David Yeung's Blog, page 6

More Thoughts on Alters – Part 1 of 5

Please forgive the length of this 5 part post. The intention is to summarize some of what I have written before as well as to add some additional points of refinement.

Robert Oxnam, author of A Fractured Mind, described how his psychiatrist came to the diagnosis of his MPD (now known as DID). This was quite similar to my experience of the diagnosis of Joan, the patient described in the first chapter of Engaging Multiple Personalities Volume 1. An alter came out and spoke with me and sneered as she called me “stupid.” It was clear at the end of the session, when that altered had disappeared, that the host personality had no recollection of what was said – the amnestic barrier remained completely in place.

It is unusual for a patient to call his psychiatrist stupid during a session, especially when the patient is depressed and seeking help. At the time I wrote my first Volume, I had not read Oxnam’s book. That his psychiatrist had almost the exact same experience leads me to believe that a therapist may face this kind of unexpected interaction on first meeting an alter. Hence, the importance of maintaining an appropriate index of suspicion with respect to the several possible diagnoses to consider when patients arrive trying to deal with depression, anger, and trauma.

How a therapist first comes to the diagnosis of DID is likely different from case to case. When the therapist has gained some experience in DID treatment, the realization of the correct diagnosis is usually quite evident and definite. In my own case, when I first met an alter – regardless of how they spoke to me – I usually had an unmistakable chilling sensation down my spine that the person with whom I was speaking had left the conversation and I was suddenly speaking to someone else, an alter.

I never experienced that sensation when dealing with the usual patients who had depression and anger. In the case I refer to, the alter is clearly one who is not the same age as the host.  A professional well educated person in her forties would not call her psychiatrist “stupid” in the psychotherapy session!

Inexperienced therapists may worry that the patient is faking, that perhaps we are cheated by the patient or that perhaps we are anxious to meet an alter as a result of our own preconceived mindset. Psychiatrists who assert that they have never seen a case of DID are mostly fearful that making that diagnosis is the result of misdirecting and creating a case of DID (iatrogenesis) because they believe the disorder simply doesn’t exist. I believe those worries and fears are inappropriate, that they lead to missing the true underlying issue of DID – that it is the result of early childhood trauma impacting the patient on an ongoing basis.

Personally, I cannot think of any reason why a patient would deliberately try to fool me into believing he/she is suffering from DID. The only circumstance might possibly be in criminal matters. Claiming an alter did the criminal deed, is not going to excuse the crime.  Nevertheless, there may indeed be a logic for someone in prison without DID to mimic DID symptomology to get a temporary reprieve from their prison cell to a mental hospital. However, whether it is a short or long term reprieve is not usually in the control of the prisoner.

It is clear to me that I have missed many cases of DID. Decades later, I came to the realization that my fault was thinking DID was a rare phenomenon. As a result I discounted the likelihood of seeing such a case or cases. In other words, it did not register in my general index of suspicion as might bipolar disorder, borderline personality disorder, or schizophrenia – even though studies show that DID is as common as schizophrenia.

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The Psycho-Therapeutic Environment

I read a discussion recently involving the set up of chairs in the interview space; the chairs for the client and the counsellor. The question was whether they should be facing each other or at an oblique angle? This prompted me to consider this and certain other aspects of the overall experience of a therapist and client interacting.

[1] Seating. When set up at an angle, the client has the option of looking at the therapist or comfortably looking straight ahead but not at the therapist. Given that some of the material that comes up in a session can be extremely difficult, having the arrangement set up so that the client is able to look away from the therapist without having to twist their head or body uncomfortably allows them more psychological space to deal with very vulnerable feelings that arise when deep trauma is being processed. This can be very important for the client’s sense of therapy as a safe space.

The oblique arrangement allows for and actually encourages clients to define their own spatial boundaries vis a vis the therapist whenever they feel the situation warrants it. This empowers the client, especially when they might be overwhelmed by feelings of shame, guilt, confusion or simply overwhelming pain when touching memories of trauma. Setting up the physical space properly for the client gives them a better environment to process what they are engaging during therapy.

Psychotherapy is much more than just what we say. It is like understanding how music is much more than the notes we hear. The pauses and silences are equally important as they shape the melody and rhythm. The silence and pauses in therapy, and the psychological space they provide, should be treated as equally important to our words. Proper psychotherapy requires setting up a safe milieu in which the client can process trauma, grow and change. Small details are often the key to the engendering the experience of safety.

