David Yeung's Blog, page 2

Stuffies, From DID to Mainstream Anxiety Support

Stuffed animals, whether it be a Teddy Bear or other stuffie, can be an indispensable significant other in the life of someone with DID. It is a safe object to touch, to speak with, and to express deep emotions. In the community of therapists that deny the ongoing impact of DID and the appearance of alters, there is often harsh criticism of the attachment to stuffies of many with DID. Their arguments is that using stuffies in this way promotes regression.

I believe this view is fundamentally wrong. It is based on the view of such therapists that DID patients should “grow up” and be “responsible adults.” Such therapists lack either fundamental compassion, understanding of the etiology and ongoing impact of early childhood trauma, or both.

As I have written before, such a view of those with DID, or, in general, patients with severe past trauma, reflects a very thick bias. That bias is the idea that only a unitary personality can be healthy. It is a fundamental misunderstanding of alters that indeed may see and express themselves as young children. They are not adults pretending to be children. As a result of early childhood trauma, such young alters experience themselves, the world, and their trauma as children.

Why am I talking about early childhood trauma and stuffies now? It turns out that a significant portion of adults sleep with a stuffed animal. Not only is this now being seen as acceptable far beyond the DID world, it is being acknowledged without any of the critique that it engenders regression of adults to children. In fact, there is even a marketing classification used in selling stuffed animals to adults who want them for there own. “Kidults” is the term created to define the commercial adult targets for stuffies.

I must say that once again, mainstream society is beginning to acknowledging wisdom which has been carried within the trauma community. I say again because this mainstreaming of the use of stuffies as a healthy non-pharmaceutical method of relating to anxiety reminds me of the way the impact of trauma experienced by those with DID was demeaned as being weak and phony until the military was forced to address the issue of PTSD. This only happened after it had become a tsunami among veterans. Once PTSD was acknowledged as an overwhelming human response to wartime trauma, many therapists began to recognize that PTSD was no longer an unreasonable way to frame, understand, and identify methods to treat early childhood trauma.

An article published in the New York Times details this now current view of stuffies.

The link is embedded in this picture

Best wishes

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Looking Back on DID in Retirement

I have been retired for over 15 years now. During that time, I have published the 4 Volumes of my Engaging Multiple Personalities series, and continue to post on this blog. In the last three years, I have had several encounters with my retired therapist peers. I remember one psychiatrist musing aloud saying, “Why is the word trauma used so often these days given that the so-called traumatic events were not really life-threatening.”

Given that trauma is defined as stress that threatens to overwhelm an individual’s ego defenses, how much ego defense does a child actually have at from birth to age 5 – a time frame that is usually considered when evaluating early childhood trauma. For that matter, what capacity is developed for ego defense at age 6 or more year by year?

In another social setting, a psychologist casually lamented that the trauma concept had been over-emphasized, saying “Everything seems to be related to trauma these days.” I was about to say something along the lines of “Maybe we (therapists – psychiatrists and psychologists) are finally coming to see the central position of trauma in our work” but instead had to bite my tongue to avoid starting a no-win argument which would have destroyed the social gathering (unrelated to our work as therapists) of old retired peers.

I am afraid that in my late eighties, I don’t have the energy to fight their ignorance. I feel my limited energy is better spent writing books and blog posts for the DID community that might be of benefit to them.

Therapists, psychiatrists and psychologists need better education, an education that includes an accurate acknowledgment of the impact of trauma – particularly early childhood trauma. I have given copies of my books to my peers as well as to younger psychiatrists who are in clinical practice. The unfortunate result is that they don’t even read them.

When I first published Volume 1, I had hopes that the community of psychiatrists, local, national and international would look at the current and past patients with a far higher index of suspicion to include trauma when evaluating patients for diagnoses. What I learned, painfully over these last 10 years since publishing Volume 1, is that most psychiatrists and psychologists continue to dismiss DID, to dismiss early childhood trauma, and simply prescribe medication to treat symptoms alone, like depression.

I have written repeatedly that “treatment resistant depression” is a label of nonsense. All it really means is that the medication is not alleviating depression. It boggles my mind that the use of that label permits therapists who so wish to not even explore the possibility of unresolved early childhood trauma or traumatic current situations that may very well be the reason for depression and dispair.

