David Yeung's Blog, page 17

Mindfulness Meditation and DID

There was a posting on a DID facebook group that expressed some real difficulties with a mindfulness meditation based therapy the DID individual was trying. This individual was not alone in having difficulties as a DID person trying to do mindfulness based therapy. I discussed the issue with a friend of mine who is also a long time Buddhist meditation instructor. He did not want to criticize the facilitator of the group because no doubt they were trying to be helpful and hopefully were for most people. However, he said quite definitely that if you are afraid to close your eyes, then don’t. It is not necessary and usually not advisable to do so anyway when practicing mindfulness. His point was that if you are trying to be “here” mindfully, then why would you close your eyes or imagine a stream? The practice is to just be where you are.

He suggested being very simple about it. A traditional technique is to start with a good posture (a straight back), comfortable sitting position, relax your jaw, eyes looking gently ahead angled slightly down and so that your gaze is falling to the ground about 6-8 feet in front of you. Allow yourself to settle and then simply count your outbreaths up to 10. Don’t try to manipulate your breathing, just go with how it is happening. If you lose count, just start again with 1. Do not criticize yourself if you lose count, do not praise yourself if you get all the way to 10. Either way, it is no big deal. If you get to 10, start again with 1. Do it for a short time, especially when beginning to become familiar with mindfulness. Even just 1-2 minutes is good or you can try just 5 or 10 breaths, however long that may take. If you can do it even just a little each day, that is great.

For someone with DID, it is critical to experience feeling safe, so don’t do anything that is going to frighten you or any parts – such as closing your eyes (or scanning your body which is a technique in some mindfulness therapies) if that is a problem. Try just sitting and counting outbreaths in a safe physical space of your own choosing. The first experience of most people starting mindfulness practice is that they become aware of just how many thoughts they really have. This is because there is so much more space for thoughts to appear when you are quieter than usual and not focusing so much on external tasks.

But for someone with DID, those many thoughts can be quite scary. Individual parts may see that open quiet space as their chance to be out and carrying all their traumatic memories. The thoughts may be coming from many different alters so quickly it seems that they are all happening at the same time. With that intensity of traumatic memory and seeming chaos, it is not surprising that dissociation would occur right away. So, DID individuals must go very carefully with mindfulness meditation so that the open space doesn’t trigger the fears of all the parts at the same time and result in retraumatization instead of healing.

But, if you can do it for only a few minutes or even just a few breaths, that starts you on the road to having confidence that you can indeed feel safe – even if just for 1, 2 or 3 breaths at a time!

Experiencing safety starts with that one first breath. Make a decision before you start about how long you will do the counting. Try to do it for that long but once you reach your goal for the session, gently stop. That way you start to get the habit of being able to create a time-defined safe space which is a great habit to engender.

If and when you become more comfortable with the practice of mindfulness, you can increase it by just one or two more minutes or a just few more breaths. If you dissociate, no problem. When you recognize that you have dissociated, just go back to counting breaths without praise or blame directed to you or any alter. Encourage whoever is out during the dissociation to please try to continue to do the counting of the breaths while they are out. If they will do so, great. If not, don’t worry. You can always gently (always gently) invite them next time. You can express that encouragement to the parts before you start, so they are acknowledged and even a bit prepared.

Slowly, there will likely be some benefit to the host, to the alters that participate, and also to those that watch without participating. Even a small benefit will encourage other alters to start to watch, maybe even participate, and to share that taste of safety in the breath. In fact, inviting the ones that appear when you dissociate is a very kind way to empower those alters, to show them that they too can be mindful of the “here and now” also – safely and without struggle.

Remember, keep it short – especially at the beginning – and always safe . Later, if the practice is helpful, keep it safe and extend it for just a bit longer. The critical point is experiencing safety in the here and now.

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DID and Schizophrenia – Part 2

Colin Ross, a pioneer and authority on DID, proposes to consider DID as a type of schizophrenia with dissociative features. He made this decision because “two thirds of people with DID meet structured interview criteria for schizophrenia or schizo-affective disorders.” [p. 131 Trauma Model Therapy, Ross and Halpern (2009.)] While this approach enables one to conform to the DSM Criteria, in essence it is making a DID diagnosis more palatable to the general community of psychiatrists who are more comfortable identifying patients as schizophrenic than dissociative.