[2] Modelling Life. This is another small reminder of the office setup. If there are flowers and plants being displayed, they must be alive and vibrant. Place yourself in the position of a client who enters your office and sees flowers on the window sill that are dehydrated and half dead, or a green plant dried to a dying brown, or a fish tank with dead fish floating or algae covering everything.

If you do not care enough to keep the plants and flowers fresh and blooming, please do not display that kind of carelessness. Some therapists have a cat or dog that clients connect with as an expression of life and support. Simple details highlighting life mean a lot to the client who enters the office with no real knowledge of who you are as they are hoping you are the right person to help them. They will likely read into details of deficiency or negativity, and such unfortunate details will have a disproportionately greater impact on the client. To put it simply, a dead flower may mean to a client that you are insensitive to pain & suffering, or even to beauty in life. Living plants and animals convey a very different message.

[3] Punctuality. Some doctors are notorious for keeping their patients waiting. This communicates the message, correctly or not, that “My time is more important than your time.”

This is not an incorrect assessment by the client. I myself am annoyed if I have to be kept waiting for half an hour for an appointment that is specified to be on the hour. There is no excuse when this occurs regularly. The conclusion that I come to is no different than what any client would come to: The doctor thinks his/her time is more important than my time. There are, unfortunately, doctors so obsessed with not wasting time which equals money if they are being kept waiting for the next patient, that they ask their secretary to double book patients. This is the opposite of creating a healthy supportive environment for psychotherapy clients.

If there is an absolute emergency, have the secretary tell the patient you are held up in an emergency. Needless to say this should not be a regular occurrence, or it will undermine the therapeutic alliance.

[5] Information gathering. There are two ways of gathering information. The first is by questions and answers according to a list. Filling out a standard questionnaire may not be a good practice. There are important basic data that one should keep in mind to eventually find out, but not necessarily in the first intake interview.

For example, early childhood adverse experience is something about which a therapist must eventually have some knowledge. But questions related to this should always be approached in an oblique way unless and until the client is comfortable and there is enough trust in the therapeutic relationship. Pursuing those questions directly, before a strong therapeutic alliance has been established, could well be met with a false negative answer. It is often wise to wait for an opportune time to pose certain questions, based on the then present qualities of the relationship between therapist and client.

I would also encourage the therapist to suggest to the client that if he/she is not ready to divulge certain information, that they can simply say, “I do not feel comfortable to talk about this today.” It is important to remember that empowerment of the client is an essential element in all therapeutic processes. So, such a statement by a client is not a confession of weakness and should not be seen that way. Rather, it should be presented and accepted as empowering the client to have more control in the therapeutic exchanges. This kind of frank statement by the client will inform the therapist that the timing is not right, raising their awareness to a higher degree. Be careful, to not push on that topic until a deeper therapeutic alliance has been established and the time is right for the client.

[6] Core Conditions. I cannot emphasize enough, even though I have repeated this umpteenth times, Carl Rogers’ core conditions for therapy of empathy, congruence and unconditional positive regard. These are also sometimes referred to as the “facilitative conditions.” In other words, they are the conditions that the client needs to experience from the therapist for therapy to work. An expert in EMDR or CBT (Cognitive Behaviour Therapy) who ignores these Rogerian core conditions will undermine their own therapeutic alliance with the client to the detriment of their therapeutic skillset.

I was not taught these points in my training as a psychiatrist, but that was over 50 years ago. I am uncertain as to whether or not this is taught in psychiatry or counselling courses today. It is possible that it is taught more as an aside and, if so, soon forgotten under the pressure of a busy practice. However, it is something for clients to mention to the therapist if the therapist appears to fail to consider these 6 points, which feedback therapists should acknowledge and for which they should express appreciation.

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Trauma and Dissociation revisited – Part 4 of 4: Comments on Alternative Treatments and General Guidelines

The approach I took to treating my DID patients is presented throughout the Engaging Multiple Personalities Series. The primary foundation of the approach is to engage those personalities as and when they present in therapy. The focus is to allow healing to take place while lowering the risk of re-traumatizaion. The risk is lowered by no calling alters out, challenging their existence, or demanding they disclose their memories. It is applying psychotherapy to the trauma as it presents right now in each session. It is remaining clear that the symptoms you see, the alters, are not the cause, which is ongoing early childhood trauma. Keeping that in mind, the alters hold the key to the path of healing.

