David Yeung's Blog, page 18

Treating Massive Multiplicity

Chapter 5 in Engaging Multiple Personalities Volume 1 documents Ruth, who eventually told me that she had over 400 personalities. I treated the fact of such a large number of alters in a low-keyed way. In my approach, it didn’t matter if she had 4 alters or 400. The important point is that the therapy was not dependent on the number of alters – it was dependent on some key general guidelines regarding alters.

Alters usually demand to be treated as separate individuals. That is how they experience their own being. In therapy, integration was not the goal. The ultimate goal is to help all the alters to function as one cohesive unit, like a football team with a common aim of winning the game. I tried to teach them to aim for cooperation, communication, and coordination. The approach was for me to help them to respect each other and encourage them to help each other. This needed to be done without my denying their desire to assert their own individuality.

Initially, there are conflicts that are often expressed quite strongly by alters that are not interested in working with or befriending any other alters. There are usually those that are quite angry with other alters and wish to be violent toward them. This approach requires the therapist to proceed with sensitivity and tact. Without hurting their feelings or telling them to drop their individuality, I would point out to them the need to acknowledge that they should work for the common good because they are all sharing only the one body. This is one of the main tasks in DID therapy, to help alters come to terms with the idea that they have to work together, to sacrifice a small measure of their individual demands so as to be able to work together for the bigger and more powerfully functioning unit.

Eventually, after alters have processed their traumatic memory, the need to be separate individuals often diminishes. As a therapist, it is paramount to control one’s curiosity and undue inquisitiveness as to the individual alters’ personality and characteristics. I never said anything other than the truth that all the alters played a part in saving the system from destruction under the direct assault of the trauma and its after-effects. Therefore, all the parts needed to respect all the other parts.

One must conscientiously refrain from trying to treat each and every alter separately as if you have 400 separate patients. My contact with each of Ruth’s alters was limited to whatever and whoever arose in the here and now of therapy. If one alter was suicidal, I would encourage that alter to come out to address that one’s specific issues, without demanding that she come out. It is delicate balance of neither denying their individuality nor encouraging their separateness. As the trauma is processed, the individuality becomes more and more of a non-issue.

On the other hand, therapy for a suicidal alter must be straight to the point. One can explain to the suicidal alter that she is angry and fighting against herself, whereas the real anger should be directed towards the abuser. It was the pain inside that led her into wanting to hurt herself. I then pointed out different things she could do to sooth and ease that pain. Critically important was to point out that she could use the anger itself as a powerful force for healing and recovery.

Empathy from the therapist goes a very long way. One can seek to motivate other helpful alters to rally to the task of facilitating the healing. Other alters may be assigned the task as co-therapists, or at least to hold the hand of the sad or suicidal alter(s) to let them know they are not alone.

While therapy has to be flexible and dynamic, it needs to be goal-oriented and task-focused. I conscientiously avoided socializing with interesting, colourful and engaging alters. Therapy is not a chit-chatting social event with alters over a cup of tea.

In this way, even with several hundreds of alters, I managed to complete therapy in 2 and half years with Ruth. It is worthwhile to note that in a follow up instigated by Ruth, she reported that she had not needed support from the mental health system since therapy over 20 years ago at this point. This is a far cry from her history prior to psychotherapy that involved 20+ hospitalizations (one of which lasted 5 months), multiple psychiatric emergency visits and ongoing and unsuccessful pharmaceutical attempts at treating her depression.

This is not to say therapy can always be completed in such a short time. There are tremendous individual variations. Nevertheless, this is a confirmation that DID therapy does not have to drag on for years and years.

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The 5% Rule

I am glad that some readers are finding my books helpful, and that some therapists are open-minded enough to read them. For patients and their significant others, my wish is that they will find hope for healing in the material. For therapists, my wish is that whatever they find helpful will prove of benefit to their own patients.

