatry up to the 1950s and beyond. Here then, in the very earliest roots of psychiatry, is the repetition of society’s historical shifting of blame onto the victim and away from the perpetrator. It is a consequence of refusing to consider even the possibility that such evil conduct can be perpetrated on a child – particularly by well-to-do educated adults that are often at the head of the family or at the pinnacle of society. The critical impact of this repetition in psychiatry is that it gave a pseudo-scientific/pseudo-medical gloss to the denial and dismissal of molestation memories.

According to my clinical experience, incest and sexual abuse within a family is not uncommon but is often ignored and disbelieved. A 1988 Finnish study, carried out on 9000 15-year-old schoolgirls, had found the prevalence of incest to be 2% with biological fathers and 3.7% with step-fathers.1 Father-daughter incest is and was not as rare as many would like to believe, even today. In my experience, the rate of incest in certain communities is staggeringly high, such as in aboriginal communities suffering the aftermath of cultural genocide.

DID as the result of early childhood trauma is not uncommon and is almost completely ignored and disbelieved. I am confident that this kind of molestation is widespread. Being part of the upper strata of society, being of any particular religion or ethnic group does not impart any immunity to this. In short, I believe Freud’s insight at the very beginning was correct. It seems far more plausible that Freud’s patients were in fact victims of incest, sexual assault, and abuse.

Returning to the use of the word seduction, it is often misunderstood as not being part and parcel of violence. It infers that there is some form of participation by the child, or that there is a quality of love, as it is conventional understood, embedded in the seduction2. This is because seduction has a soft romantic connotation for most people. However, one must not forget that it has nefarious connotations in cases of fraud or of trapping people into sexual exploitation such as trafficking for example. There can be no “consent” by an infant or child to incest or other early childhood abuse – sexual or otherwise.

Let’s not continue any such misunderstanding. Considering the use of the term “seduction” when analyzing the relationship between an adult and an infant, toddler or other young child is wrong, dangerous and a critical warning that bad things are happening. Calling something seduction, when in the the context of sexual contact with a child, whether it be an infant, toddler, or beyond is violent. While it does not necessarily physically injure the child, that is often the case. In all cases of which I am aware, it most definitely injures the child’s psychosocial development – at least through the first 5 stages as categorized by Erickson. Through seeing that injury in a child, one cannot avoid the conclusion that it was the result of violence.

Molestation in the guise of seduction is violence. Do not be deceived by it being dressed up in fancy clothes, fancy language, or accompanied by gifts. Seduction of a child is molestation. It is violence, full-stop.

I have gone into some detail because Freud’s seduction theory and characterization of expressed memories of sexual abuse as wishful thinking had been embraced for a century as a fundamental truth. It is only with the more recent findings of the severity, prevalence and universality of incest and sexual abuse that it is being questioned.

To me, the rate of occurrence of incest and abuse has been – and continues to be – grossly underestimated. Taking sexual abuse as a myth to be dismissed re-traumatizes all those who have been abused. Even as society now begins to acknowledge the violence against young children, in particular young girls, one continues to see the societal prejudice against acknowledging abuse and its effects on boys.

With respect to the statistics on DID, there is reported to be a 6:1 ratio of DID diagnoses for women as compared to men. It is my clinical experience that women tend more often toward direct self-harm and thus are shepherded into the mental health system while men are more likely to engage in physical altercations with the result that they are shepherded into the criminal justice system.

The tension over the question of declaring the memories to be fantasy or reality continues. It prevents many trauma patients from receiving proper diagnoses as well as proper treatment. In my psychiatric practice, after gaining a few decades of experience, it was clear that the body doesn’t lie3. Traumatic events may not be recalled with precision. Whether this is due to the age of the individual when abused or the intensity of the circumstances is irrelevant. The real tension should be understood as the difference between explicit and implicit memory. The body stores only implicit memory when conceptual faculties are not yet developed, or when they are overwhelmed at the time the trauma is inflicted.

Events that might have seemed phantasmagorical to Freud or to a currently practicing therapist may be explicit memory or it may simply be implicit memory being stored and subsequently expressed in archetypal forms. Simply because you cannot imagine the trauma does not mean that the trauma did not happen.