Despite my view presented in part 1 of this topic, of the logical inconsistency of merging a disorder that is classified as a neurosis (DID) with a disorder classified as a psychosis (Schizophrenia), there may be other tangible benefits to Ross’s re-definition of DID as a schizophrenia sub-type. Such an inclusion of DID as a subtype of schizophrenia may prove effective for heightening awareness of DID within the psychiatric community. As such, it may be very helpful to DID patients, so long as the therapy is correctly targeted to the DID rather than the conventional (and drug treatment related) approach to schizophrenic patients. Without that refinement in treatment understanding, this may prove difficult for practitioners to truly grasp and implement. Below, I have paraphrased Ross’s explanation of this view, and as such, any error in the paraphrase and explanation is entirely my responsibility.

1. “A proposal of having a dissociative sub-type of schizophrenia facilitates the technique of talking to the voices, otherwise therapists will never talk to the voices.” This is a reasoning that may have wide benefits in the treatment of DID, if it enables psychiatrists to grant themselves the permission to indeed engage directly with alters.

2. “A large number of schizophrenic or schizo-affective patients do not respond to conventional treatment using medication. The ethical burden or political barriers of talking to the voices are reduced when conventional treatment has not worked.” This is a subcategory of 1 above with an important added benefit of a specific criteria indicating the need for directly talking to the voices – that the medication that has been proven to work with schizophrenics has not worked for the patient in question.

3. “Talking to the voices often works.” As I said before, the proof is in the pudding. It seems to me the main purpose of including DID under the broad rubric of schizophrenia is to remove mainstream psychiatry’s roadblocks to the technique of direct engagement with alters. It is my hope that the more psychiatrists experience the treatment benefit of speaking directly to alters, the more they will understand the efficacy of that approach in healing the trauma that is at the root of DID.

Returning again to the ABCD of schizophrenic symptomatology, when speaking to the voice(s) respectfully, a genuine schizophrenic will likely respond with a statement that indicates a wide gap in his connection to reality while DID patients respond with contexts that make the content understandable in that specific context. The statement from the patient could be as simple as “ There is no way I can speak to you.” A true schizophrenic may give an explanation along the lines of “The clouds this morning were shaped like pumpkins so clearly I am unable to communicate with you.” No matter how you go at that kind of response, there isn’t a bridge to enable understanding. A DID patient would say something quite different that does indeed give a context that enables understanding.

This example comes from a DID patient that trusted me enough in our first meeting to tell me, unprompted, of her abuse history, Then, in a somewhat different voice, immediately said that she couldn’t continue therapy because there was no way she could speak to me. This made no sense as she clearly had just spoken to me on an extremely deep level revealing core trauma issues. A few moments later, when I asked why she felt she couldn’t speak to me, she gave the context: She had been abused by someone named David. Therefore, she (or one of the alters then presenting) simply could never trust me nor anyone else with that name. I immediately understood the issue and did not argue. Instead, I referred her to another therapist with a different first name.

Nevertheless, I could have mistakenly convinced myself of an ABCD analysis fairly easily. I could have presumed that the different sounding voice telling her she could never trust me was an auditory hallucination she was simply describing out loud, the non-trusting voice was broadcasting thought to the “actual” patient, the non-trusting voice was asserting control over the thoughts of the “actual” patient, and finally that the “actual” patient had the delusional perception that I was irrevocably related, solely through the link of my first name, to an abuser.

While this ABCD analysis may seem trivial or specious, I saw many such analyses in patients diagnosed as schizophrenic that were referred to me – even as their files indicated strong dissociative features. The impact on such patients of the incorrect diagnosis followed by the impact of inappropriate medications – often over long periods of time – was incredibly harmful to the patients and their families.

I included a few examples of success using the approach of speaking directly to alters in Volume One of Engaging Multiple Personalities. I also included failures when that approach was not used. Without talking to the voices, the patients who succeeded in healing would not have stood a chance of any recovery. In Volume Two of Engaging Multiple Personalities, I make recommendations to therapists concerning implementing the technique of direct engagement with alters.

Again, it is my aspiration that more therapists will at least explore directly communicating with alters in patients with DID, or suspected cases of DID, so that they will have their own experience to consider. They can then make their own assessment as to “the proof in the pudding.”

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DID and Schizophrenia – Part 1

This is a short theoretical and philosophical discussion concerning whether or not there is any difference between DID and Schizophrenia in terms of classification, diagnosis or treatment. There are not necessarily any confirmed definite answers, but I believe there are guideposts to consider.

Schizophrenia is traditionally classified under a group of functional psychoses while DID belongs to a group of neuroses. In the traditional understanding of psychosis, the patient may lose touch with reality. In neurosis, the patient retains some acknowledgment of his illness. From this traditional perspective, Schizophrenia and DID are two entirely different kinds of mental disorders.

