David Yeung's Blog, page 4

Considering Spouses/Significant Others in DID Treatment Part 1 of 4

In traditional psychotherapy, the communication between therapist and client is privileged and confidential. There is no place for including a third person as part of the therapeutic process. I believe that this should be reconsidered, on a case by case basis, in the context of psychotherapy with a DID client.

My suggestion is based on considering, with the benefit of hindsight in my retirement, the therapeutic journeys of my limited number of DID patients. I had some experience with supportive spouses/significant others as well as some experience with spouses/significant others that were quite the opposite. This post includes the rationale for my proposal, some suggested considerations/warnings, and some potential guidelines.

Comments are most welcome as this is intended to open a discussion about something that is generally not considered in therapy. Indeed, I am expecting negative push-back from therapists as well as appropriate concerns. Please remember that there are risks, some clear and some not so clear, associated with even trying this approach. These risks must be taken into account for and with each patient individually when considering this approach but before deciding to try it. It must always be subject to permission of the patient to test the waters, both at the beginning and throughout any ongoing therapy.

While there are certainly spouses unsuitable or incapable of assuming a helpful role in therapy, there are some really caring, insightful, and potentially extremely helpful, spouses and significant others who can and wish to contribute to the healing of the DID patients.

The fact is that it is much more likely that alters will come out when the patient is at home with their spouse/SO than when he/she is with the therapist. A therapist generally sees a patient at most once per week. There are clearly many more opportunities for benefiting the patient available to a supportive spouse/SO given their 24/7 interactions with their DID partner. The grave risk is that an unscrupulous spouse/SO could use information of such diagnosis, and what they might learn in a therapy session, in a more effectively abusive way. One cannot discount that risk. So, inclusion must be dependent on the patient, the individual capacities of the spouse/SO, and the therapist as well as the potentials tools a therapist might be able to incorporate for them to use at home.

Why is this such an important consideration? It is because the most common places and times that an alter might come out is at home, perhaps at night in bed, or when he/she is driving in a car with the spouse/SO. That was the case with my DID patients.

So long as supportive spouses and significant others are kept in the dark about 1) the actual diagnosis their DID spouse/significant other has been given; and 2) the impact of their DID spouse/significant other’s early childhood trauma, there is a problem. Supportive spouses cannot fully engage as a support or as an advocate because they lack the necessary information and the permission from their partner with DID to do so.

This is potentially changing the options for DID therapy from the ground up. Hence, my use of the term “groundswell.” Through social media, those with DID and their spouses/SOs have begun to establish communication networks, the predicate for groundswells.

The purpose of this multi-part post is to begin the conversation. Please share your thoughts about extending therapeutic guidance to include considering how spouses and significant others can learn, engage and therefore protect as well as advocate for their DID partner.

We know that early childhood trauma based DID, a complex PTSD unrelated to wartime service trauma, has been generally ignored since the beginning of psychiatry. I think a primary reason is that there simply were no advocates for those with DID forcing the issue. The fact is that early childhood trauma is usually connected with sexual and physical abuse by family members and close friends of the family – all people that the family unit usually doesn’t want to confront. It is my hope that advocacy for those with DID by their spouses and significant others will become ever stronger.

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Emotional Reset: Using the Diving Reflex

I learned of this technique in the early 1970s from a paper in physiology:

It seemed then (and now) to be a simple yet elegant way of affecting a physiological and psychological change that could be of benefit to patients suffering from anxiety and panic. You can try a simplified method by putting a cold soaking wet towel over the head, forehead and face, and counting to ten.

Underlying anxiety always comes with a sense of loss of control, e.g., one’s heart rate become elevated, sometimes skyrocketing, for no reason other than the internal experience of fear whether or not external circumstances – to an outsider – justify it.

As I have always insisted with my patients, both DID and otherwise, that the best therapeutic methods guide them to find their own way forward in dealing with those issues. There is tremendous benefit to acts of positive self-empowerment. Unfortunately, my efforts faced with tremendous resistance from patients and colleagues at the time.

Doctors were supposed to prescribe medicine(s). The standard practice for patients suffering from anxiety and panic was (is) to prescribe the appropriate pharmaceutical magic bullets. At that time, those would be valium or sublingual Ativan. Any deviation from that was viewed with suspicion by both patients and doctors.

My lack of power of persuasion, in a field hijacked by pharmaceutical companies, led to my colleagues laughing at such an ‘”absurd” practice. It was suggested that I could be sued for malpractice because the laws and regulations specified that one’s treatment practice must conform to that of one’s peers. In psychiatry, anything other than prescribing physical or chemical intervention at that time was discouraged, ignored, denigrated or dismissed.