As my readers know, I was and am averse to the use of psycho-active medications as anything other than an adjunct to psychotherapy. I am aware of, and have had questions from, people that seek help with their DID from alternatives to psychotherapy that are not based on psycho-active medication, such as hypnosis and EMDR.

With respect to HYPNOSIS, I have great reservations about it. There is often the suggestion that using hypnosis will enable the therapist to verify or help the patient retrieve a memory. This betrays the misunderstanding of dissociation as memory impairment rather than a protective device to shield one from being overwhelmed by trauma. It also betrays a general misunderstanding of the trauma that produces DID.

I did pursue training in hypnosis early in my career. I found it unnecessary, and potentially harmful, for those with DID if the sole or even primary purpose of using it is to get a picture of the original trauma(s) as a predicate to or part of treatment. I do not believe hypnosis is helpful because treatment does not require a detailed level of accuracy regarding the original trauma(s). The therapist really only needs to see how the trauma has affected the patient in the past and how it is affecting the patient in the present to move forward with therapy. Seeking details, parsing them or evaluating their accuracy, is of very limited value. Further, it runs the risk of being perceived as attacking the patient/alter expressing those memories and re-opening wounds that the patient may not yet be prepared to process.

There are numerous therapeutic techniques to help a patient get in touch with a present feeling of safety and comfort (grounding techniques.) These are less flashy and much safer for the patient than hypnosis. They take time and practice, but give patients tools they can use outside of the sessions. In short, they empower patients in their own healing journey.

Hypnosis is the inducement of dissociation. Because DID patients are already experts at dissociation, it is easy to induce dissociation in a therapy session through hypnosis. This can intensify the already hierarchical aspects in the relationship between the client and the therapist. Structuring therapy around hypnosis can accentuate both the issues and consequences for the patient’s panic of being out of control. It undermines the possibility of the patient’s self-empowerment to process past trauma.

Self-empowerment is key to a patient strengthening their ability to work with flashbacks while avoiding re-dramatization. Given that flashbacks will happen outside the context of a therapy session, further undermining a patient’s ability to deal with triggers they encounter in their everyday life, this is not something I would encourage.

If a therapist is comfortable in using hypnosis and is aware of the dangers that I have mentioned above, I suggest they discuss the issues with the client. That way there is more likely consent possible from the patient. Actively seeking that consent is at least an acknowledgement to the patient that they are in control. The patient being in control of the choice can encourage the sense of self-empowerment.

EMDR is another alternative treatment that people discuss and sometimes pursue. I don’t believe that any treatment, other than as an adjunct to psychotherapy, should be pursued. However, I am aware that there are people with DID who feel they have received great benefit from EMDR. Please do not stop any therapy that you believe is helping you simply because of my bias.

And yes, like all human beings, I do have my bias: I think it is erroneous to state that EMDR is a treatment specific for DID. While it may have benefits for some with DID or other disorders, and there are some studies showing that to be the case, it is like saying the scalpel is the specific treatment for cancer. Like a scalpel in skinful hands, EMDR is a tool which can be usefully applied. But in the wrong hands, like anything else, it is useless and may indeed be harmful. As always, it depends on the skill of the therapist to deal with potential re-traumatization issues, many of which likely will occur outside of any EMDR session. If you do explore EMDR as a treatment for DID, make sure that the EMDR therapist has an understanding of the dangers and risks of re-traumatization within and beyond the confines of the therapy sessions.

GENERAL GUIDELINE is that there are many disorders unrelated to DID that have symptoms that are common in DID as well. The message for therapists is the importance of retaining DID in one’s index of suspicion when working with patients. Without that, it is easy to misdiagnose those with DID.

There are many who suggest that DID is a fad diagnosis, not a real one. This is despite the fact that DID, under the acronym MPD, has been in the DSM since its 3rd edition in 1980. The most common logic I have been given is for the presumption that it is not a real diagnosis is, “Since I don’t remember what happened to me when I was 3 years old, I don’t believe that a patient could remember anything that happened to them at that age.”

This is foolish. If those same horrific things had happened to such therapists at the age of three, it is quite likely they would indeed remember,unless the memory is dissociated and stored in a separated part or an alter. Horrific experiences and the response to them are burned into a person much differently than say, the time your Aunt brought you a birthday cake at the birthday party when you turned three. The difference is that trauma may show up as symptoms, not readily accessible memory.