The term schizophrenia was conceptualized by Eugene Bleuler and further refined by Kurt Schneider (1959), a German psychiatrist whose delineation of “first rank symptoms of schizophrenia” remains widely adopted. Unfortunately, Schneider’s primary criterion for schizophrenia is the experience of “hearing voices.” Hearing voices is how those with Dissociative Identity Disorder – especially pre-diagnosis – often describe their experience of alters expressing themselves internally. It is crucial to consider as an analogue the fact that having fever and abdominal pain are symptoms common in both malaria and typhoid. In other words, just as malaria and typhoid are two completely different physical illnesses with symptoms in common, Schizophrenia and DID are two distinctly different mental disorders with symptoms in common.

The first rank symptoms of schizophrenia are summarized in the following mnemonic of ABCD:

Auditory hallucinations: hearing voices conversing with one another, voices heard commenting on one’s actions;

Broadcasting of thought: a form of auditory hallucination in which the patient hears his/her thoughts spoken aloud;

Controlled thought (delusions of control);

Delusional perception.

Patients with dissociative identity disorder may report “hearing voices” even more commonly than patients with schizophrenia. If one is trained to presume that hearing voices is always an hallucination, then most therapists will jump to the conclusion that the correct diagnosis is schizophrenia. They will mistake the auditory manifestation of internal conflict between the alters to be an auditory hallucination that come from nowhere, points to nothing understandable in any context, and is completely disconnected from reality.

Spiegel and Loewenstein have commented on the considerable overlapping of the symptoms of the DID and Schizophrenia. But, if we follow Schneider’s diagnostic criteria with that presumption, we will have to come to the inclusion of DID within the group classification of schizophrenia. This is despite that fact that they are as different as apples and oranges in terms of classification (psychosis vs neurosis), diagnosis and treatment.

In my experience in treating both schizophrenic and DID patients, the hearing of voices in DID is quite distinguishable from the auditory hallucinations of a schizophrenic. This and other mistaken applications of the ABCD as applied to DID patients are discussed in Volume Two of Engaging Multiple Personalities.

A crucial difference between the two disorders is that schizophrenia usually causes the patient to be highly impaired in his/her thinking. Schizophrenic impairment is generally quite pronounced and leaves the individual severely dysfunctional. In the case of patients with DID, some can be extremely high functioning, while others can barely get along, but most have alters that are usually quite capable of relating to the outside world. Nevertheless, they may be impaired in other ways, such as having co-morbidity of drug addiction and/or alcoholism in one or more of the alters. As a side note, this may be why many DID individuals come to the realization that they may have DID in the course of addiction treatment – whether at AA, NA or at addiction treatment facilities.

Generally, specific diagnostic criteria are followed in making a diagnosis, This is necessary for consistency and uniformity so that treatment guidelines can be applied correctly. It is a key tool for clinicians but like all tools, one must know when and how to use it. When one fails to recognize that there are many psycho-pathologies that display identical symptoms to DID on first, second or even third encounters, the clinician will have failed to use the tool of the DSM properly. This highlights the importance of maintaining a proper index of suspicion for all illnesses having common symptoms – physical and/or psychological – until one or another has been definitively excluded or confirmed.

Simply put, a patient presenting with “hearing voices” may be schizophrenic but, based on the percentage of incidence in the general population, may be equally likely to have DID. This highlights the limitations inherent in relying on one or two symptoms alone in making a diagnosis for mental disorders. One must examine the entire milieu of the presenting patient. This is completely analogous to the danger of diagnosing either malaria and typhoid based on fever and abdominal pain alone.

It is an inconsistency in logic to force a psychiatrist to choose whether to follow Schneider all the way and call DID a true schizophrenia with dissociative features, while understanding that in nosology (classification in medical science,) Schizophrenia is a form of psychosis while DID is a form of neurosis. At the moment, I am merely explaining the dilemma in psychiatry. While I have no definitive answer to that dilemma, I do have my experience of treating patients with both disorders that I relied upon in my practice.

I can say, definitively, that when the logical inconsistency is ignored, psychiatrists are more and more led down an incorrect path of treatment for individuals with DID. This has dire consequences that may take years to play out, investigate and correct. Unfortunately, for many patients, the dire consequences mean more trauma is inflicted in the attempt to heal as a result of the psycho-pharmaceutical blinders the incorrect diagnoses place on the therapists, in the patient files, and on the patient directly. Having a schizophrenic patient talk to the voices he hears will exacerbate his Schizophrenia. Having a DID patient engage in communicating with the voices of alters is part of the necessary treatment of his DID disorder. So, it is crucial to be able to distinguish the two in order to properly treat, and not harm, the patient.