Now, many decades later, we have a rational explanation for the beneficial results of this “absurd” practice. It seems now to fall under the term “Vagal Stimulation.”

It may still take a long time to be communicated generally as an option for patients to consider trying. But, I think if I were still practicing psychiatry, I would promote this option more by highlighting its self-empowering potential. While it may not always work as effectively as we would wish, actions like this that patients can take on their own initiative have an intrinsic power to heal.

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Therapy and The Inner Child – Part 3 of 3

Some therapists believe that they should not engage with alters, particularly child alters, because that would encourage dissociation. There is no need to fear that you are encouraging dissociation in your clients. DID clients are already experts in dissociation. Dissociation has been and remains their survival defense mechanism. No one can encourage them to dissociate any more than one can encourage a fish to swim.

Therapists: Stay on your toes, so to speak. While you should not try to bring out an alter, never miss the opportunity to respond to alters when they come out to communicate with you. Seize that opportunity and engage them. It is the most important therapeutic opportunity in DID psychotherapy.

There are critical guidelines to keep in mind when dealing with alters. Always remember that the alter is part of the whole of the individual. They exist as part of the whole person. You cannot consider any one alter as a unique individual existing apart from the whole person. Avoid picking favorites, avoid identifying those you don’t like, and avoid even appearing to do those things. Maintain your own stability in engaging with alters. Do this by engaging with impartial attentive kindness whichever alter emerges whether they be nice or mean, happy or sad, young or old, manic or depressed.

Always remember that the whole person is your patient, not the host alone and not any individual alter alone.

In the absence of a clear and present danger to the system, seeking to call out front a child alter, or any alter, is a mistake. When an alter, especially a child alter, feels safe enough to engage you (or angry enough for some), that is when you relate directly with them. The alters will usually withdraw on their own, and someone else may come out. That withdrawal is not a mistake, so don’t try to prolong the interaction. It is far more likely a decision (conscious or otherwise) by that alter or the system to allow for further processing of the material you engaged about.

It is also an expression of them establishing a sense of their own agency – an important aspect of healing. This is quite distinguishable from an alter’s appearance in the midst of a re-traumatizing trigger, which displays a lack of agency in that kind of uncontrollable eruption out.

Having that engagement, even once, is a great opportunity to invite that alter to listen in when therapy is taking place – whether or not they will emerge in that session. It is also a great opportunity for you, as a therapist, to be reminded and appreciate that many alters may indeed be listening when you speak to any one particular alter. So, make sure your words are well considered. But, at least as important, remain stable, warm and kind – whichever alter you may be speaking directly with at the time.

If alters do not withdraw and the session will be ending soon, particularly with young child alters who remain out, therapists need to guide them to quietly process what they need to process and gently lead them into a neutral space before they leave the session. This allows for one more gentle transition, from the office to the reception area.

Make sure you allow for at least 5 to 10 minutes to allow the processing and transitioning to take place. After all, once outside that very brief therapeutic hour in the office environment, the patient returns once again to the conventional world. Providing time for a transition is critical to avoid re-traumatization by allowing time for processing what has come up in the session. Remember, patients cannot simply switch a child alter on or off at a moment’s notice..

Further, in the conventional world, child alters likely need the protection that other parts of the system provide. A gentle transition makes for yet another opportunity for the patient to briefly practice co-consciousness and self-directed agency.

Boundaries

Enthusiastic therapists probably feel the urge to re-parent the inner child in their clients, as we often perceive the desperate need of the inner child for the nurturing that was missing in her childhood. As much as we may wish to do this, experienced therapists follow certain boundary guidelines for the safety of all concerned. These include no socialization outside the office as well as rules against any exchange of gifts or money outside the therapist/client office fee transaction.

In other words, some aspects of a normal relationship between parent and child may be inappropriate in the patient/therapist relationship. For example, a parent will generally respond to phone calls at random hours of the day and night. They will hug their child, often very close, as part of a greeting or goodbye. They share meals, vacations and other family events. But while they are important in the family dynamic, these are not acceptable between client and therapist because they can, despite the best of intentions, undermine the actual therapeutic relationship.

As I said above, in DID therapy, when talking to the inner child presenting as an alter, one must assume the presence and attention of all the other alters. While you may be speaking appropriately to a 4 year old alter in language that might be used by a kindergarten teacher, one must also be cognizant that other alters may be listening to what is being said, and the other alters may have their own different connection with the system’s trauma history. They may, as a result, have needs and reactions quite different from the 4 year old.