I recently received a request for more detail on the 5% rule I discussed with my patients. In Engaging Multiple Personalities Volume 1 page 31, I suggested to a patient that she could try to limit her experience of pain to 5% of the actual memory of pain. In that way, she could begin to relate to the pain while remaining in control and avoid being overwhelmed by it. 5% seemed to give the pain a boundary of tolerability, regardless of that boundary’s illusory nature. Further, if 5% was too much to handle, at that point she could decide to only take on 2%. Again, the idea was to create a vehicle through which she could begin to process her trauma on her own terms -rather than being uncontrollably swept away by the memories.  

The notion of 5% is a way of pointing out that a difficult task can be divided into small bits, so that each part can be handled successfully without overwhelming the system.  In concrete terms, if one has to climb a tall mountain, it might seem impossible at the beginning.  By dividing it into 20 sections, each part is only 5% of the whole. That small part appears on its own to be manageable. The next 5 % will be likewise manageable too, and so on. When climbing Mount Everest, even the professional climbers acclimatize by spending time in a series of Base Camps that are each a bit higher in altitude than the prior camp before making the final ascent. 

When it comes to pain, one has to use some imagination.  I once treated a patient with severe snake phobia. I applied the 5% rule in this way. I suggested that she could imagine 5% of the fear to be like imagining a snake placed in a locked cage, in a locked room in a locked building, situated in the next city block over.  The next step would be for her to imagine allowing the snake to be brought in the locked cage just outside the locked room, but still being kept in the locked building in the next city block. This amounted to her feeling a certain percentage of the fear of the snake without succumbing to panic. In this way, she was able to have some measure of control. Step by step she was able to regain control of her reactions to snakes.

The important suggestion is that one can use one’s imagination to break down into fractions whatever it is that one is frightened of. As in all behavioural therapy, the key point is generating that sense of control in the hands of the survivor. With control, one is no longer a helpless victim. Rather than being a victim of onslaught of debilitating memories, the patient (NOT the therapist) is then in charge of allowing whatever amount of the distress to come through for processing.  

Even simply talking and planning such a technique with the patient in a secure milieu is in itself therapeutic. It is best to engage the patient to fully participate in the therapeutic procedure. The primary default response to a trauma is helplessness—a sense of loss of control. This approach gives the patient the tools to transforms the default response of helplessness into a powerful controlled processing response.

 

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The Therapeutic Window

The concept of “therapeutic window” is discussed in detail in Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment by John N. Briere and Catherine Scott. The therapeutic window, as presented by Briere and Scott, refers to a psychological midpoint between the inadequate and overwhelming activation of trauma-related emotion during treatment. It is a hypothetical target where therapeutic interventions can be most helpful. Psychotherapeutic interventions within the therapeutic window are neither so trivial that they provide inadequate memory exposure and processing; nor so intense that the client’s balance between acceptable memory activation and overwhelming emotion is tipped towards the latter. In other words, interventions that take into consideration the therapeutic window are those that trigger trauma memory enough to promote processing but do not overwhelm internal protective systems such that untoward avoidance responses take over.

To put it another way, interventions that “undershoot” the therapeutic window are ineffective and a waste of time. Those that “overshoot” the window constitute re-traumatization. In the former, the client may avoid returning for further treatment because they feel nothing is being accomplished. In the latter, the client may avoid returning for treatment because, having been retraumatized, they are frightened.

The therapist must remain completely attuned to the client, their verbal, emotional and physical presentations give you the keys to see how far to go and how not to go farther. Each encounter between the therapist and client should be more powerful than the titrated exposure to the trauma within that therapeutic window. In that way, each time a client comes to therapy they will leave feeling just a little bit better than when they came in. This is critical to encouraging their hope for recovery and their further establishing of a therapeutic alliance with the therapist

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Working with Angry Alters

This is in response to several postings on Facebook about potentially dangerous alters. These are angry alters that may harm the body or harm others. This touches on some very basic and frequently misunderstood issues pertaining to DID therapy.