DID usually presents to the therapist as an individual suffering from depression, personality disorder, anxiety disorder, schizophrenia, and substance abuse. According to Colin Ross, author of a key textbook on DID in 1989, only 1/5 to 1/3 of DID patients are initially diagnosed as DID. If the initial diagnosis is depression and the psychiatrist is vigilant, with the proper index of suspicion, he/she will in due course identify the real diagnosis as DID and will apply the right kind of psychotherapy. This separates the conscientious therapist from those who just rely on blind faith in antidepressant medications.

Both traumatic memory and amnestic barriers within a mind’s system need to be taken seriously. Nevertheless, there are still psychiatrists who personally told me that childhood trauma is much exaggerated. They insist it is exaggerated, both in number and intensity, despite the ever increasing numbers of abused children showing up in studies, hospitals, and psychiatric wards. Some percentage of these children will show up again as adults with Complex PTSD and likely some DID when they are adults – just as was the case over the course of my career.

It is not dissimilar to the early days of what is now labeled PTSD from war related trauma – military and civilians both. Before anyone wanted to acknowledge it, this was happening – whether it was termed “battle fatigue” or some other term. Once acknowledged, clinicians heightened their index of suspicion and identity war related PTSD. But this was only acknowledged due to the overwhelming pain of veterans and their families dealing with their return.

If clinicians are taught to have the proper index of suspicion for DID, they will see, as I did, that DID presents alters suffering from past unresolved trauma that need healing.

In treating DID patients, my job was to regulate the outpouring of remembering. If anything, it was to titrate the patients’ exposure to their memories, rather than to dig around in the past. The only time I got details of abuse was when patients needed to express them. The abuse always displayed its impact through alters, hyper-vigilance, and other PTSD symptoms.

There was no urgency or even need to prove the accuracy of each and ever recollection my patient might hold. Again, that is because therapy is based on how past events resulted in present dysfunction – not about whether the patient remembered details of the abuse sufficient for a judge or jury.

Consider it to be analogous to treating a veteran with PTSD: Knowing that veteran was hurt in a roadside bombing, you know there is PTSD. That is all one needs to provide therapy. No therapist needs to ask about the details of that bombing to provide therapy. In fact, unless and until the veteran brings them up one shouldn’t push for them. DID clients need help in reducing the internal conflict among alters inhabiting that one body. In general, alters are in varying degrees of co-consciousness with the host and each other – from none to quite a bit.

If they are not, the therapeutic goal is to gently weaken the amnestic barriers step by step.

To do so safely, it must be done small step by small step. When they begin to find ways to co-exist peacefully, their previously violent clashes of individual claims of freedom and demands begin to ease. Slowly, slowly, healing is seen as more and more possible. And the path of healing is traversed.

Some therapists appear to be obsessed with the idea that therapy means convincing a patient that alters are not real, that they should be eliminated, or they should disappear into integration. This is wrong, a complete waste of time and counter-productive for a therapist to try to convince a patient that the alters are not real. Fundamentally, it is unkind and a barrier to establishing the critical therapeutic alliance necessary to working together.

To a custom officer at the border looking for a single passport, whether alters are real or not might be a relevant point of discussion if a DID individual shows up alone in a car and states that there are 30 people inside wanting to cross the border. But, in other situations patients may find themselves in, alters are as real as the painful sensation I feel when I bang my shin on a low table as I walk around my apartment.

No reasonable person would consider it helpful therapy to argue with a depressed patient that he/she should not be depressed because there are so many people around the world who are starving, dying from cancer, or in broken relationships? That is what people often try at home. It usually doesn’t work there which is why the patient with depression goes to a therapist. Let us be kind, be compassionate, and be a support for our patients’ healing, not a further obstacle.

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Trauma and Dissociation revisited – Part 3 of 4: Denial and Myths

DID continues to cause so much controversy, and remains a hot topic among mental health workers. In my opinion, this is for two reasons. The first reason is pretty clear. It is that some famous professors and heads of universities deny even the notion of DID. They continue to denigrate the diagnosis, claiming that it is based on unscientific misunderstandings.

They argue against accepting it even as a possible diagnosis. They assert that it should be removed from the DSM diagnostic formulations. This is despite several studies that show it is statistically as common as schizophrenia – a diagnostic formulation that no one disputes.