In other words, conversational boundaries we might presume, such as that we are speaking during a therapy session to one person in front of us and not a crowd, is not a boundary that our patient may share with us in common. And boundaries, amnestic barriers within a DID system, might not be so immediately apparent to the therapist when alters switch during a session.

Once again, this is an opportunity. The therapist can let the other alters know, indirectly, that other parts inside can be very helpful to the young alters (as well as to each other). It is not that you have to figure out what language to use that would be appropriate for a 4 year old as well as a concurrently listening 44 year old. Instead, you can explain what the 4 year old needs and invite other parts inside to fulfill some of those needs. For those that will not or cannot, you can invite them to listen. In this way you can create an environment where the parts grow to be kinder and more respectful to each other’s needs, wishes and responses to trauma history.

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Therapy and The Inner Child – Part 2 of 3

In his 2010 book, Reconciliation: Healing The Inner Child, Thich Nhat Hanh suggests using mindfulness to listen with compassion to our inner child. This can be very helpful for those patients without DID. In such situations, mindful listening with compassion is something the therapist must model for the patient as they encourage the patient to mindfully listen to their inner child within.

For those without DID, the inner child remains part of our subconscious – an accessible metaphor the patient can themselves use in explaining their difficulties to themselves or to others. For the patient, this approach offers a ray of light that there is a healing possibility based primarily on acknowledging the unmet need.

For Those With DID

For those with DID, there are commonly young child alters. These alters are seen within the DID system internally as children. They can and do express themselves as such when interacting internally within the DID system as well as externally when triggered. Child alters should not be dealt with as if they are metaphorical. Alters are not metaphors. They are an inseparable part of the whole personality system of those with DID.

I agree absolutely in Thich Nhat Hanh’s recommendation for using mindfulness to listen with compassion, but it is mindfulness on the part of the therapist that is key. It is the therapist’s exercise of mindfulness, not the patient’s, that is critical to establish the foundation of a proper therapeutic alliance and to guide progress in therapy. Beware therapists who place the burden of mindfulness on their patients rather than on themselves.

Meaning no disrespect to Thich Nhat Hanh, meditation is not therapy. Thich Nhat Hanh’s meditation experience was extraordinary, mine is definitely not. But, while meditation can be helpful in supporting therapeutic work in non-DID patients, there are risks to encouraging meditation in DID patients. As a result of having seen major difficulties for individuals with DID who had been strongly encouraged to do mindfulness meditation, I posted on my blog some of these risks, along with some recommendations: https://www.engagingmultiples.com/mindfulness-meditation-and-did/

In those with DID, why would introducing mindfulness meditation be a problem? Why is there such a grave risk? It is because one needs to understand the potential re-traumatization risks for someone with DID.

For those with DID who have yet to resolve their internal negative dynamics, beginning a mindfulness practice creates an open space, a flash of quiet. However brief that flash may be, it can open the floodgates to many if not all the alters simultaneously. These alters, with different traumatic memories, can clash violently with each other as they, all at once, clamor for attention – demanding to occupy and express themselves in that open space.

DID patients do not experience alters as metaphors. Alters are not something to be analogized or otherwise manipulated. They are not a conceptual tool to clarify unmet needs. They are the potent and therapeutically accessible result of incredibly horrific trauma. This kind of inner child, when triggered, has little to no choice in whether or not they erupt out. If the therapist tells the alter erupting out that they are merely a metaphor, that they don’t exist this will destroy any therapeutic alliance that may or might have been established. The direct result is that the therapist will be unable to help such alters interrupt the re-traumatization cycle the therapist has just triggered.

In urging mindfulness practice on a patient, the therapist may be creating the opportunity for triggering that patient to re-experiencing old traumas that are not ready to be processed. Why? Because alters re-experience their trauma of abuse, of those “unmet needs”, directly when they are re-traumatized, not at a distance of any kind. Re-experiencing trauma is not conceptual. It cuts the patient off from any sense of the safety of the present moment and isolates them into the past triggered trauma.

Again, for those with DID, an alter is not a metaphorical. An atler inner child is crystallized, concretized and anchored in their trauma. At the same time, he/she is an inseparable part of the whole personality system of your DID client. For the patient, the inner child alter exists, and is experienced as just as real as the child living in the house next door. Alters perceive themselves and behave as if they are real individuals, and should be treated as such during therapy. The therapists who question their authenticity, or are afraid to speak to them as individuals, are doing more harm than good in a therapeutic relationship.