The original function of the angry alter is protection. It is an ingenious defense mechanism for an abused child to establish a self-protective function when they are faced with repetitive abuse that often extends over years. Without that protective function, it is unlikely that a child could survive such impossibly difficult situations. It has the aspect of asserting power, that the child is not solely a victim. There is at least one part that is still fighting the abuser.

The angry alter is not the enemy. These alters arise from a deep survival instinct, filled with power and energy. Without these alters, the trauma would likely overwhelm the child – or, later in life, overwhelm the DID system. These alters keep the system alive within the context of and following the trauma. Without connecting to that energy, the prognosis in therapy is not good. The likelihood of the system simply giving up increases tremendously. In my practice, I had patients who were unable to access the energy of those alters and therapy was, fundamentally, a failure. The key point is to work with the energy, with the alter, rather than seeking to eliminate it. Far from being the enemy, these alters are potential partners in healing the system.

As a result of the hypervigilance that results from ongoing trauma, the anger that arises as that alter is often directed towards other alters or the host. This is despite the fact that the dissociation and resultant alters arose because there was no other way to survive the abuse. They usually blame the host or other alters for “allowing” the abuse to take place. This mistake in perception by the angry alter can lead to debilitating internal conflict. That same anger can also be turned on anyone outside that the angry alter might see, presume or experience as threatening – including the therapist.

The therapist must be sensitive to the presence of the angry alter(s). An alter’s subtle but definite show of power in a threatening manner is often discernible to the alert therapist – just as it would be in treating any non-DID patient.

Early in therapy, as soon as I had confidence that DID was the correct diagnosis for a patient, and regardless of whether or not I communicated the diagnosis to the patient at that time, I stated aloud that in order to proceed with therapy I needed the patient to understand and agree that they could not seek to frighten or threaten me. Without that agreement, one cannot proceed with therapy. This is because a proper therapeutic alliance cannot be established if the therapist has concerns about their own safety.

I would inform the DID system that if I felt unsafe, I simply could not be an effective therapist. I would make that statement while concurrently expressing appreciation for the protective function the alter was fulfilling. This is an honest approach that was much appreciated by my DID clients – particularly when that message was coupled with the message that you appreciated – and all the other alters should appreciate – that the function of the angry alter was to enable the system to survive at the time of the original trauma(s).

Following that, whenever I sensed that an angry alter was around, I would seek to engage that alter directly. This is a priority. Genuinely, always genuinely, I would thank the alter for having protected the system in the past. I let the alter know that it is good that they are keeping an eye on me, the therapist. Acknowledging this – because it is true – is telling the alter that it is no longer necessary to try to instill fear in me as a protective shield. This was because their function, along with the DID system in general, was now safely in the open. The system and all the alters within it were within in the container of compassionate therapy. That was further assuring the alter that between the two of us, therapy could be conducted in a safe and secure manner.

I would invite the angry alters out if they were willing to engage me, but I would never provoke them to come out. I would point out that they needed to remain vigilant to continue protect the system – definitely encouraging them to keep their watchful eye on me – but that being hypervigilant was not so helpful. Being watchful without being hypervigilant was the healthy quality of their protectiveness. It was something to be maintained and applied to the other alters as well as to people they might encounter in their daily life. In this way, they were invited to reclaim their original role as a guardian.

Generally speaking, prior to DID therapy, alters have not been recognized, acknowledged or appreciated. When directly engaged in communication, they have the capacity to change. Like any patient, they appreciate the experience of being treated with kindness and dignity. In most cases, over time, they understand and change their protective view from one of hypervigilance to appropriate vigilance.

Unfortunately, many therapists take the opposite approach. There is a general reluctance to engage alters for various reasons, especially angry alters, including fear and the consequent denial of alters. It is the therapists fear that cuts off communication and solidifies the mistaken view that the angry alter is the enemy. They are potentially potent collaborators in healing. On looking back on my decades of experience treating DID, I still find cases where I wish I had taken a more direct approach to engaging the alters, particularly the angry ones, in therapy.