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WHY SOME CLINICIANS REFUSE TO ACKNOWLEDGE DID

I previously posted on the danger of diagnosing a mental disorder based on clinical symptomatology alone. In that post, I discussed my own failure to diagnose DID in a patient because she presented what appeared to be a classic case of Bipolar Disorder. DID is rooted in early childhood abuse. It seems that many psychotherapists, and others throughout society, prefer to avoid the issue of the rampant abuse/molestation by people across all economic, religious, social and cultural boundaries. To acknowledge DID is to acknowledge the epidemic level of abuse that occurs in one’s own societal milieu.

The purpose of this post is to highlight other reasons for the failure to diagnose DID correctly and, in particular, why clinicians affirmatively choose other diagnoses over DID. During my years of practice, I received many referrals of patients that had multiple diagnoses, usually borderline personality disorder, bipolar disorder and schizo-­affective disorders. In many, but not all, there were clear acknowledgments of dissociative qualities indications. Nevertheless, in the referral documentation dissociative disorders were simply not considered in the diagnoses.

I have long puzzled over the fact that there are deniers of DID even among seasoned psychotherapists. I think the crucial issue is that in the experience of many therapists, they have never encountered even one patient with DID. With that background it might understandable why he/she would reject such a diagnosis. But that should not be the end of the inquiry.

It is my experience it was not that therapists, certainly the vast majority of those that referred patients to me, never encounter DID, rather they simply fail or refuse to recognize it.

Human beings have a predisposition to perceive things in a certain way. In psychological terms, this is known as a perceptual set or a perceptual expectancy Numerous studies confirm that perception is highly influenced by what one expects to perceive. For example, because we are highly attuned to hearing our own name, we recognize it even in a loud and chaotic environment. In a similar way, if we believe that our key has been stolen we will fail to see that key even if it is right in front of us.

Applying that same expectancy analysis to psychotherapists and DID, if a clinician believes that DID is rare, its presentation in a patient will be missed. This happened to me on many occasions before I came to realize that DID was no less common than many other disorders. I needed to modify my diagnostic index of suspicion to include DID as a possible diagnosis as likely as bipolar, borderline personality disorder or schizo-­affective disorders.

Another common reason for missing DID is that the DID is hidden behind some other presenting symptom. For example, many patients come presenting with depression. Others may be presenting with sexual or other addictions. Still others may present with difficult so­-called character flaw problems like pervasive anger. Therefore, it is important to examine the problem of basing diagnoses on mere symptomology without an appropriate index of suspicion.

By way of example, malaria and typhoid are two different diseases but sometimes physicians are unable to diagnose them properly due to certain symptoms they share in common. In the initial stages, both may present with the following clinical features indistinguishable from each other: high fever, abdominal pain and lethargy. Yet they are completely different in etiology and demand Typhoid fever is caused by a gram negative bacteria named as salmonella typhi whereas malaria is a protozoal disease due to different species of Plasmodium invading the red blood cells, transmitted via mosquito. Treatment for malaria will not help a patient with typhoid, nor will treatment for typhoid help a patient with malaria. Fortunately, some simple lab tests can distinguish between the two. However, there are no such laboratory tests to distinguish between most psychiatric disorders, such as between schizophrenia and DID.

So, again, one must not end one’s inquiry simply because one has seen what one expected. One can see bipolar disorder in mood swings, but the mood swings might also be different alters presenting themselves to the therapist. Depression may be a disorder, but it might also be an appropriate response to difficulties in life or it could be rooted in DID that is held by one or more alters.

Competent therapists need to examine their own index of suspicion. DID should be included in that index of suspicion when seeing patients with presenting symptoms that are found in common with other disorders, whether it be depression, addiction, schizo-­affective disorders, bipolar or borderline personality disorder.

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ALTERS ARE NOT THE PATHOLOGY

Many years ago, a fellow psychiatrist courteously wrote and explained why he disagreed with my therapeutic approach of speaking to the alters. He clearly considered this an error that would lead to “consolidating a pathology of dissociation.” He was taking DID as a disease in which the 6 year old alter speaking in a 6 year old voice was seen as the illness rather than a symptom. Effectively, he saw the alter as the pathology that needed to be eliminated. Thus, he viewed engaging in dialogue with the “voice” (the alter) as clearly an unwise practice that would only consolidate the problem rather than eliminate it.