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Therapy and The Inner Child – Part 1 of 3

All children, however young, picks up messages way long before they are able to process their meaning conceptually. From birth, we immediately begin to construct our our ego, our lens, through which we perceive and engage the world using the impact of those messages, good and bad. We all hold emotions, memories and beliefs from our early past that are experienced well before language and logic forms. The critical, initial connection we make, that we are hardwired to make, is to our immediate caregivers – usually our parents.

Despite our most fervent wish and attachment, no parent can be perfect. Why? Parents are also influenced by their early experiences, good and bad, as well as those subsequent life circumstances they have encountered. It is not possible for parents to easily navigate their own life journey in ways that would enable them to fully insulate their children from the experience and aftershocks of difficult circumstances that arise in the child’s life. This is true for everyone. So, it is not surprising that we all have an aspect of ourselves that was never quite loved the right way or the way we needed as a child.

But, not everyone experiences the depth of trauma that results in DID. In DID, the question is not whether one has been loved the right way, or of having some of our conventional needs unmet. For those with DID, instead of love they were given terror. The needs that were “unmet” so deeply as to result in DID were not simply some of a child’s conventional needs. The unmet needs of individuals with DID were so basic, so fundamental, as to undermine the child’s very ability to survive.

For Those Without DID

There are two kinds of “inner child” one might consider in psychotherapy. There is the metaphorical inner child one can use in encouraging patients to uncover and touch in to difficult circumstances they experienced in the past that still impact them. This approach, of seeing the inner child as metaphorical, can be helpful for patients without DID. This is not the approach to take when treating or dealing with DID, as will be discussed below.

Jung first wrote of connecting with our playful, childlike selves. Since then, many people find “inner child work”, a loosely defined term, to be very useful. While we cannot go back in time, we can imagine that inner child so as to explore the parts of our selves that still bear scars, or even open wounds, from our early past experiences. We try to connect with that inner child so that we can imagine what that child experienced. We do this by using the images we hold of ourselves as that young child.

It is noteworthy that the idea of the inner child is not exclusively raised by Jung. The Buddhist spiritual leader Thich Nhat Hanh said,“The cry we hear from deep in our hearts comes from the wounded child within.” Any wounded child, inside or out, cries out for healing, for kindness, warmth and compassion. It is the therapist’s task to stop, notice, and listen to this wounded child within. We cannot fully develop our potential without healing that inner child’s pain. Healing begins with acknowledging that sadness, fear or anger.

In the self-help movement that developed in the 1970s and 80s, people having difficulties were encouraged to connect with their metaphorical inner child as a means to acknowledging and understanding how they felt when they were actually young and failed to get the nurturing support they needed from their parents.

The inner child self-help movement was prominently promoted by John Bradshaw during the 80s and 90s in the USA, with his works translated into 42 language. Born into a troubled family, he was abandoned by an alcoholic father, who himself was also abandoned by his father. In working on his own healing, Bradshaw came to the idea that there was a metaphorical inner child in himself, who had been deprived of a protective and loving father during his growing up years.

He needed, but never had, a loving father, and realized that his own father had that same unmet need. This is an excellent example of trans-generational transmission of psychopathology, rooted in a lack of nurturing rather than a genetic error. His approach was to encourage people to address those still unmet needs of that inner child which continued to impact them as adults.

This idea of a metaphorical “inner child” makes sense in guiding therapists and patients in their non-DID work. Once can imagine the patient experienced as a child, in the form of that metaphorical inner child, and then consider a path to meeting those unmet needs and healing. In short, that inner child needs to be listened to, to be taken seriously, to be understood, to be valued. That “child” needs to be metaphorically held, as a way to respond to that previously unmet need which continues to be a burden.

Simply using that imagined child increases the chance of patients healing. It may be that it opens the possibility of quickly establishing a therapeutic alliance between the patient and the therapist with the result that the inner child finally feels heard. This is far better than categorizing the patient with a DSM label, sending them with some psycho-active medicine, while ignoring that still unmet need from the past.

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Thoughts on “Re-parenting”

Therapists aiming to deal with patient’s adverse experiences in childhood sometimes attempt to offer corrective experiences to reverse the damage. In trying to describe that approach, the term “re-parenting” is often used to describe what therapists are trying to do. The methods used are quite diverse. The language used in doing this work is often metaphorical, but there are also therapists whose methods may include physical contact of some sort.