A colorblind person may argue with you that there is no such thing as “red.” They believe it doesn’t exist because they don’t see it. They can only understand “red” as a concept because it is something they cannot perceive. They are not lying, they simply cannot distinguish and identify what people without colorblindness see as “red.” In that same way, some famous university professors and heads of their psychiatric departments irresponsibly conclude that because they have never identified a case of DID in their exalted and long careers, that such a thing does not exist. Their conclusion really comes from their blindness to DID as a clinician.

The second reason is simple: DID continues to come up because it is a correct diagnostic formulation. The question then becomes, “Why is schizophrenia an acceptable diagnostic formulation and DID is not?” I suspect it is because the etiology is quite different: The root cause of DID is ongoing horrific early childhood abuse.

This means that the incidence of DID is connected to the incidence of early childhood abuse. To acknowledge the statistical studies of DID shines an uncompromising and embarrassing light on psychiatrists’ (and society’s) blindness to early childhood abuse.

Some wish to deny DID because one cannot measure or prove the existence of DID with a laboratory test. But, that is true of many psychiatric disorders. The fact is that if you are open to hearing a patient’s early childhood history of abuse, even ordinary levels of empathy reveal the internal reality of a traumatized individual. Applying the balm of that empathy opens doors that a patient would otherwise keep locked shut.

If you are not open to hearing a patient’s early childhood history of abuse, which they are already trying to keep locked up from themselves, ask yourself why they would reveal anything to a therapist that is predisposed to denying their experience. The result is that ever since the case of Anna O, a patient of Breuer whose case study was described by Freud and includes indications of DID symptoms, there have been numerous cases of DID mistakenly identified as disorders under other diagnostic labels.

A key myth that needs to be overcome by therapists treating DID is the view that alters are pathological mental deviations to be eliminated. Instead, alters should be seen for what they are; an integral part of a whole system. It is not for the therapist to choose alters to accept and alters to reject. In fact, the problem for the host personality is often the internal conflict resulting from accepting and rejecting the other parts.

As I have said repeatedly, alters hold the keys to healing. The job of a therapist is to help the client to understand what drives the alters, and to invite them to participate in the whole system without undue conflict. This can be accomplished by engaging such alter(s) by first listening with empathy to what they need to say, and second by speaking to them with respect, with kindness. In this way you encourage them slowly to understand that they are not only a part of a whole system, but play(ed) a significant role in the system’s survival of the original cycles of abuse.

A surgeon, seeing something pathological, can treat problems through excision, or incision and drainage, like treating a tumor or an abscess. In DID treatment, healing is by inclusion not denial, suppression or excision. It is a bad for a therapist to think like a surgeon.

Alters may have originally been deemed by the individual showing up for therapy as undesirable, unworkable, a nuisance, or some other kind of problem. But they are not going to be eliminated by cutting them out like a tumor or draining them like an abscess. All of the alters, but particularly the “difficult” ones, are pointing out the therapeutic path to follow if only we therapists will truly listen.

Perhaps a better way for people who don’t understand DID to get a small glimpse of it is to look at “normal” people with a conventional unitary personality. Consider a judge at work putting on his wig in an English court. There, he behaves with dignity, representing the law of the land or the imperial crown (in England). He projects a very particular powerful persona. If that same individual was raised by an alcoholic parent, once he leaves the court, he might sloppily carouse with friends at a bar – projecting quite the opposite of his persona as a judge.

In another non-courtroom circumstance, that same person may try to learn to ski because they want to accompany other friends already skilled in the sport. But, if that judge had broken a leg skiing when they were young, they might become quite frightened, quite hesitant and even paralyzed, getting on the chairlift for the first time in decades. In fact, he might look somewhat like a frightened child. Only a person who knows or suspects that long-ago injury might be able to help him overcome the paralysis of the current moment – or tell him it is ok that he doesn’t get on the lift. This example includes the paralysis that can some with a traumatic trigger to a past event.

It is the same person, with the same name and picture on the driver’s license. But depending on the context, he may behave with a completely different persona in each different circumstance. This is somewhat how a system, with host and alters, feels. The difference is usually that the individual with DID is often not capable of choosing what face to project in the event of a triggering event.

Alters are best incorporated into the whole in the operational sense, not in the sense of integration. I see no harm in their individuality so long as they all work toward common goals with minimal internal clashes.