In fact, the correct analytic approach should be to consider that the unprocessed trauma is the pathology, not the alter. The alter needs to be brought back into harmony with the other parts because they are all pieces of the same psychological system.

The treatment of DID is to engage the patient’s experience of having an alter as a separate part. Talking to an alter, acknowledging its presence, is a necessary step to draw that split-off piece of the self back in order to bring the whole system into a functioning unit instead of a group of perpetually conflicted and competing parts (alters).

This means that the therapist must be open to the fact that a 6 year old alter in the body of a 46 year old adult is not a symptom to be eliminated. Rather, it is a separated part of a wholeness to be healed, like a fragment of broken bone. With a broken bone, it is the fracture that is the pathology, not the bone fragment. And just as with a fractured bone, the broken piece that manifests as an alter is not garbage to be excised and thrown away. Treat the brokenness, which is the unprocessed trauma, don’t denigrate it.

A fractured bone can become quite strong and functional once it is healed – although never exactly identical to the bone that has never broken. It doesn’t need to be. In that same way, once a DID system is healed, it can likewise become strong and functional – although never exactly identical to a mind that has never been fractured in that way.

I learned over the course of 40 years of practicing psychiatry never to ignore or try to get rid of an alter. This is true however vicious an alter may initially present. Even the most angry and self-destructive alters can be seen as a repository of highly charged energy, worthy to be engaged and brought into harmony, not eliminated. Often they hold the keys to the knowledge of how the system protected itself under the pressure of the trauma as well as the clarifying the path to healing.

All of the alters hold gems of insight. With a proper therapeutic alliance, they will show the therapist those gems without interrogation, prodding or challenge. Kindness and connection open the doors to healing. It is the task of the therapist to invite the patient through those doors. Just as setting a broken bone in its proper position will allow the fracture to heal, creating the proper invitation to the alters will allow that fracture the is DID to heal.

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Misdiagnosing DID

Psychiatric diagnoses are based on clinical features rather than laboratory tests as in organic pathologies. For example, a patient presenting with a fever might have a common cold, a kidney infection, pneumonia or many other illnesses. It is the task of the clinician to determine what disease the symptom, fever, is resulting from.

In psychiatry, it is necessary to maintain a proper index of suspicion in that same way. When a patient presents with depression, it could be that they are bipolar, it could be that they have borderline personality disorder, it could be that they are in the midst of a divorce, or perhaps they have DID. It is the job of the psychiatric clinician to be open to all of the possibilities as they commence the diagnostic investigation.

Psychiatric disorders according to DSM 5 are based on symptoms, just like fever in the case of Malaria. Treating malaria with fever lowing drugs is akin to treating the depression in DID, which are cases of trauma and dissociation, with prescriptions that do nothing to treat that underlying cause. Just as treating malaria solely by lowering the fever will not cure the malaria, treating depression with anti-depressants alone will not necessarily cure the underlying cause of the depression.

When a patient presents with depression, the answer must not always and simply be an anti-depressant. The therapist must understand, first of all, that depression may simply be a symptom, not a syndrome or disorder, and it is not always a pathology. It is often an appropriate human response to difficult situations.

In my practice, it was quite common to see patients referred to me by other psychiatrists with diagnoses of Bipolar Disorder, Borderline Personality Disorder, and Clinical Depression that have not responded to medication. For those patients, it was almost always because the diagnoses were in error. The referring psychiatrists had focused on one symptom rather than the patient’s overall circumstances.

I believe this is due to a failure in training – a failure that I was subject to for many years as a practicing psychiatrist. I had been taught that I would never see a case of DID because it was such a rare phenomenon. Most of my colleagues, all veteran psychiatrists, had never a case of DID either. Looking back over my 40 years of practicing psychiatry, I would correct that statement to say that most of my colleagues (including me at the time) had never recognized a case of DID. Indeed, many referrals I received included notations of dissociative features being displayed by the referred patient but a refusal to include dissociative disorders as a primary or even secondary diagnosis.

I still remember my encounter with a patient in an infectiously happy mood who came to see me for recurrent spells of depression. Applying the DSM 4 criterion applicable at the time, I could not have been more certain that I was encountering a case of Bipolar Disorder. No one could have convinced me otherwise. I had certainty in the diagnosis and felt greatly relieved. I knew exactly what to do, how to follow the well laid-out protocol of mood stabilizers and so on. With the diagnostic certainty, I was confident that my task was virtually accomplished.