You know a large boat has passed in the ocean by its wake, you don’t need to know what country the boat came from, or how many people were on it, in order to know that it passed by. For treatment, the fact that trauma has occurred is the point to work with. As a therapist, you see the wake of the trauma, you don’t need to dig out the details. The details as expressed by the patient indicate the triggers and the impact of those triggers. They are not points for cross-examination by the therapist. I encourage therapists to avoid this as well as to redirect patients from cross-examining themselves in their internal dialogues.

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Christianity and Forgiveness – Part 1

This post is a follow up to the short post entitled “The Trap of Forgiveness” at http://www.engagingmultiples.com/trap... . It was written following feedback and questions from some readers that are very focused on the Christian notion of forgiveness as part of their healing. It is directed primarily to Christian patients and therapists whose therapeutic work is based on forgiveness as one of the central teachings of Jesus.

Some patients and therapists with deep roots in Christianity see forgiveness as the confirmation of healing. It is sometimes their view that being able to forgive is the ultimate expression of being healed. It is my experience that one needs to be extremely wary of how forgiveness is defined in the context of treating survivors of early childhood abuse.

For example, it is not uncommon for a typical female patient who has survived early childhood abuse by her father to face a spiritual crisis when that father, late in life and perhaps with failing health, asserts his dependency on her as a command. Now insisting on a “normal” father-daughter relationship, he may be conveniently ignoring, making light of, or rationalizing his abusive behavior. The patient may then struggle with this: Should she abandon her abusive father or perform her duty as a Christian daughter forgiving him his past sins?

I cannot emphasize enough the importance of defining forgiveness. Depending on the definition you choose, it is either a path to further healing or a path to further retraumatization. In the absence of clearly defining forgiveness, it is a dangerous goal to set for a DID patient.

Therapy must be practical. It must take into account the trauma that patients must process in order to heal. One must consider the likelihood of success, as the goals in therapy must be within the grasp of the patient. Positing conventional notions of forgiveness as the path, goal or indication of success in therapy seems to set both the therapist and the patient up for failure. Setting an unattainable goal will only reinforce the patient’s negative self-image engendered by the abuse.

We must be clear that forgiving a living abuser is not like forgiving someone who stole an extra cookie when your back was turned, nor is it like forgiving someone when they are no longer able to harm you – such as someone who has already died. Promoting or attempting forgiveness can be very dangerous if it involves an abuser who has brutally harmed the patient in the past and is still capable of inflicting further deep wounds and retraumatization through physical or psychological means.

A colleague of mine listened to a woman speak of her sexually abusive father, explaining that he really loved her and the abuse was simply his confusion about how to express it. This seemed to be her conventional version of having forgiven her abusive father for his conduct – having an explanation she thought she could live with. My colleague told her in no uncertain terms that her father did not love her, that calling his molestation “love” was a psychological tactic common used by many abusers – particularly paternal or older male abusers, and that until she understood that power dynamic she would not be free of the abuse, not healed. She reacted as if he had thrown a bucket of ice water on her; causing her to reconsider the import of what she herself had said.

It later came out that her father had continued to abuse other children – including her toddler aged daughter. When this was discovered, she and her family moved within a week to another country to escape him. Had she not “forgiven” her father in that conventional sense, she would likely have been more on guard against him and thereby protected her own daughter as well as others. I use this real example to demonstrate that conventional notions of forgiveness can hold ongoing danger to the patient and others.

Most trauma that leads to DID is so overwhelming that ordinary individuals cannot truly imagine or comprehend the experience. To presume that one will eventually be able to forgive their abuser and, as a result, have an ongoing positive or at least neutral relationship, as a general rule, is a fantasy. From the Christian theological view, Jesus was able to forgive all their trespasses and sins. From that point of view, one can take joy in Jesus’ power to forgive and leave that level of forgiving to Him. However, this is not something within the capacity of ordinary people whether they are DID or not, so do not push that as a therapeutic path or goal.

If you are bitten by a poisonous snake, you can forgive that snake its poisonous venom and understand that it was simply defending itself when you accidentally stepped on it in the jungle. Having venom is in the nature of being a poisonous snake. To forgive the abuser and engage him as if there was no current danger, would be like forgiving that poisonous snake and deciding to carry it back home with you in your pocket to prove your forgiveness. Don’t do that!