I remember a patient with two toddlers stuck in an abusive marriage who was labelled as having treatment resistant depression. No psychiatrist, psychologist or family doctor she encountered ever acknowledged her psycho-social issues, her abusive family of origin, her church community that insisted she was obligated to remain in her abusive marriage. The result, when she did not respond to antidepressant medication, was that she repeatedly was in hospital for suicide attempts.

If someone had a symptom that didn’t respond to treatment, a competent doctor would re-evaluate the patient to see what else might cause such a symptom that perhaps had been missed in the initial diagnosis. In psychiatry, and particular with respect to diagnoses that are treatable with psycho-active medication, common sense is sometimes shockingly absent. By using the label “treatment resistant depression”, some mental health professionals simply absolve themselves of medical, moral and human responsibility for potential failures in diagnostic evaluation.

Over these past 10 years, it has been clear that at least some DID patients have benefited from the books and posts. I know from correspondence that they have used some of the material to clarify to their own therapists many of the issues they need to have addressed and healed. Some therapists, a small number of psychiatrists and psychologists have read the material and wrote to let me know they are using the material in their own clinical practice.

Originally, I saw these are as wonderful but small victories in bringing awareness of trauma and DID to the communities of abused individuals. Wonderful is the accurate word to describe my feelings when I learn that the material has been helpful. I called those victories small because I had hoped that the larger therapeutic community would examine, explore and use the material to benefit their patients.

But calling those victories small was inaccurate. The fact that the material has and has had a positive impact on even one individual is great, not small.

I now believe that each victory of DID awareness is wonderful, great and cumulative within the community. And it is through the efforts of those in the DID community that those cumulative victories will benefit more and more people.

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Gabor Mate’s View of Trauma

What does trauma mean in psychiatry? The conventional concept of trauma that usually comes to mind is, for example, a brutal beating suffered by the victim. However, trauma may come in subtle yet no less
traumatic forms.

Trauma is a much-misunderstood word and often-overlooked phenomenon. The acronym PTSD stands for Post Traumatic Stress Disorder and highlights the term trauma. But the term itself was coined as late as 1980. Before this and for many years since then, psychiatry has been downplaying the role of trauma in the etiology of mental disorders. In the last few decades, the term trauma has re-emerged in psychiatry.

Vancouver, British Columbia, which for many years been rated as one of the most desirable cities to live in the world, ignores the trauma of the individuals that inhabit our local Skid Row.

Dr. Gabor Mate, who is not a psychiatrist, is a medical doctor who has spent more than a decade in the Skid Row of downtown Vancouver working with the traumatized people living there; alcoholics, drug addicts, prostitutes and others with severe mental health issues. Such on-the-ground experience gives credence to his insights into trauma and make them so valuable.

Dr. Mate has received the order of Canada in recognition of his work. He is the author of several best sellers, is in numerous YouTube videos, and is a much sought-after speaker who focuses his work on psychological trauma, illness, and drug addiction.

In a recent online conversation at https://www.youtube.com/watch?v=L7zWT3l3DV0&t=1450s, Dr. Mate simply and directly describes what happened to both Prince Charles and Prince Harry at particular critical moments in their respective childhood (minute 15:00 to 18:30). He then points out that this has had a profound effect on them later in life. The video is long, but contains great and accessible insights.

Psychological trauma is one of the most misunderstood topics we have in psychiatry. This almost 2 hour long conversation covers and crystallizes much of what Dr. Mate has to say about trauma. In my view, he has been one of the most important and relevant guides to identifying this critical issue in psychiatry and life.

In addition to the many key points he makes in the video regarding the critical importance of being touched with love, warmth and affection, I would point out that both the skin and the central nervous system develop from the same embryonic ectoderm tissue. This points to the strong link between the lack of genuine warm touch in etiology of trauma, and the power of genuine warm touch in the healing of trauma. The power of this linkage should be spotlighted when considering the impact of negative touch, brutal in both physical and sexual abuse, as well as the impact of the complete absence of touch as part of the etiology of dissociative disorders.

Whether you are in agreement with every one of Dr. Mate’s points or not, we should be appreciative of his extraordinary efforts to bring both individual and societal awareness to the impact of trauma on individuals, families and society. Such awareness is critical to healing individually, as a local community, and as a society.