As a result, I never even considered the possibility that what I was seeing in my office was an alter who appeared carefree and happy. A careful consideration of the patient’s life history and early incestuous abuse should have alerted me to the possibility of quite a different diagnosis. In fact, after seeing her numerous times, she disclosed that she had been abused by her father. Rather than raising my index of suspicion, as should have occurred, I simply said “Oh, that’s part of your personal history.” Although my response was in accord with the standard psychiatric practices at the time, it was an abject failure that I did not reconsider the bipolar diagnosis.

Thanks to the bravery of some of my DID patients, I can say with confidence that a more appropriate approach to the “hypomanic” part as a possible alter would have opened the door to healing. My conduct at the time, instead, confirmed for the patient that I didn’t think the abuse history was all that important in the context of the bipolar diagnosis – again this conformed to the standard practice of psychiatry at the time. This was ignorance, dangerous ignorance on my part, and a continuing regret.

I should have understood that her opening up that personal history to me was dangerous and frightening for her. It should have been met with gentle kindness and openness. It should have led me to reconsider the therapeutic approach. There existed an alter who could have connected me to the severe inner turmoil and complexity of a psyche suffering from complex PTSD. That would have further established and strengthened the therapeutic alliance. It would have enabled her healing to have proceeded in a safe, supported and appropriate way.

I believe that many therapists make the same kind of mistake as I did for the first many years as a practicing psychiatrist. One must always be aware of the possibility that by simply labeling a patient as Bipolar or Borderline may mistakenly lead the therapist toward concentrating on a pharmaceutical treatment that will only cover up the real pain of a badly traumatized individual. It is often worse than no diagnosis at all as the patient’s difficulties are both compounded and hidden by the cascading effects of psycho-active medications.

What do I suggest to the current and future generations of therapists? Pay attention to the following research statistics:

The incidence of DID is not rare. According to Lowenstein1, DID may occur at a 1% rate in the general population, which is close to that of Schizophrenia.

The prevalence rate for schizophrenia is approximately 1.1% of the population over the age of 18 (source:NIMH) or, in other words, at any one time as many as 51 million people worldwide suffer from schizophrenia. There is an almost identical rate of prevalence for DID.

Physicians and other therapists are all aware that schizophrenia is not uncommon. Let us raise our index of suspicion about DID as it is just as common, statistically speaking. Just because high functioning individuals with DID exist and are well known, such as Dr. Robert Oxnam, Herschel Walker and others, it is not a rare disorder. In my opinion, the diagnostic bias against DID is connected to the discomfort people have acknowledging the constellation of circumstances that give rise to it: early childhood abuse, dissociation, and betrayal.

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The Failure to Acknowledge – Comparing Abuse in the Military and Childhood Trauma

In my books, Engaging Multiple Personalities Volume 1 and 2, I briefly discuss the fact that PTSD was not really acknowledged until the military was overwhelmed with veterans suffering from it. I pointed out some of the similarities between veterans with PTSD and DID patients whose trauma arose from very early childhood abuse. The key similarities are the inescapability of the danger and the resultant hyper-vigilance. The key difference in PTSD resulting from the battlefield is that a soldier has the support of other soldiers who understand the wartime environment whereas a child being abused is all alone, with no buddies, no peer group to support them or get them help.

There is now a report from the General Accountability Office of the US Federal government on the “staggering number of men in the military that have been sexually assaulted, and hinted at the underlying problem, writing: ‘DOD has recognized that a cultural change is needed to address sexual assaults but has not yet taken several key steps to further this change.’ For all victims, male and female, the environment frequently acts as a deterrent rather than a support structure; but for men the effect appears to be more significant.” http://www.huffingtonpost.com/rep-nik...

It is a societal bias that the issue gets attention when it impacts men but no so much when it impacts women. This is simply wrong – terribly wrong. It has been known, and not particularly seen as a “staggering” problem, that women have been similarly victimized. However, the fact that sexual assault in the military is now being scrutinized may have a positive impact on men outside the military – particularly those abused as children – who have been sexually attacked. Hopefully the changes that the military makes to protect its men will similarly protect its women. From my experience treating both men and women who have been sexually abused, I think it is quite possible that the finding that “for men the effect appears to be more significant” will be seen as wrong – terribly wrong.

The information described in the article ties into my experience treating DID patients, where they were raised in an environment that was a deterrent to reporting and healing, where the risk of retaliation is stupendous, and where the assaulted individual has no safe option to confront their attacker(s). It is instructive that the language within the military report context talks about betrayal: “Retaliation compounds the injustice and personal betrayal survivors experience and has been a lasting concern among survivors, advocates and those of us in Congress fighting to institute reform.” Betrayal trauma is almost always a key component in child sexual abuse.