One must work with forgiveness in a way that is not predicated on continuing to put oneself or others in danger of further abuse. The risk of retraumatization is too great to permit a patient to confuse conventional forgiveness so as to blur the boundaries of their personal safety.

It must also be understood that the critical sense of safety a patient is developing in therapy is the key. Forgiveness, from a therapeutic point of view, must be understood to be an internal process that does not require endangering proof of accomplishment. There are many important reasons to protect the patient from the danger of retraumatization. There is absolutely no need to test the depth of one’s forgiveness by engaging an abuser as an expression of forgiveness to him. Patients can be encouraged to simply check their own hearts. Neither from a spiritual nor psychological point of view does forgiving an abuser in your heart mean that one presents the abuser with another opportunity to harm you.

I set out some realistic therapeutic goals for this kind of case in Engaging Multiple Personalities Volume 1 and 2 as well as some practical exercises for establishing safe boundaries in those volumes and in my blog posts. Hopefully, they will prove helpful to readers.

I have yet to define forgiveness in this piece, in part because there are many aspects and understandings of this in Christianity. However, before any notions of forgiveness can arise, it is important in DID therapy to understand and make sure the patient understands that it was often the angry and protective alters that enabled the patient to survive the abuse. So, while I consider that it is a healthy aspiration to forgive others, meaning letting go of bitterness and hatred that is rooted in the past, in therapy one must be very careful to allow that to come to its own fruition. Introducing or promoting forgiveness is denying the insight and role of the angry alters. It will be counterproductive to the therapeutic alliance and the overall healing path.

In my view, being unwilling to forgive means holding on a hateful feelings and bitterness which results in further suffering and prevents healing. My definition of forgiveness does not mean that you go have coffee with your abuser and chat about current events in the world. My definition of forgiveness means letting go of the hatred in your heart. That should happen as a by-product of therapy, maturing in its own time as the system’s sense of safety permits. Forgiveness like that, with the warmth and lightness in the heart that results, is an indicator of the final stages of therapeutic success.

The post Christianity and Forgiveness – Part 1 appeared first on Engaging Multiple Personalities.

Spirituality and the Healing of Traumatic Wounds

I have thought about this topic a great deal but have hesitated to write much about it. Communicating about spirituality in the treatment of early childhood trauma is difficult because, for many, religion as well as pseudo-religious imagery played an integral part in the trauma. On the other hand, spirituality has also, for many, been a key foundation upon which healing has arisen.

In my experience, spirituality, whether with or without formal doctrinal religious faith, played a powerful role for many of my patients in their becoming successful survivors. I have seen patients rise up from the depths of despair despite horrendous and prolonged backgrounds of traumatic experience. For those, spirituality gave them the hope and strength necessary to overcome the tremendous difficulties that resulted from their history of early childhood abuse.

Again in my experience, formal religion and religious doctrine can be a source of hope for patients as well as the source of their trauma. Therefore, as a therapist, one must be able to help a patient connect with the spiritual aspect of their life in a way that avoids the risk of re-traumatization. This means that one must be flexible enough to support the patient’s religious faith when it differs from one’s own as well as be able to invite a patient’s spirituality in the complete absence of or antipathy toward religious doctrine if that is the path of safety for them.

A therapist friend of mine, a Buddhist, once sat with one of his patients in a church. The patient knew the therapist was a Buddhist and was surprised at the suggestion. But the patient had already made it clear to the therapist that religion was important to him and that he felt safe sitting in a pew in a church. My friend pointed out that if the goal was to make the patient feel safe as a way to set the ground for genuine therapeutic communication, why not do it in the place the patient felt most safe. To have taken him to a meditation center and asked him to sit on a cushion with legs crossed would have made him feel quite uncomfortable, if not completely unsafe. This is an example of the benefit to patients of therapists not being too stuck in their own personal religious view.