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Advice For Therapists Without DID Experience – Part 3

In response to the original 2 part post, a reader asked “Do you mean that they are listening in, even if there is not awareness of them listening in? And there isn’t access to communication for me like you described in order to bring them into the session or as “helpers.” I very much appreciated the question and thought it deserved an inclusion in the post – making it a 3 part post.

I think a classroom is a good analogy here. You never restrict a classroom discussion response to the one single student asking the questions as the rest of the class hears both the question and the response. While all the students can hear, some are probably paying more attention than others to what you are saying.

When a therapist talks to one alter, all the others are, literally, within earshot. We have no idea if everyone is listening attentively, but some most probably are. Do not presume you are just talking to one particular alter because there are other alters and they can all hear you. It is not a private conversation that excludes any or all alters.

A very hostile and paranoid alter, after quietly listening to many sessions, may draw the conclusion that you are potentially a good person to be trusted rather than automatically being categorized as a likely abuser waiting in ambush. So, take this opportunity to spread the good news that as the therapist, you care about everyone inside. After all, it’s the goal in therapy to heal the impact of the bad traumatic history and abuse experience of the past.

In this way, some alters, even the most hostile or mistrustful, will finally accept you as “this person who actually cares”. They may individually come to the conclusion that they might want to participate, slowly and with vigilance, in making changes and to help as a co-therapist on the inside.  That will be a good corrective emotional experience for the entire system, not just for the alter who has up to now expressed itself solely as hypervigilant, angry and deeply hurt.

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Advice For Therapists Without DID Experience – Part 2

Second, there will be chaos/confusion in the patient when alters are in conflict. At the beginning of therapy, some of them may not have the capacity to understand the fact that they share the same body as other alters as well as with the host. Some alters do not even know of the presence of the others, and some simply don’t care. Often, they are caught up in competition with other parts for control of the body – looking for the chance to emerge, communicate or assert their will.

Some parts may focus on monopolizing control of the system as much as possible, while others come out briefly to make a point or react to something they are triggered by. Fighting for control of the body is a common indicator of DID. It can show up, for example, if the host is tired and needs to sleep. As the host tires, an alter may feel strong enough to hijack the body for a night out because that alter wants to go dancing. It can also show up when a trigger of some kind is encountered. When a retraumatizing trigger is experienced, the power of that retraumatization opens up such a powerful memory of trauma that the alter connected with that specific trigger takes over in an instant.

This hijacking of control may produce time loss, another common indicator of DID. Time loss is amnesia related to a chunk of time when an alter other than the host is out and in control. That chunk of time is often inaccessible to the memory of the host because the host was not co-conscious with the alter that seized control of the body. This is very distressing for the host. In fact, it is often the complaint/concern/confusion that drives someone with DID to seek therapy.

This lack of co-consciousness of the host and alters is a major difficulty that is to be worked through in therapy. It can only be worked with and through when the different parts begin to establish a therapeutic alliance with the therapist. In other words, healing can begin only when the traumatized alters begin to feel the possibility of safety in therapy.

Invariably, some alters are present who hold the original unresolved trauma and have been holding it since it occurred. It is true that the body keeps the score with respect to unprocessed trauma, both the original and subsequent traumas. Therapists can be confused by this in that the way unresolved trauma expresses itself is cloaked. It is usually not accessible to either the patient or the therapist.

The fact is that traumatic memory has likely been expressing itself as symptoms for decades, but the symptoms aren’t labeled “unresolved trauma.” More likely, they are physical symptoms or pain, discomfort, anxiety, depression and panic attacks, for example. These are all symptoms that may result from DID, from non-DID trauma, from car accidents and other difficult experiences. It is up to the skill of the therapist to establish a therapeutic alliance that will allow for clarity in diagnosis and successful
psychotherapy – whether the diagnosis is DID or otherwise.

Therapists can be confused as the patient may have no explanation or awareness for the triggers, or for the linkage between triggers and the trauma. For example, I have seen the pain from motor vehicle accidents bringing back fragmented painful flashbacks of the original trauma. A patient with that kind of pain, triggered by experiences that their general medical practitioner may not recognize as being based in old trauma can produce pain that is quite intense. The result is prolonged and unnecessary use of pain-killers that generally doesn’t solve the pain problem. Why? Because it fails to address the underlying source of the pain which, in the case of DID, is early childhood trauma that has not been healed.