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Trauma and Dissociation revisited – Part 2 of 4: Therapist Biases

[1] Therapists Need to Stop Protecting Their Own Ego

Many psychiatrists and other therapists continue to question whether DID exists as a clinical disorder. Maybe they fear that by making such a diagnosis or that they will get laughed at by colleagues and be denigrated both publicly and privately. I speak of this from experience.

As I have written before, at the same time as my approach to treating DID was sneered at and demeaned by other local psychiatrists, I was referred a number of patients whose clinical files included the word “dissociative” when referring to the patient’s symptoms. And yet, not a single one was given either a primary or contributing diagnosis involving dissociation.

Given the statistics, it is extremely unlikely that any psychiatrist with a general practice has never seen someone with DID. However, it is quite possible that they never recognized it, given the training they likely received. For example, when I was trained decades ago we were told that DID was so rare that no one in the class would likely ever see anyone with DID.

A rough way to assess whether or not a psychiatrist has missed DID cases might be to see how many patients they diagnosed with “treatment resistant depression.” In my experience, treatment resistant depression actually means “drug resistant depression” – a very different thing. In my opinion, the odds are that most of the cases in that group are DID. Imagine how embarrassing it would be for a psychiatrist to publicly admit that, throughout a long career, he likely misdiagnosed DID cases because he didn’t recognize what he was seeing.

Therapists need to get over those fears in order to do what they are called upon to do – to help patients heal.

I find it heartbreaking and enraging that professionals would identify dissociative characteristics in a patient simply because they lack the courage, or even common decency, to make an obvious dissociative diagnosis. The result is that those patients likely endured years of misdirected and harmful pharmacological interventions rather than psychotherapy. When they reached my office, that harm, and the wariness of psychiatry as well as of psychiatrists in general, made it difficult for a genuine therapeutic alliance to be established. The negativity needed to be undone before we could begin to work on healing their early trauma.

[2] Bias Toward Integration

There is the question of whether integration is or should be seen as the final goal of DID. Putting it simply, I would never encourage this for my patients. To be clear, I have seen patients who had made strong recoveries, processing deep old trauma, and have accomplished much healing. While they were able to navigate the world safely, perhaps for the first time, they were still subject to being re-traumatized by an encounter that was simply too triggering.

Intense triggers can result in re-traumatization and the resumption of dissociative defense patterns. Whatever integration has been accomplished will simply fall apart under enough triggering stress. For patients that didn’t cling to the idea of integration, the re-traumatization were aware of as a risk and was something that they have worked with in the past.

Without clutching at integration as the goal, re-traumatization doesn’t have to undermine hope, nor does it destroy the understanding that there was healing and progress. For patients that cling to the idea of integration as the definition of healing, under the power of intense re-traumatizating triggers, I fear that alters will consider the idea of hope for healing as another gas-lighting tactic by the world to hurt them again.

[3] Holding to a Fuzzy Definition

Dissociation is the term chosen to refer to something that is common and poorly understood, The concept of dissociation is borrowed from chemistry and means the breaking up of a compound into its simpler constituents which, under certain conditions, can re-form as the compound. For example, it can be used to refer to the breaking up of water into the elements of hydrogen and oxygen.

In psychology, one is unable to be so precise because of the inability to define what whole is breaking down up into what constituent parts. In the same way, there is the inability to define what can be re-formed. Perhaps the problem can be clarified by asking: Can we explain “trust” in chemical terms. This kind of borrowing a word from one discipline to be used in a different discipline that has no real analogous qualities is never accurate or satisfying.

Further complicating the meaning of dissociation is that it may be used to refer to several quite different experiences. It is a loosely applied concept to denote the following conditions:

[a] Splitting sensation from awareness: Walking on fire and not feel the burning heat; or seeing a needle piercing the skin and not feeling the pain.

[b] Spitting the memory from the awareness: Genuinely not remembering being under gunfire until it stops. A soldier only hears the “silence” after a period of artillery bombardment ends.

[c] Escaping immediate pain: A child being beaten by an abusive father, who escapes by watching someone else being beaten – which person/personality is later termed an “alter” – rather than himself.