Alters behave like other patients in therapy. They get relief when encouraged to express themselves and feel reassured when they are understood. Once the hypervigilance is transformed into vigilance, they respond to reason and very often make appropriate changes.

DID patients can heal, even after years of neglect and/or abuse. I hope that DID individuals read this so as to gain confidence in the importance of making friends with all their parts. I also deeply wish that therapists consider these points so that they may overcome their reluctance to engage and learn from alters.

I have written Engaging Multiple Personalities Volumes 1 and 2, and continue to write this blog, in retirement. It is my opportunity to reflect back, to acknowledge my past mistakes in my practice, and to offer my painfully learned experience to others so that DID individuals and their therapists can further and quicken the healing process.

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Working with Despair and Anger

My patients who connected with their anger safely were the ones that made the strongest and safest recoveries. Those unable to connect with their anger had more difficult journeys. This is clear in the case histories discussed in Engaging Multiple Personalities Volume 1.

Despair arises because it seems that there is no way out of that depression and fatigue. But there is: It is to work with the anger. Angry alters can often be converted to protectors in DID therapy because they usually arose originally in a protective function. It is getting back to that basic protective energy so therapists take note: We don’t get rid of the angry alter. He/she can be a highly valuable co-therapist or protector in the healing of a DID client.

It is very common for survivors of trauma and dissociation to feel tired, depressed and hopeless. Energy has been and continues to be drained away dealing with the pain of the past. Colin Ross clearly explained, in the chapter “The Healing Power of Feeling: Anger and Grief” in his book Trauma Model Therapy, that “Anger and depression are psycho-physiologically incompatible states.” The polar opposite of depression is “anger, (which) is energy, arousal, adrenalin, good posture, aggression, and the fight response.” He continues, “Assisting clients to step into their anger leads to stepping out of depression. That is partly because of the state switches to an energized, activated state, and partly because it takes considerable energy to repress all that anger.”

It is much preferable that you have a therapist who assists you to step into that anger. If you are doing it by yourself, through journaling or otherwise, be extremely careful and following these guidelines:

[1] Go into it slowly. Instead of trying to do it all in one sitting, be prepared to do it over weeks or over as long a time as is needed to do it safely!

[2] Take baby-steps. The first step is to learn to how to stop, and to be able to go for a walk to ensure that you are establishing safety and control of the anger. It is like when I first learned how to drive a car – I made sure I knew how to step on the brake correctly to stop the (slowly) moving car first before I went driving around on the real roads. Control is the key.

[3] Be kind to yourself – to every part of your dissociative self. The usual mistake is going too fast. Old anger, when it is first released, tends to go overboard. The risk of getting in touch of your anger is that it may become destructive, such as getting physical and breaking furniture. So, I do not recommend doing this alone without the strong support of a significant other or supervision by a therapist.

Every survivor of abuse has the right to be angry. They were abused – often by people that should have protected them but instead betrayed the relationship in the most vile ways imaginable. Get in touch with that anger SLOWLY AND IN A CONTROLLED SAFE MANNER. It will generally lead you out of depression and fatigue.

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Reflections On Responding To Reports Of Abuse By Public Figures

Reports of famous personalities being accused of sexual abusing young girls decades ago, such as Jimmy Savile (deceased English TV celebrity, knighted by the Queen) or Bill Cosby, appear regularly in the news. People without experience dealing with sexual trauma always ask, “Why did it take so long for the accusations to come to the public attention?” The question is asked in a way that is intended to challenge the credibility of the accusers. People with experience dealing with sexual trauma know that, invariably, abusers take advantage of their social position and power to make sure victims are intimidated, frightened, and therefore very reluctant to come forward to report the crime.

Often, when complaints are actually made, they are not taken seriously. They are blocked at the very beginning, by lower levels of administrators, celebrity handlers, and sometimes at the police level. The complaints almost never get to the right place even to be investigated. The abusers are usually not threatened with prosecution until decades have passed and, unfortunately, not until dozens of accusers come forward to break through the “he-is-famous, that-cannot-be-true” barrier.