Direct memories of trauma are excruciating, retraumatizing, and will often only return as flashbacks when the individual is triggered. The result is that a therapist sometimes has to spend time with one alter treating his/her PTSD, and then with the next presenting alter treating that one’s PTSD, and so on. At the same time, this does not mean that each and every alter needs to have direct psychotherapy.

Remember the original caution about who you are speaking with and that other parts of the system are always watching and listening? In my experience, this allows for alters that do not directly present themselves to receive the benefit of therapy being applied directly to a different alter.

People with DID often trapped in their hypervigilance. Hypervigilance is the result of having one’s sense of safety decimated by trauma. It is expressed by the continuous searching for threats regardless of any external metric of safety. There remains the ongoing fear that one might miss a dangerous threat that may be lurking about, waiting for the slightest relaxation on the part of the DID individual so as to pounce without warning.

If you can help one alter lower their hypervigilance down to ordinary levels of general vigilance, this will ease pressure experienced by many other parts of the system. This happens because those parts listening in on therapy directed to other alters will hear the therapeutic message as well. They will evaluate its impact on that alter and consider how it will impact them.

In order for this dialing down of hypervigilance to be effective, the therapist must always remind and caution the entire system that dialing down hypervigilance does NOT mean eliminating vigilance. It
means maintaining a watchful eye at the level of ordinary vigilance – like looking both ways before crossing a street.

As I mentioned, psychotherapy is focused on working through and processing early childhood trauma in each alter as they present it to the therapist. In this context, EMDR, Exposure Therapy, and other treatments may be used, but to maximize the effectiveness of any mode of treatment the therapist must understand the complexity of the relationship between early trauma and current flashbacks, depression or anxiety.

Understanding this context, therapy will then make sense to both the therapist and the patient. If the process makes sense, then the treatment will be far more effective than mechanistically applying EMDR, CBT, or DBT in targeting a symptom or even in the application of a medication. The positive aspect of remaining aware that all the alters are watching and scrutinizing you as the psychotherapist is that you can sometimes invite one or more alters to begin to function as an inner guide/helper, as a co-therapist, or even simply as a friend to another frightened isolated alter. When such invitations are accepted, which you can suggest even on a trial basis, it very much accelerates the healing.

The benefit of an alter accepting this role is that helpful alters can be present all the hours between therapy appointments, while the therapist is only present during that one hour of psychotherapy in the office. When therapy is going smoothly, this possibility often arises. This is one of the pleasant surprises in DID therapy. As a therapist, encourage this periodically after the therapeutic alliance is established and deepened. Please don’t waste this possibility of what can be a positive and powerful internal support.

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Advice For Therapists Without DID Experience – Part 1

Given that therapists generally receive no training in treating DID, I searched some Internet
sites for “Treatment of DID” so as to get an idea of what they might find.

For example, here is one site: https://my.clevelandclinic.org/health/diseases/17749-
dissociative-disorders. With respect to treating DID, it says:

**********

“Your therapist can help you understand what you’re experiencing and why.
Therapy also gives you the space to explore and understand the different
parts of your identity that have dissociated, and ultimately, to integrate
them.

Dissociation is your body’s way of distancing you from an intolerable
experience, which is an effective survival strategy in the moment — but
over time, chronic dissociation can form separate identities from your
“core” or “main” personality, leading to the symptoms of DID.

Besides helping you understand the reasons behind your dissociation,
your therapist can help you deal with dissociative states and develop
useful coping mechanisms.

Your treatment plan will be based on your own unique needs, but may
include:
 education about dissociation and DID
 body movement therapy to release trauma that’s held in the body
 relationship support
 trigger management
 impulse control
 mindfulness and self-awareness
 coping methods to tolerate difficult emotions

Some specific therapies used to treat DID include:
 cognitive behavioral therapy (CBT)
 dialectical behavioral therapy (DBT)
 eye movement desensitization and reprocessing (EMDR)”
**********
Generally speaking, the information is ok as far as it goes. But, it fails to give practical
guidance for novice therapists. It neglects to clarify two key points a therapist must keep in
mind. In brief, one must know to whom you are speaking as the therapist, and one must
know the common issues that need to be addressed in DID treatment.