Dissociation is much more commonplace than is generally acknowledged. In fact, I believe it is both a universal and normal occurrence. It only becomes pathological when, due to a state of ongoing extreme distress, it becomes a habitual defense mechanism that causes dysfunction. It is the poorly defined boundary, a vagueness, that separates the normal ability to occasionally dissociate from the abnormal habitual dissociation coupled with hyper-vigilance that makes it so confusing to many therapists. This is how the misunderstanding arises that dissociation is by definition pathological and must be eliminated.

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Trauma and Dissociation revisited – Part 1 of 5: Misinformation and Misunderstanding

After seeing yet another post from someone whose therapist told them that “DID is a diagnosis that we have come to doubt as therapists…”, predictably, I once again got upset. I responded directly to the post because such a statement is offensive, demeaning and wrong. It will undermine DID patients and produce no benefit.

Knowing that this is a long uphill battle of educating therapists as well as supporting those with DID, I feel compelled to revisit some key points I have been making in my books and blog since 2014. Although it is now about 15 years since I retired from practicing psychiatry, I remain unable to let go of my interest in the treatment (and mis-treatment) of trauma and dissociation. I continue to do what I can to promote the healing of those who suffer from DID.

I find that there remains a good deal of misunderstanding on DID in the general public and, most unfortunately, among professionals in the mental health field. What continues to disturb me is the number of individuals continuing to post messages about their difficulty in locating qualified therapists to help them. This is a sign of our ongoing professional failure to support those suffering from DID.

This is a denial both about the depth and extent of early childhood trauma as well as its impact later in life. It seems to have resulted in a lack of confidence on the part of many therapists which prevents them from treating individuals with DID. It is as if they are frightened of identifying clinical presentations of DID. I am not sure why this is the case, unless they would place themselves in danger should they either diagnose or treat someone with DID.

Many authors of psychology textbooks state that DID is rare. But they don’t even argue their case, they just make the flat statement without citing anything that would contradict the studies that show DID is not so rare. Simply because an otherwise experienced psychiatrist near the end of his career says that he has never seen one such case doesn’t change the statistics. In fact, DID is often simply misdiagnosed as depression, panic attack, borderline personality and bipolar disorders. Relying on a history of misdiagnoses fails to prevent the perpetuation of that ignorance to the next generation of therapists.

[1] DID Prevalence

The prevalence rates found in psychiatric inpatients, psychiatric outpatients, the general population, and a specialized inpatient unit for substance dependence suggest otherwise. DID is found in approximately 1%–5% of representative community samples. Using a questionairre method for measurement in a representative sample of 658 individuals from New York State, 1.5% met criteria for DID when assessed with SCID-D questions. Similarly, a large study of community women in Turkey (n = 628) found 1.1% of the women had DID .

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I am not sure if there is really a “normal’ person who has never experienced dissociation. Dissociation occurs over a wide spectrum from normal individuals to those with full blown DID. As I have said before, dissociation is something we are familiar with because it occurs in all of us. For example, when you are driving a long stretch of freeway listening to your favorite music, your attention is definitely not 100% on the road and you may easily be unable to remember having passed by this or that town.

Consider whether you know anyone that has never had conflicts with members of their family, or gotten angry at a driver who cut them off? Would you feel comfortable being operated on by a surgeon who is distracted, even marginally, by such thoughts? I certainly would feel extremely nervous if a neurosurgeon operating on me was incapable of some degree of dissociation.

[2] Obsession with Alters

Many people are obsessed with alters because one can only have a single citizenship card from a particular country, a single driver’s license from a particular Province or State, and a single social insurance number. This logic is then used to define “healthy” as meaning that we cannot behave or feel like we hold different identities. This misses the point and sends both therapist and patient in the wrong direction.

I think we need to review and revise the intensity of the focus on multiplicity in DID.

Perhaps it would help psychiatrists, psychologists and patients see the therapeutic path forward more clearly if they shift the emphasis from treating multiplicity as the disorder to treating the trauma and dissociation that manifests in multiplicity. The alters are not the problem. The problem is the internal conflict that untreated trauma generates.

When I was still practicing psychiatry, Multiple Personality Disorder as the diagnostic label made more sense than Dissociative Identity Disorder to my patients. It was more helpful because they experienced the different parts as different personalities in the common understanding of the term “personality.” Because they had more than one part, usually many more, calling it a “Multiple Personality” disorder acknowledged their internal experience whereas Dissociative Identity Disorder seems more geared to how they would be viewed by a therapist.