I will say from the outset, as I have written in my blog and books, that my view is that “…If a parent has abused their child, they no longer qualify to be defined or treated as a parent.” https://www.engagingmultiples.com/christianity-forgiveness-part-2/

Nevertheless, it is easy to see a therapist taking on the role of a pseudo-parent in the sense of paying warm non-judgmental attention to their patient. It can be akin to the way a kind parent would listen to the difficulties of their child, and reassure them of their basic safety. In DID therapy, this can certainly happen while engaging with a young alter. It does not extend to the physical comforting one might expect from a loving parent.

An actual kind parent would likely hold their child physically close as part of the comforting dynamic. As the child ages, the physical comforting generally happens less and less, as the child/teen/adult grows capable of processing difficulties and being comforted without the need for the close physical contact an infant/toddler may need. I refer to a therapist taking this approach as a pseudo-parent because they are simply not a parent. They need to be kind, compassionate and insightful, but they do not have the rights, status or definition of a parent. They need to maintain therapeutic boundaries so as to maintain clarity in the relationship between therapist and patient.

One can use the sense of touch in therapy by encouraging the patient to use their own hands on their belly to feel the weight and movement as they breathe. I am aware of some therapists who encourage their patients to put rubber bands on their wrists and snap them a bit to help ground them. I prefer the weight of one’s own hands on the belly as a safer approach that is as far away from self-harm as possible.

I believe there is a severe risk of boundary issues arising in the context of physical contact between therapist and patient, even, potentially, by shaking hands with the patient. Any such contact must be extremely limited and geared to avoid the boundary issues. As I have said elsewhere, on very rare occasions when a patient’s young alter needed physical contact to ground themselves when a difficult memory arose during therapy, I used a large couch bolster as the intermediary. I pushed against it from one side while the other side was touching my patient.

In this way, the patient experienced the grounding aspect of the sense of touch without any direct contact. I used a bolster rather than a pillow due to its larger size and stiffer quality. This limited the patient’s perception to a grounding sensation of touch without experiencing the sensation as if it came from a hand.

The through-line of this is that by remaining fully present with warm deep listening, a therapist can open the possibility for the patient to be guided in reclaiming their own sense of agency. This agency is critical. It is also the goal of proper parenting – to enable one’s child to become a full complete human being with agency as well as proper boundaries when engaging the world. With time and healing, this can enable the patient, on their own, to access the safety of the present moment rather than remaining trapped in a re-traumatizing flashback – just as a proper parent would wish. Such guidance requires kindness, compassion and empathy, coupled and capped with psycho-therapeutic insight.

There are other therapists who take a different approach. While they do seek to provide care and nurturing, rather than listening in a non-judgmental way to enable the patient to re-learn the experience of safety, without proper boundaries they insert themselves but as if they are an actual parent who will provide the missed nurturing. In lieu of applying psycho-therapeutic insight to guide the patient to distinguish the flashback cycle of re-traumatization from the safety of the present moment, they take on that parental role, blurring the boundaries of the therapist-patient relationship.

This ignores the fact that one cannot change the past. One can therapeutically intervene to interrupt the complex PTSD flashback cycle, but one cannot erase the past. The goal is healing, it is to step beyond triggering flashbacks so as to enable the patient to live safely in the present circumstance. Creating a false parental relationship with goal of an alternative parent/child dynamic is, in my opinion, a dangerous path.

This blurring of roles may show up in a patient’s desire for continual accessibility of the therapist, just as a child desires continual accessibility of a parent. It sets up a dynamic that will eventually, sometimes sooner and sometimes later, fail. The therapist will at some point demand space for their own life, which the patient will, understandably in light of their past trauma, experience as abandonment by the therapist that has allowed the blurring of therapeutic and parental roles. Without the appropriate boundaries, therapy itself can set up this kind of re-traumatizing experience.

I have seen comments in DID social media where patients feel abandoned if a therapist fails to return a text or email in what the patient deems an appropriate time frame. From the patient’s point of view, per the re-parenting therapist, a “good” parent, would be there to speak to their child. This boundary issue is not the fault of the patient. It is the failure of the therapist to establish clear boundaries from the outset. Further, if the therapist has established with the patient that emails, texts and phone calls are not a problem, then the therapist has truly invited that that risk of the re-traumatizing experience of abandonment for the patient.

In treating some of my DID patients, I have seen infant/young toddler alters seeking parental style comforting. Therapists need to understand that one can give the needed comforting without undermining therapeutic relationship boundaries, but not if the therapist gets their own psychological reward from responding as if they were the actual parent.