We tend to think of ourselves as amalgamations of mind, body and spirit. We have a general idea of the meaning of mind and body, but sometimes we don’t pay much attention to what we mean by spirit. Often, we simply assert spirit to be something that is mystical, with no presence or relevance in the everyday aspects of life. My understanding of spirituality is that it refers to that which is both of and beyond the material world. It is more than a weekly visit to a church, synagogue, mosque or meditation center. However, spirituality does not need to be tied up with religious dogmas, rituals, heavens or hells.

I define spirituality as the framework of how we face our existence, how we face our selves. It is a fundamental understanding of how we might be kind to ourselves in both body and mind. It suffuses our awareness, leading us to be more in touch with our inner core.

Trauma is a fact of life in the natural world – as when a tiger is chases down a deer. Both therapists and patients have to accept this as part of the human condition as well, and each of us needs to find our own way to handle it. We need spiritual strength in our own life journey but we also need to cultivate, protect and enhance our spiritual strength when we try to guide someone on their healing path.

In 1968, Joseph Campbell said, “In India, two amazing figures are used to characterize the two principal types of religious attitudes. One is ‘the way of the kitten; the other, ‘the way of the monkey.’ When a kitten cries ‘Miaow,’ it’s mother coming, takes it by the scruff and carries it to safety; but as anyone who has ever traveled in India will have observed, when a band of monkeys come scampering down from a tree and across the road , the babies riding on their mothers’ backs are hanging on by themselves.

Accordingly, with reference to the two attitudes: the first is that of the person who prays, ‘O Lord, O Lord, come save me’ and of the second of one who, without such prayers or cries, goes to work on himself.” In China and in Japan, the two attitudes are termed, “outside strength” and “one’s own strength.” No matter which religion one pursues, or for that matter, or spirituality in the absence of a religious tradition, these approaches need not be contradictory. I respectfully request the indulgence of those literal dogmatists in any particular religious affiliations to accept that it is an individual matter to choose either of these approaches or a mix of the two, no matter if you are a Buddhist, Muslim, Christian, Jew or none of the foregoing.

You have to find a reason to fight to overcome the tremendous obstacles of an abusive childhood. One good example of a reason to overcome the obstacles of abuse is to defy the abuser’s threats, to make yourself whole despite and against all odds, surviving the trauma and betrayal. If you subscribe to a personal deity, prayers asking for specific help and guidance can give you strength to overcome those obstacles. Like escaping from a deep well, you may need the sense of an external power to throw a rope for you to grasp and pull you out. On the other hand, if you do not engage a religious tradition, simply touching the power of the earth or feeling the warmth of the sunlight, those fundamental connections of life that are beyond you, may be enough to chase away the dark clouds and overcome past trauma.

In short, you need to have hope. Many of my atheist/agnostic patients relied on AA, NA or church fellowship for support in their difficult journey of healing, there is no need to fight alone.

Accessing genuine spirituality requires intention, practice and experience – rather than just wishful thinking. Spiritual practice within a formal religions tradition is usually quite clear within that tradition. One can see spiritual practice outside of religious strictures as keeping still and paying attention to the now, the present moment of existence.

Be still. Within that, learn to be kind to your own mind. Start doing one-breath meditation. The gradually advance to more than one breath, then to 5, 10 or even 20 minutes. Move toward being non-judgmental. Slowly learn to love yourself, without evaluating that thought as being good or bad.  Do not worry about closing your eyes, you may let them open if you so choose. Breathe each breath slowly, be alert and be stable in your sitting position.

You might try something like this:

Breathe in God and breathe out darkness

…..or…..

Breathe in love and breathe out fear.

The need for a spiritual component to one’s life applies equally to therapists who, day in and day out, listen with deep empathy. Listening in that way to the horrendous tales of their patients’ extreme past and often present sufferings, therapists are in need of strength to purge such toxic material that is capable of inflicting vicarious trauma on them. I have suggested extracurricular activities such as physical workouts as well as creative hobbies of music, sculpture, pottery etc. These remind you that there is something wholesome, beautiful and noble in this world, that it is not simply filled up with ugliness, betrayal and negativity.

In their uncertainty, people tend to grasp hold of dogmas to anchor their sense of security. They tend to gravitate to an extreme end of some belief, unable to see compromise as healthy in their dogmatic system. But, kindness transcends dogma. It is the secret and quite magical ingredient for healing. Always be kind.

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