Therapists may have the concern that they themselves will be sued by people in power who are accused of abuse. They may worry that they will be attacked on some kind of a claim that they were incompetently affirming a client’s delusion and, in that way, threaten the therapist. We must remember that we practice psychotherapy for the benefit of patients that have been traumatized. Often it is the therapist that is the first individual to undermine the belief instilled by abusers that no one will take their claims of abuse seriously. We cannot help them heal if we do not communicate our confident belief to our client.

If a client told me that she had been abused by someone revered by the public, like Bill Cosby or Jimmy Savile, a critical question will then follow, implicitly or explicitly, “Do you believe me?”

I would respond just as I would if they told me that someone not famous, perhaps their parent, had abused them. Experienced therapists usually have developed enough insight to determine whether the client is telling their truth or lying for some ulterior motive. If the client shows all the congruent body-language and demeanor of someone telling me of past trauma, I would have no difficulty recognizing that truth. Within that recognition, the truth I am concerned about is whether or not the patient has been traumatized. As I write in Engaging Multiple Personalities, the exact details are not important to the therapy. What is important is to recognize the truth of the trauma and proceed to support the patient in the healing process.

To show doubt about the traumatic memory, or to demand external checks on the accuracy of any memory, will likely be an experience of re-traumatization for the client. The key to understanding this is that abusers always impress upon their victims that no one will believe them, that they have no power to convince anyone that any abuse has taken place. This is why in the case of Sir Jimmy Savile, it took decades for these cases of child sexual abuse to come to the public awareness.

At the time of the crimes, victims were generally far too scared to tell anyone. Indeed, if they told someone, they were not believed. After all, Sir Jimmy was honored and knighted by Her Majesty the Queen. Her Majesty would never knight anyone who had done such an evil thing. How dare the victim suggest that! A similar logic is used against those accusing Bill Cosby of sexual abuse.

As a therapist, if your assessment is that the client has been traumatized, you need the courage to stand by your client, to support the truth of their painful history of abuse. If, in the unlikely situation the therapist is put on the stand in court, the therapist has every right to affirm and assert that:

Yes, I believe the patient was telling me the truth of her abuse experience.
No, I did not seek external corroborating proof as no such proof was necessary to proceed with psychotherapy. Investigations are the responsibility of the police. Following those investigations, it is up to the lawyers and judges to argue about whether or not the burden of proof for criminal law purposes has been met – which is a very different standard than a therapist needs to determine whether or not a patient has been traumatized. My expertise allows me to determine that the patient has indeed been traumatized, and that is all I need to provide therapy.
The attack by the defense lawyers will likely be based in the argument that the client’s identification of the abuser to the therapist is hearsay. But, hearsay evidence is permitted in court if you are stating it not for confirming the truth of the statement but rather for the purpose of confirming that the statement itself was made. Remain confident. You can clearly state that you are not accusing the public figure, your client is and you have no reason to doubt her. In truth, the only reason for doubting the accusers of Jimmy Savile was his public persona. Again, this is the same argument people use for doubting the accusers of Bill Cosby. Any therapist who has dealt with trauma knows that the public persona of abusers is often quite different than their private conduct. The Catholic church is dealing with the repercussions of this dichotomy and their failure to protect innocent children for many decades.
All I need for doing therapy is the confidence that my client is telling me the truth of a past abuse experience, and I have no doubt, based on my training and experience, that she was abused. I am not interested in who abused her, except that in all abuse situations where there is a relationship between the abuser and the abused, the abuser is always someone in a position of power over the abused, that it was someone she could have trusted, and that individual took advantage of her. I do not need a lie-detector test or a police forensic report to confirm that abuse happened for providing therapeutic support to that client.

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The Importance of Hope

As a retired psychiatrist reflecting on a life of treating broken bodies, spirits and souls, I have had the extraordinary privilege to learn from my past experience, both successes and failures, and identify the most basic fundamental ingredients essential to helping people heal.