Re-parenting is ill-defined in the therapeutic context. While it can be seen as one way of engaging with this need, it is a broad term covering many possible approaches. While any individual therapist’s definition of it may indeed be helpful in a given specific situation, concretized re-parenting should not be seen as a generally applicable approach. I would discourage any therapist from concretizing a re-parenting relationship in therapy – particularly when treating a patient with DID. The risk of re-traumatizing one or more alters is too great.

In addition to the risk of re-traumatizing the patient, there is the risk of the therapist’s own potentially confused parental dynamic, with their own parent or child, being pushed onto the patient. There is the risk that the therapist will use the re-parenting dynamic with their patient to work out their own parenting issues. This is inappropriate ethically, and dangerous to all involved.

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Depression: Normal Emotion, Symptom or Disease? Part 2 of 2

In general, therapists are taught that depression has a good chance to respond to medication when it is feels like a physical illness. In other words, if a person is tired and exhausted, feeling physically sick with symptoms such as weight changes, loss of appetite, loss of libido and ongoing insomnia, there may be benefit. There is difficulty in concentration, no stamina, and everything feels flat. Other symptoms indicating potential appropriate use of antidepressant medication are feelings of intense sadness and/or loss of interest in what used to interest them. 

According to the guidelines, the depression should last at least two weeks, not just a few days, before anti-depressants should be considered.

Unfortunately, antidepressants are often given as a first response to depression – without considering whether a patient’s circumstances might reasonably invite the emotion we also label depression. For example, I had a patient in her forties who came to be depressed for years. She was deeply conflicted between trying to be a “good daughter” and her unwillingness to face her abusive father.

This conflict was exacerbated each year as she was expected to attend every Christmas family dinner. She feared missing the change to see her ailing mother, but dreaded the next Christmas party. Understandably, she was unable to effectively communicate this to her father. Whenever she tried to confront her verbally and sexually abusive father, he just laughed it off, saying that she was too uptight and had no sense of humor.

Would antidepressant help to alleviate those circumstances? At best, it might allow her to see her mother at the dangerous cost of being abused by her father. That re-traumatization likelihood is not an acceptable trade-off and would not fundamentally change the dynamic that was causing the depression. Using an antidepressant in those circumstances is not mental health treatment. Rather, it is the expression of the mental health system dynamic of treating symptoms solely with chemicals. That expression would fundamentally be equivalent to participating with abusers in a known emotionally and potentially physically violent event.

The question is what do you do with a creep like that as your father?

This patient finally decided to sacrifice her chance of seeing her mother. She chose to escape to live in another part of the country.

I had another patient, a single mother of two, who made arrangements to drive over 900 kilometers to see me about her “depression.”  Before I saw the patient, it was clear that this was not a patient for whom I would blindly prescribe high doses of antidepressant. Why? People who are diagnosed as having Major Depression per the DSM-V are not able to plan and organize such a long and complicated trip.  She had to drive hundreds of kilometers to a far away city and to make arrangements to stay there for a few days with only limited financial resources – all while pressured by the uncertainty of meeting a new psychiatrist.  

The first thing I needed to do was to listen to her.  Why? Because the first thing she needed from me was to be listened to. Incredibly, for many years the only treatment she received was heavy doses of antidepressants.  No treating therapist had made any note on her chart that her husband was physically abusive, that her own family was against divorce, and that her fellow church members and her pastor could offer her prayers but not support in divorcing her abuser. All she could do to express her emotions was to cut herself.  By the time she came to see me, her children were already taken away for adoption – with the support of her family – because of her repeated hospitalization for “depression.” 

Her depression was not Major Depression per the DSM-V. But by ignoring her circumstances, her relentless self mutilation was seen as an expression of “depression” and therefore was mistakenly treated with anti-depressants. To me, that self mutilation is more anger than depression. My thought was the depression was not inappropriate at all under the circumstances. Her primary goal was to resolve this difficult relationship and get back her children. She also was suffering from undiagnosed DID.

This was clarified even further by the fact that she did not talk with me about her depression. Instead, she spoke about her life-long history of being abused and traumatized. There was zero support from her family of origin, or from her close-knit Church, to acknowledge her abuse history of the past or for leaving her abusive husband in the present.   (See Chapter 5, Ruth, in Volume 1 of Engaging Multiple Personalities.)

This example from my practice where, as I mentioned before, a patient’s level of depression does not always indicated by how many times they commit self-harm. The patient mentioned in the last paragraph was certainly thought to be severely depressed and was hospitalized with that diagnosis multiple times since early in her life. A few months prior to coming to see me she was kept in a general hospital for 5 solid months just so that she could not continue to cut herself.