First, include DID as part of one’s index of suspicion in meeting with patients. This
doesn’t mean to have it as the main or primary focus in your index of suspicion. An
index of suspicion is simply maintaining a reasonable awareness of potential diagnostic
considerations. Given that studies indicate that DID is as common as schizophrenia,
you should keep it in your index as much as you keep schizophrenia in your index.

If you, as the therapist, suspect that you may be speaking with a DID individual,
you must assume and conduct yourself based on the fact that you may be speaking to a
host as well as a group of alters. The approach you take needs to include the view that
you are possibly talking to far more than the individual you see in front of you. Why is
this so important? It is because a DID individual is a composite system made up of the host and all the alters. An awareness of the composite nature of such a system is key to establishing the initial
therapeutic alliance with the parts you are able to engage. Therapy is not circumscribed to just one part – host or otherwise. The key point in DID therapy is to engage the alters when and as they present.

To establish and nurture such a therapeutic alliance, be clear in your own
understanding. If you are talking to the host or a single alter, there are others also
watching, listening, and evaluating you. Maintaining awareness of this paves the way to
invite the parts that may be in the background to consider engaging directly or indirectly,
as they deem necessary, with the therapist in psychotherapy. The decision for a
background part to engage is connected directly to how safe they feel within the
therapeutic alliance/environment. This critical point is frequently missed or ignored by
those who deny even the diagnostic criteria of DID that is laid out in the DSM.

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How to Conclude a DID Therapy Session

I would like to make clear the importance of concluding any DID therapy session with at least 5 and preferably 10 minutes of simply allowing the patient to process whatever has arisen during the session. By this I mean that the therapist should ensure that the interactive talking part of the session is completed with sufficient time remaining for the patient to process what has transpired. It should be made clear to the patient that gently ending the session’s verbal communication at that point is not to cut off any part’s communication. Rather, it is to permit the entire system to take in and begin to digest what was exposed, addressed and/or clarified during the day’s session.

Why do I feel this is so important? I believe it is important for two different but connected reasons. First, it allows for all the parts to begin to process what has come up through one alter without any outside pressure to resolve anything conceptually. In other words, it is often really important to let the body and mind synchronize after what can often be an intense experience in a place of complete safety.

This dovetails with the second reason. Following a session, there is the critical boundary of transition as a patient moves out from a safe place under the protection of their trusted therapist to that unprotected space outside the office door. Remember, there is always a period of increased vulnerability following working in a session on trauma. It is extremely important for the patient to be able to focus on processing, synchronizing and feeling grounded as a system before going outside the office where hyper-vigilance will often be triggered given the sense of increased vulnerability due to the immediacy of working on difficult material in the session.

Within that short period of quiet in safety, the patient is able to direct their internal resources first to process what arose during the session and then, with that, to be able to redirect their internal resources to re-establish their external boundaries needed for safety outside the therapist’s office environment. How patients utilize that time can differ but simply sharing the therapeutic space together, resting in the safety of the therapeutic alliance, has benefit.

I had one patient whose husband told me that following the early sessions, before I introduced this quiet period as part of the therapeutic process, he always had to pull off the road when driving his spouse home. By doing so, his spouse could walk as different parts expressed themselves – usually quite intensely. By allowing her the space to do this while they walked, he could safely pay attention to all the parts. Paying such close attention was not something he felt he could do while driving in traffic. The walks were usually 10-15 minutes in duration. Upon returning to the car, he was able to safely drive them home as she quietly became more settled.

Once I included 10 minutes at the end of her sessions, there was never a need for him to pull off for a walk on the way home. For that patient, when I encouraged the transition to quiet processing, she would invariably and almost immediately fall asleep. It was quickly clear that this was her way of processing the trauma material. So, as we came to that part of our sessions, I told her that once she fell asleep I would go out of my office, close the door behind me and wait outside with my cup of coffee or tea. I made clear that she was allowed to sleep as long as she needed to, and to come out when she was ready.

She would come out in about 10 minutes to use the washroom, and then, regardless of which part(s) had been speaking in the session, upon returning from the washroom, the host would say goodbye to me. I found it interesting that when the host returned from the washroom to say her goodbyes, there was never anything that would indicate that she had either gone deeply into trauma material or had awakened from a nap. With her stability re-established, she and her husband would then leave the office.

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How Do You Identify Your Alters?