The SAPRO report acknowledges the high levels of retaliation, and in May a report conducted by Human Rights Watch drew similar conclusions. Human Rights Watch made the problem vividly clear by sharing candid stories from service members who experienced backlash firsthand.

It is interesting to note that many comments were made about this report questioning who was doing the assaulting. A specific concern was raised that, once again, those doing the assaulting were not being identified, called out or punished for their crimes. All of this is quite familiar to anyone with experience treating the trauma of early childhood abuse.

It is my hope that just as the military’s concerns about veterans ended up mainstreaming the understanding of PTSD, this report and any follow-up work will clarify for the therapeutic community that betrayal trauma has a lasting deep impact and must be understood and addressed. This is true whether that betrayal affects an adult in the military or a child living in a domestic war zone.

I see it as an optimistic sign that finally there is an opening that may force psychiatry to face the issue of trauma and possible dissociation directly. It is something we can no longer ignore or keep silent with the prescription of a pill.

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Panic Attacks

There are always many postings about DID and other PTSD patients being overwhelmed by panic attacks. I have discussed this in both volumes of Engaging Multiple Personalities in some detail but I want to emphasize that there is a path to dealing with panic attacks.

The essence of any panic attack is the complete loss of control. First, one must engage in preparation – learning what you need to do to avoid that loss of control. For anyone, DID or otherwise, panic attacks are terrifying. They appear to come out of the blue, they arise with immediacy and always involve the sensation of a loss of control. It is very helpful to practice how to work with your mind and body at a time when you are not in the midst of a panic attack.

For all human beings, there is a completely intimate connection between mind and body. If your mind panics, your body will follow. If your body panics, your mind will follow. Triggers, therefore, can come in many ways – events that trigger either one’s mind or body. While this can be confusing to some patients and therapists, it is quite straightforward.

The mind following the body and the body following the mind is actually quite good news. If the mind starts to panic, by calming the body the mind will settle down. If the body panics, by calming the mind the body will settle down. While it is sometimes too hard to settle a panicking mind with thought, you can often settle the body with exercise. Get the body in exertion mode (such as a brisk walk, push-ups or even dancing), exerting just a bit more than the bodily arousal produced by the panic. Then, as soon as you stop the exercise, the body will automatically settle down. As the body slows down, the mind goes along with it.

Alternatively, sometimes it is the body initiating the panicking. While it may be too hard to settle it down with exertion, by settling the mind through mindful breathing, the body will often follow.

Some patients ask what mindful breathing is. It is simply paying attention to a specific aspect of your breathing. There are many techniques, but the simplest is to count each outbreath up to 10 – and then repeat. You can also pay attention to the feeling of the air moving out through your nose on the outbreath and in through your nose on the inbreath.

You can be mindful of when the shift from outbreath to inbreath happens, and vice versa, just as you can be mindful of when you are holding your breath. When you see that you are tensely holding your breath, you can then control its release by intentionally breathing out. When you release the breath, the air goes out along with the tension that subtly caused you to hold your breath.

Whatever method you use, understand that using a method rather than simply being carried along by the panic is an indication that you are re-asserting control. This is very positive.

Practice is what is called for, usually a lot of it done regularly. In a quiet safe space, you can intentionally allow a very small slightly negative thought to arise – something that is an ordinary everyday irritant and not a deep trauma. This is something which you are controlling, that is key. Remember, starting with baby steps is extremely important.

As your heartbeat increases, choose to do some exercise or some mindful breathing. Then, after a few minutes when you choose to stop the exercise or mindful breathing, you will see that your mind and/or body has settled. Making a choice about the technique and trying it is a second indication/assertion that you are in control.

The point of the exercises is to re-empowerment. It is to create new habits in both your mind and body so that when you actually are hit by a panic attack, you have already created new pathways to react to it – all of which are marked by being in control.

Do not try to generate thoughts of trauma and try to work them out this way. That is dangerous and will not be helpful. Please work directly with a therapist on the trauma material.

When in the midst of a panic attack, first try to remember what you have practiced, and second, try to do it. Don’t worry if you cannot quell the panic right now. Do not be angry with yourself if you remain terrified and panicked. That is not an indication of failure, it is simply an indication that you need to practice more in a safe place. Remember, this is a path that needs to be trod step-by-step. Even remembering that you are panicking more than you had hoped you would is an indication that you have retained some level of control in the midst of the attack.