Soon after she started therapy with me, I discontinued her antidepressants. She was so motivated to heal soon after therapy began. Why? Because, for the first time, someone was listening to her circumstances. Someone was able to see her suffering in context, and healing quickly progressed. I have been in touch with her over the past several decades, and she had never needed any antidepressants since then.

Remember, doctors get wined and dined by drug company representatives in the name of continuing education. Certainly, that is how things ran for decades before my retirement from practice in Canada.  With enough alcohol and food, and the vast majority of peers taking the marketing push without even a single grain of salt, anyone can be bought.  

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Depression: Normal Emotion, Symptom or Disease? Part 1 of 2

Depression is a term with several meanings that are easily conflated, and therefore leads easily to confusion. It can refer to a normal emotion, such as “I am depressed because I had to cancel my vacation to pay for a car repair.” It can refer to a symptom of another disease, which may be related to a separate physical or mental health issue. Or, it can refer to the DSM V definition of Major Depression, something that indicates a need for hospitalization.

There has never been an agreed-upon fool-proof way to differentiate depression as an ordinary emotional response to one’s circumstances, as a symptom of a different physical or mental illness, or depression as a disease in and of itself.  However, there are guidelines to consider.  A clinician must use common sense while also closely following the guide lines in accepted literature as to if, when, and how to use medications when a patient presents with depression.   

As a psychiatrist, retired now for many years, I would like to say something about how one decides whether or not to prescribe a pharmacological agent. Unfortunately, although it should be obvious, it must be stated that anti-depressants should not be prescribed to a patient as soon as one hears the word depression. If the depression is Major Depression as described in DSM 5, medication is indicated. One has the impression that the patient can barely find their way to your office. At this stage, psychotherapy is likely to be experienced by the patient as you speaking in a foreign language. He/she simply is unreachable in any significant way through verbal communication.

Dysthymia, a long-term milder form of depression, is ill-defined. I might try using an anti-depressant but without genuine confidence that it would work for this classification of depression. I might try it on a short-term time-limited basis, but only as an adjunct to psycho-therapy, which is where I would expect to provide more benefit to the patient. Again, I am not averse to the use of anti-depressants, so long as it is used as an adjunct to psycho-therapy. One must be clear that Psychiatry is not an exact science.

The clinical features for Major Depression per the DSM-V have been well described in medical literature. Nevertheless, many psychiatrists fall into the sloppy habit of just prescribing drugs regardless of any refined analysis of a patient’s depression; forgetting what they have learned in preparation for their Board Examinations. Along with those psychiatrists, many doctors that are not therapists, and therapist that are not doctors, prescribe drugs based on the marketing propaganda of the pharmaceutical industry that exclusively promote anti-depressant treatment through chemistry.

In many ways, one must rely on one’s clinical experience. But, interpreting symptoms is always subjective. The nature of human beings is to isolate things within their environment in order to label what they perceive as a way to create order. Psychiatrists, and all therapists, are subject to that same innate perceptual process. One tends to “cherry pick” and organize perceptions that fit with one’s own pre-existing ideas, wishes, and habits. Without applying the most stringent self discipline, one will quickly embed a habitual view of patients who present with depression.  

This has been a long-standing concern of mine. It is my clinical experience that the number of times a patient engages in self-harm does not necessarily reflect his/her depth of depression, or how important it is for them to be prescribed anti-depressants.  There are other reasons than depression that prompt self-harm.  I have seen many patients’ depression cease to be an issue once their reason to be depressed has been clarified and addressed. At the same time, this is not to say that pharmaceutical treatment is always wrong.  

In my practice, I did use anti-depressants for some of my patients. Why? I believed their depression would be temporarily eased with some pharmacological agent such that they could proceed with psychotherapy. Nevertheless, in some cases, patients who arrived through referrals from other therapists with existing anti-depressant prescription, I tapered off and eliminated their anti-depressants in cases where I did not believe the drugs would help them. There are certain features of depression that may indeed respond to medications. However, seldom is it the case that psychotherapy is appropriately replaced by medication.

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Key Qualities For DID Therapists: PART 4 of 4 – Patient Assessment of Therapists

I suggest that patients who are able to speak to therapists about their own treatment needs, do so as early in the relationship as possible – including at any initial intake interview. For some, it may be too frightening so please don’t worry, don’t argue inside about it. It is fine to take your time so long as you internally assess the therapist. For all patients, I recommend checking in with your protector parts, as always encouraging vigilance rather than hyper-vigilance to the extent possible, to help with the assessment of a new potential therapist.