A new member of a Facebook DID group asked, “How do you identify your alters?” As a retired psychiatrist and the author of the 4 Volume series Engaging Multiple Personalities, I would like to make some recommendations.

Within the general understanding of DID explained at length in the series and blog posts, keep in mind that there are reasons why alters are not readily seen or identified by the alter serving as the host or front. So, rather than trying to identify an alter conceptually or otherwise, consider how you would try to connect with someone you meet if that acquaintance is not certain that you are trustworthy or a friend. Conventionally speaking, you might decide to gently invite that new person to spend a brief time with you so that you can get to know each other a little bit at a time. Invite them to listen in when you speak to other alters and when you interact in the world. This is a way to allow them identify and understand boundaries of safety, which is helpful both to you as the host and to that alter. Then, as you get to know a bit of each other, seeing what feels safe and what doesn’t, the ability and opportunity to connect increases.

In short, don’t push any alters into identifying themselves to you. Allow them to come to you through welcoming warmth. Allow them to identify themselves when and as they wish. Patience, empathy and kindness, and gentle invitations are the keys to this.

Sometimes my patients or I would ask an alter that was out to let us know some things about him/her but only after they were clearly appearing and the request was without demand. I would request simple things only, like name, age, gender for example, so that I could know a bit about who I was speaking with.

Never did I ask any alter about their trauma. If they wished to mention it, and how they wished to talk about it was their decision alone. The purpose this approach was to model and establish a zone of safety for them, which is a pre-requisite to any DID healing. Allow the identification to happen gently and without pressure in order to expand that experience of safety. This is critically important as the experience of safety is something alters have had taken from them by the trauma. Relearning that experience is foundational to healing.

Volume 4 of the series is my collected blogs post from 2014 to 2021. It is available as a free ebook or pdf download at engagingmultiples.com. best wishes.

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Anxiety and DID

Treating Anxiety is a central concern in psychiatry as it is a common symptom shared by most patients.

Anxiety is expressed in both the mind and body when facing a dangerous or unfamiliar situation. This happens whether that danger is tangibly real, such as when facing an enemy approaching with a weapon; a mistaken perception, such as mistaking a rope for a snake in a dark shed; or a projection into the present of past traumatic situations, such as when you encounter a triggering perception like the smell of alcohol and sweat as had been present on an perpetrator during an abuse situation.

Ordinary vigilance in the form of alertness and focus of attention, is not anxiety. Anxiety is an anticipatory sense of uneasiness, distress, or dread. Ordinary vigilance has a protective function. It allows you to scan for danger but without the anticipatory fearful qualities. Anxiety can be more likened to hyper-vigilance in DID, where the constant scanning is based on the assumption, the anticipation, that a dreadful circumstance is about to appear.

Consider a performer on stage who modulates their anxiety about the quality of the performance with their confidence based on training and experience. This allows a performer to maintain an appropriate measure of focus of attention and alertness. Unfortunately, when it rises to an ongoing level of hyper-anxiety, of hyper-vigilance as to each step, it becomes “stage fright” – a disabling experience for a performer.

It needs to be clearly understood that anxiety in those with DID is similarly disabling. Those with DID who have not healed from their early traumas, have good reason to be anxious. That is because it is, like the performer, also based on training and experience. In those with DID, that training and experience is repeated abuse from early childhood. Those with DID were trained to understand that they would continue to be attacked, and that their safety was dependent on dissociative based responses. Because DID doesn’t result from a single isolated event, they develop confidence that they will be attacked because of that repeated and ongoing experience of trauma. It should not be a surprise that their everyday experience is a disabling stage fright playing out in real time every day.

The core components of anxiety include feelings of distress, helplessness and fear. While these sound like only symptoms of the mind, there are always accompanying physical responses. Anxiety activates the autonomic nervous system (mainly the sympathetic nervous system) in preparation for a flight, fight, or freeze reaction. All three options are connected to the intensely stimulated sympathetic nervous system going into survival mode. Ongoing anxiety, such as results in DID from repeated trauma, can create a vicious cycle – a self-perpetuating feedback loop. Understanding this is important in the management of anxiety disorders, in those with DID and others.

Merely taking a pill to calm down the hyper-stimulated sympathetic nervous system is, at best, an incomplete treatment for anxiety. In the short term, it may enable one to bypass some of the mental and physical distress of anxiety, but especially for those with DID, alone it will not address the root causes. The dis-empowerment, experienced as fear-laden helplessness, and the establishment of a vicious self-perpetuating loop must also be addressed. Unless these are addressed, healing will remain incomplete.