While medication can support you in working with panic attacks, genuine healing occurs only when the disempowerment experience of the trauma is overcome. Re-empowerment is the goal. It is much more important than simply wrestling the agitated mind into submission again and again by a chemical which will have limited ongoing impact on the panic.

You have that power for re-empowerment in the present moment. Practicing before a panic attack, again and again, enables you to access that present moment power when you need it.

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Advice for Novice DID Therapists

If you are a therapist who has never treated DID…

Is there a point to deny, discount or argue with different alters in a DID patient? Bluntly speaking, the answer is no. While DID/MPD deniers will deny the existence of alters no matter what evidence or experience you present to them, I have seen and engaged many different alters in DID cases. Further external validation is unnecessary to proceed with treatment.

There are two key points to keep in mind when acknowledging the presence of different alters:

1. Alters feel strongly about their individuality. To insist that they are just one identity or personality is going to push them away from the therapist and destroy any possibility of a therapeutic alliance. I accept their way of thinking of themselves as separate individuals. I will not impose my own “unitary” concept of personality and try to convince them that they are deluded or simply wrong. This multiplicity aspect of personality is prevalent in all of us. It is only a matter of degree. When I play tennis, I am acting and feeling like a teenager, trying to hit the ball to the other side so that my opponent cannot return it. It is the “teenager” in me that is playing the game. It is a conceit to think that the teenage quality of me playing tennis is not part of the continuum of experience that includes alters in DID patients.

A therapist should never argue or try to convince a client that he/she does not have different alters. It would be akin to attempting to convince that a schizophrenic patient’s voices are not “real.” However, common sense and appropriate therapeutic demands dictate that clients’ alters should all work out a way to handle the practical aspect of day to day business. Alters should obviously find a way to live in a cooperative way because there is only one body – one cannot go to a party and simultaneously rest at home.

2. When treating a DID patient, unless a therapist acknowledges the presence of alters, treatment cannot even begin. Therapists cannot get anywhere if they insist on ignoring an alter because that means shutting down therapeutic communication. This is so basic but is one of the major obstacles in DID therapy for psychiatrists who have no experience in treating such patients. There is a strongly held but erroneous belief that if a therapist talks to an alter, it is going to make things worse. In fact, the opposite is true. Ignoring the alter(s) undermines the therapeutic alliance. The patient will close down this most important support and gateway for healing. It is the equivalent of telling a non-DID patient that the therapist does not want to hear what is really bothering him/her.

Once these two points are understood and agreed upon by the therapist, treatment of a DID client is no different from treating patients with most other psychiatric diagnoses. In DID therapy, therapist should focus on processing past trauma, and bringing together the alters so that they learn to live together in harmony and mutual support, like a team of athletes with different strengths and skills all pulling together toward the common goal of healing.

Sometimes a therapist who has never treated DID will be open-minded and even read my books to get started in treating DID. Claiming to have no experience is not a good excuse because DID is not rare. Sooner or later the therapist will see or at least recognize another case of DID. No therapist should deprive themselves of the opportunity to learn to treat DID.

If you cannot find a psychiatrist, any psychotherapist from other disciplines can work with DID patients. Social workers, psychologists and others can equally engage in treating DID. Anyone trained in psychotherapy can treat DID if one follows the simple principle of processing trauma and bringing together the different alters to work as a team.

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Post Stroke Thoughts

I apologize for not updating my blog or participating in any of the DID Facebook groups for awhile.

I am recovering from a small stroke. While the recovery is going well, such events are always an important opportunity to take stock of one’s life, conduct and aspirations. As you know, I wrote Engaging Multiple Personalities Volumes 1 and 2 last year in order to pass on the extraordinary knowledge and insight I received from my DID patients. Prior to my stroke, I was doing a bit of traveling but each evening I kept coming back to recollections of my patients. In hindsight, before I actually became aware of my lack of understanding, it is clear that I missed several DID cases.

In fact, early in my career there were a number of cases where I believe I fell into the traps I warn about in my books, diagnosing patients as bipolar or borderline. Like other psychiatrists of my generation (even up to now), I had been taught the DID was simply so rare that it was highly unlikely that I would ever see even one case. The result was that I did not pay attention to alters that showed up to see if I was trustworthy and open to their presence. Unfortunately, for some of my patients, out of my own ignorance, I missed the correct diagnosis/therapeutic path.

I hope that my books will guide other therapists to avoid making those same mistakes. I will continue to blog and participate in supporting the DID community as best I can during my recovery.

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