I am speaking primarily to patients for two reasons. First, because I do not see a willingness within the profession to change from the current pharmaceutical dominated mechanistic orientation of mental health planning controlled by that industry, accountants and the Insurance health care planners. Second, through my limited participation in social media, I have seen the benefit and power of the DID community members supporting each other in ways that should guide therapists in their treatment plans for DID.

Within the profession, there remains the erroneous view that treating depression with SSRI medications and anxiety with benzodiazepines is the most economic way of dealing with mental health issues within the population. To those in control of how the money is spent, I like to point out that shifting to a trauma based model of psychopathology will ultimately save far more money, more effectively treat trauma survivors, and appropriately apply existing manpower. While medication prescriptions may be essential for dealing with symptoms, we must not allow symptom treatment to blind us to the importance of a more humanistic approach, of applying psychotherapy to the underlying causes of the symptoms. Why? If the underlying cause is treated, the need for medication diminishes, the need for hospitalization diminishes, the need for social services diminishes, and the need for police intervention diminishes. Without treating the underlying cause, prescriptions will remain endless, the cost of monitoring the medications will remain endless, the disproportionate use of all government services will remain endless and the patients will not heal.

Based on experience with my own patients, admittedly a very small sample size, when the DID diagnosis is missed, those with DID become super-consumers of the medical insurance funds. Why? Because they generally have repeated suicide attempts, repeated hospitalizations, repeated self-mutilations and an ongoing inability to safely navigate society. Cases of depression and other extreme difficulties, often identified as “Treatment Resistant” that are the result of diagnostic error. Given that the time lag between initial intake in the mental health system to accurate diagnosis of DID is an average of 6 years (per Putnam in 1979 – I am unaware of current data), if this kind of misdiagnosis is liminated, the suffering that could have been eased, and the money that can be saved societally, would be enormous.

While a single isolated case does not prove anything, I still remember my patient who had spent 5 solid months in a psychiatric ward simply for suicide prevention. When she was discharged, the notation in her file about her then condition was simply that she was still alive. She came to me for therapy after the discharge and we worked together for 2 and1/2 years. With proper diagnosis and treatment, this resulted in her reclaiming a fully functioning life as a mother of two toddlers, without needing psychotropic drugs or any mental health professionals for at least the next 20 years.

Ask your therapist for the empathy, compassion and patience that you need for treatment to be effective. It is one way to take back and restate your own power to heal. Confirm for yourself the possibility that they will take that to heart. They can learn about treating trauma through study and practice. It is much harder to learn genuine empathy, compassion and patience. Best wishes.

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Key Qualities For DID Therapists: PART 3 of 4 – Understanding The DID Survival Response

The essence of being a therapist is to be a compassionate guide. It is to guide patients through the healing process with insight tempered by kindness. For DID treatment, it requires a willingness to work as a guide rather than a director, to have deep reserves of empathy and patience, and to understand the power of active deep kindness. While an intensive course with a supervised apprenticeship is important, those qualities of empathy, patience and kindness are critically important. At the same time, the therapist needs to know how to protect him/herself from vicarious traumatization that can occur simply by virtue of genuinely working with survivors of early childhood trauma.

Such a therapist needs to understand that:

1) you have this condition of DID because of early childhood trauma;

2) your current symptomology is an adaptive survival response to years of trauma;

3) your adaptive survival response, when continuing as an ongoing hyper-vigilant state, creates problems of its own;

4) you need guidance and support to work with the diverse parts inside which cause conflicts and gently pursue solutions aiming at co-consciousness, cooperation, coordination and working as a team, like a sports team always aiming to achieve the common goal;

5) you likely have partial and/or total amnestic barriers between different parts inside which can be great obstacles in your daily functions, barriers which arose for reasons connected with surviving trauma, and that loosening those barriers requires protection from retraumatization; and

6) you need guidance and support to retrain or reset your body’s neurological and emotional responses.

This last point means learning to safely dial down the hyper-vigilance so as to be able navigate daily life and identify what in each present moment is safe and what is dangerous. In short, you need help to readjust to what is encountered in ordinary everyday non-traumatic environments with ordinary vigilance rather than hyper-vigilance; like looking both ways at the corner before crossing the street rather than repeatedly scanning the streets for hours while being paralyzed at the idea of crossing the street.

To be guided and supported in your DID healing journey, more than academic/scientific credentials, you need someone with genuine compassion, good will, patience and willingness to work as a guide. When those with DID say that empathy, compassion and patience are the pre-requisites to their committing to begin working with any particular therapist, that can become the basis for a grassroots shifting of the views of therapists on how to treat DID.

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