They boil down to:

[1] Establishing a genuine therapeutic alliance, which necessarily involves congruence and empathic understanding on the part of the therapist.

[2] Installing (or restoring) faith and hope in the client.

In all the cases of successful suicide by patients that I am aware of, the common threads were the client being overwhelmed by loss of hope, and the failure of the therapist to instill or restore hope in the client. And all too often, when a patient successfully committed suicide, it was clear that they felt that their therapist had lost hope in their recovery too. It is a great sadness that therapists can and do lost hope in just that way.

We must do better as therapists, and it is possible to do so. I believe the key point is to understand that hopelessness, manifesting as depression, suicidal ideation or suicide attempts does not happen in a vacuum. Serotonin alone will not eliminate the risk of suicide if the underlying cause is not addressed. That underlying cause, in cases of abuse, is overwhelming fear. The dyad of hope and fear must be clearly understood.

In cases of Complex PTSD, the trauma is overwhelmingly powerful, leaving the client terrified. Being terrified, without any safe haven from the abuser, leads to hopelessness which must be recognized and addressed. For those suffering from Complex PTSD, the hopelessness is intimately tied to and a product of that fear. For abuse survivors, the fear is often tied to the direct inflicting of pain, physical, sexual, emotional, coupled with the repeated assertion that no one will believe that the survivor has been abused.

The patient hopes the abuse will stop, they fear it will not. They hope that someone will believe them, they fear no one will. They hope that if they act is whatever way the abuser demands, that they will be spared and they are not. Fear is the flip side of hope.

While the psychiatrist assesses the patient, the patient assesses the psychiatrist. The patient hopes the psychiatrist will understand, and fears that they won’t. When those with complex PTSD have a long history of ineffective and somewhat destructive relationships with the mental health system, they fear – often correctly – that everything they had been programmed to believe about no one believing them is true. In this way, the dichotomy of hope and fear is brought into the therapeutic relationship from the very beginning.

To combat this and strengthen the therapeutic alliance, the psychiatrist must effectively communicate that the therapeutic journey will undermine that foundation of fear. To avoid scaring the patient, one must encourage them that taking the smallest steps toward healing are the safest – particularly at the start of therapy. Each time any fear is undermined, a glimmer of hope emerges. That is the nature of the relationship of hope and fear to communicate to the patient.

Time and time again in my own practise, I was reminded that little gestures are the crucial building blocks of healing. Healing does not come from grand breakthrough of revelations or enlightenment. It is built on small building blocks even at the level of regaining the control of one comfortable breath.

Offer hope by helping the patient make tiny, achievable goals with each therapeutic encounter. Each session with the patient that enables them to exert some control, even in a very limited way, over the the runaway flashback symptoms is a critical “baby step” in healing.

As related in Chapter 1 of my book “Engaging Multiple Personalities”, I told Joan in our first session that my aim was to help her feel just a little better each session. According to her, this was a most powerful suggestion that propelled her toward healing when she was in the darkest period of her life, having almost given up as a result of the total dis-empowerment of PTSD.

In another case, my last patient of the day calmly told me that she was going to kill  herself after seeing me. There was no doubt in my mind that she was simply stating her intention, and that it was not an empty threat or desire for attention. There was literally only one hour to intervene.

I related to the angry part of her, understanding that the source of the anger was the deep hurt of past trauma. I helped her connect to the anger as a source of valuable energy that could be redirected to her healing. I gave her hope that she could turn around the anger, the hate, and see that the best revenge was to overcome the trauma inflicted by the abuser by showing that the abuser had not succeeded in destroying her.

The best revenge is indeed to show the abusers that they failed to destroy the child. Many survivors of childhood abuse carry this sense of hope, of mission, to survive to tell the world that such abuse did happen. To stay alive, to fight for the future so that one could bear witness to such horrendous crimes. We need to change the world so that every child grows up nurtured, loved and protected from abuse.

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