Without fully addressing the root causes, stress now and in the future will always bring back this experience of helplessness, leaving the individual gravely predisposed to a recurrence of the anxiety or, in the case of DID, dissociation. One’s first thought is likely to be, “If only I had those pills the doctor gave me last time.” This is just another self-perpetuating feedback loop of reliance on chemical intervention. This loop of reliance will take precedence regardless of the accuracy of any current experience – including those in which anxiety is well-warranted – as well as precedence over the difficult therapeutic work of processing one’s trauma history.

Therapists and patients should understand the potentially life-saving value of a healthy internal warning system. Learn how you to keep anxiety in balance. It is useful as a warning system so long as one is able to control the uneasiness so that it doesn’t overpower one’s basic vigilance. I suggest it is important to treat anxiety as an adjunct, neither an enemy nor a replacement, of your friend vigilance.

The best results in treatment is when self-empowerment is incorporated into the healing regime. When the patient makes the efforts to participate and accomplish healing, that healing process is ever more firmly established. The present and future protection a patient acquires over the dysfunctional symptom by him/herself, with the support of the therapist, is far superior to protection which is chemically dependent or overly dependent on the therapist. Therefore, working with anxiety with the tools of self-empowerment is an important part of the healing journey.

Guidance on addressing anxiety

[1] Assess the current situation to see if the anxiety is related to a present warning signal or an echo of distress in the past. If the anxiety is related to a distressing current situation, pay attention to it so as to resolve the present issue. If it is related to some distant past distress, ground yourself in the present so that you can identify that the past is really in the past, a memory rather than a crisis in the present.

Focus on the direct experience of the present, like returning the attention to the breath to the diaphragmatic movement of breathing. As I have discussed in my blog and Engaging Multiple Personalities series, confirming the specific details of any original early trauma is not critical. However, being aware that there is some antecedent primary trauma/distress impacting the present is critical.

Reclaim control of the body and empower yourself in the present. When anxiety causes a disconnection between the mind and the body, try using self-initiated physical methods, such as working with the breath, to reconnect the mind and the body. With any type of working on the breath, we are re-directed to pay attention to our body and our internal state. Anxiety is all about worrying about the future. The essence of breath work is to bring your attention to the NOW.

[2] Understand the risk of feedback loops, and work to interrupt them. This is the way to undermine one’s habituation to those loops which further supports staying grounded in the present. Your heart rate is pounding because adrenaline is pumping into your bloodstream. There is a reason for the heart to go fast – it is preparation for a fight or flight. If you start doing sit-ups or push-ups, you give yourself a physical basis for the heart to beat faster. You are in fact causing the heart to go faster, rather than passively experiencing the heart rate going out of control. Feeling a rapid heart beat when you are physically at rest can be a frightening experience. Anything you do either to match physical activity to your heart rate, or anything you can do to directly bring the heart rate down can very quickly calm your both your body and mind.

In a previous blog post, I mentioned that eliciting the diving reflex can similarly be very useful. Just apply a cold towel or cold water on the forehead. This alone can bring your heart rate down. It is better to access this kind of physiological response than to use a pharmaceutical agent, unless the physiologic response remains overwhelming.

https://www.nytimes.com/interactive/2023/03/03/well/mind/breathing-exercises.html?action=click&module=Well&pgtype=Homepage&section=Well

This article from the New York Times is about breathing exercises that may be helpful. I hope readers will find this useful.

Please do remember that any physical process that begins to interfere with the trauma dynamic needs to be practiced, beginning very gently. Proceed slowly as it is like building up your muscles. In other words, you don’t begin to start lifting weights by using a 100 pound barbell. You begin with just a bar, and then add a small amount of weight as you gain strength. View grounding exercises in that same way.

Practice the exercises every day rather than trying them only in the middle of an anxiety attack. That way, when you do call upon them to deal with an anxiety attack, those “muscles” are already primed for actions.

Best wishes

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The Principles of Exposure Therapy for DID

Joseph Wolpe popularized the idea of desensitization in therapy during the 1950s. He was a forerunner in the development of Cognitive Behavior Therapy. With great care, we can apply the principle of Wolpe’s Systematic Desensitization in the treatment of DID. As in all varieties of exposure therapy, the goal is to diminish the power of the past trauma to impact the victim in the present moment.

Exposing a patient any cues that remind them of their trauma has re-traumatization risks. That is why it is critical to guide the patient to identify, at the beginning, a minimal trigger. The therapist must ensure that the trigger is not so strong as to bring back the full force of the traumatic memory.

In vaccination, a patient receives a dose of the virus in a weakened form. This way it provokes the defensive response of the body without overwhelming it, which is what the virus can do in its unchanged natural potency. Using a weakened form of the virus, the vaccine allows patients to build up and strengthen their own defense system in preparation for a later encounter with the unadulterated form of the virus.

With desensitization therapy, you must tread carefully. Take baby steps to make sure the triggering exposure will not overwhelm the patient’s current capacity to cope with even the minimal cue the patient has identified with you. Exposure to cues that activate the sympathetic nervous system without triggering re-traumatization, with their concordant heightened blood pressure and pulse rates, is the goal in exposure therapy.

Continuing on the same path by then exposing the patient to successively more intense cues, can lead to deep healing. In this mode of therapy, the patient is supported through gradually increasing their ability to successfully overcome stronger and stronger traumatic triggers.

When I let my patient Joan talk about her past abuse (trauma), I used time and space variables to give herself a clear path to ground herself in the safety of where she was right at that moment. In other words, when she, or any alter that emerged, became frightened, I asked her to look out the window and tell me what she saw. I asked her what year it was right now and who she was sitting with in the room. With those perceptions grounded in the present, I reminded her that the trauma took place thousands of miles away as well as many decades ago.

This allowed her current perceptions to be an anchor to hold onto for a sense of being protected and safe. While it was difficult in the beginning, like exercising any weakened muscle after an injury, it became, more and more, a comfortable and comforting exercise for her to reclaim her present moment from the impact of past trauma.

When Joan spoke of her past, it was necessary to permit it only in small doses that were clearly within her capacity to speak about. I let her tell me more or less, whatever she wished, on any given day. When her memories would start to become overwhelming, I would go back to asking her to look outside through the window. Asking her to pay attention to her perceptions and physical sensations in the here and now was a positive anchor for her increasingly solid sense of safety.

Upon her return to safety, I generally suggested that she simply sit where she was and rest. I did not try to re-engage with the traumatic memory, nor did I encourage her to do so. With this approach, we were able to regulate the intensity of the trigger and give time in the safe confines of our session to allow everyone inside to process that re-engagement of traumatic memory without being trapped in the cycle of uncontrollable re-traumatizing flashbacks.

I was actually giving Joan one form of exposure therapy. If exposure therapy moves too fast, a patient may drop out or be reluctant to ever participate in therapy. In Joan’s case, I was able to regulate how fast the therapy was proceeding by how much I let Joan go engage with the past in any single session. It was easy to stop the flow of her abreaction as indicated above.

Once she became acclimated to checking the outside through the window as a way to remain or return to the present, I also would accomplish the same thing by asking her to slow down and attend to her breathing. I would simply ask, “What is the feeling in your lower chest as you exhale?”, “Can you breathe into your belly?”, or “Can you feel the weight of your right arm on the arm rest?” These were all techniques she was able to use outside of our sessions, exercising the mental muscles needed to remaining grounded.

In this way, you can gently move the engagement with past trauma to safety by diluting the emotional intensity through asking a few simple neutral questions that connect to the patient’s sense perceptions. You can do EMDR or any other variant of exposure therapy in this way, so long as you sure the patient’s emotional reactivity level is manageable. What matters is the control you jointly exert in presenting the stimulus step by step during the desensitizing process. I think that is more important than the method used.

Looking at the case histories I presented in Volume 1 of Engaging Multiple Personalities, each of those case histories is different, based on the needs and presentations of the patient. No psycho-therapeutic method is a “one-size fits all”, and therapists must adjust their approach based on the patient. Once again, this critiques and distinguishes genuine therapy from the cookbook recipe style approach of therapists focused on psycho-active pharmaceutical treatments. When therapy accomplishes its goal, the patient can talk about the past trauma safely; meaning that the patient can consider it, not be perturbed, and see it as past history rather than a present threat.

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