This approach of tying the label to the therapists’ outside view gives an undue weight to the presumption that mental health is restricted to the idea of a single ego structure that others experience as relatively consistent. To tell one of these alters that they were not real and only an expression of dissociation was not only unhelpful but ran the risk of undermining the necessary therapeutic alliance.

Again, I urge therapists not to miss the forest – the early trauma and its ongoing impacts – for the trees – the personalities/identities/alters/parts. Missing that forest will make genuine successful treatment difficult, if not impossible. Engaging alters without obsessing about them will enable you to treat the DID and help the patient heal from their trauma while limiting risk of re-traumatization.

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Social Media

There was a recent article in the Washington Post title: Social Media Is Traumatizing Us More Than We Realize.

The article focuses on the widespread implications of repeatedly engaging with social media in these difficult times. Underlying the article is the understanding that trauma is insidious and doesn’t just go away.

So, maybe this is a chance for people who deny the impact of ongoing repeated trauma in early childhood to understand that it doesn’t just disappear. If people without deep trauma in their personal histories are getting traumatized by social media, it may be possible for them to extend their understanding, with compassion and empathy, to people with a history of deep early childhood trauma.

The article is written from the point of view represented by its sub-title: “Here’s how constant COVID-19, racial injustice and political posts can alter your brain and body, plus advice on fixing it.” In essence, it is trying to point out how social media habits rewire people in negative ways – and what to do about it. Again, if people consider the rewiring of brains through social media negativity, maybe they will consider the possibility of vulnerable very young brains being wired and rewired through repeated direct abuse.

I have many concerns about those with DID interacting on social media outside of the safety of trusted/trustworthy online support networks. I find it difficult to accept how the trauma of interacting on social media is characterized as so dangerous while the real world trauma that those with DID experienced, and still are affected by, is ignored or dismissed by so many people – including psychiatrists and other therapists

Perhaps if those who are experiencing (and perhaps treating) the adverse impact of social media on those who willingly participate in it consider how a small child might respond to repetitive ongoing trauma that are choicelessly subjected to, they would get a small glimpse of the poisonous potency of early childhood trauma.

From the hopeful point of view, PTSD was not dealt with until the military could no longer ignore it. Once that happened, complex PTSD related to DID slowly started to become acknowledged at least as a possibility. It would be helpful if this explosion of articles on social media related trauma led to a greater understanding of the consequences of repetitive trauma such that there becomes another gateway to acknowledging ongoing early childhood trauma resulting in DID.

At the same time, there are dangers discussed in the article that may be relevant to the DID community. For those interested, here is the link to that article: https://www.huffpost.com/entry/social-media-traumatizing_l_602d2c88c5b673b19b654d88

best wishes

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From Hyper-vigilance to Trust

Moving from hyper-vigilance to ordinary vigilance is one critical expression of the ability to trust. In fact, it is the path for making one’s multiplicity workable in everyday life. I believe it is actually more important and a better marker of the healing process than whether there are more or less alters, whether there is some, none, or so-called complete integration.

There is a very good reason that those with DID show hyper-vigilance. DID arises from the destruction of a child’s experience of safety. For those who have not experienced ongoing terrifying early childhood abuse, the ordinary ups and downs of life usually involve being taken by surprise sometimes. Except in cases of accidents, it is usually without terrible continuing consequences. As a child who is not in an abusive situation, you are usually comforted by an adult who is a reasonably trusted reference point. If effect, you are taught to learn from your mistakes. With guidance of that adult, you learn to pay attention to the risks you encounter in everyday living and how to navigate them ever more safely.

Contrast this with a child caught in terrifying and inescapable intentional abuse. The consequences of missing the start of a cycle of abuse are horrific. There is not and likely was never an adult in the situation that was a safe trusted reference point to comfort you. Usually, it is the exact opposite. The adult reference point in that situation is specifically the completely unsafe abuser. There is no one to teach you to learn from your mistakes except that abuser, and the teaching they give is that abuse will happen without notice, without an avenue of escape, and will continue to occur when you are least able to protect yourself from the risk. Of course hyper-vigilance by that child is a necessary consequence.

People understand the hyper-vigilance of a soldier on patrol in enemy territory. Why? Because everyone knows it is a life or death matter to miss even the slightest hint of danger.

What most people don’t understand is that those with DID grew up in enemy territory. Their world was such that missing that slightest hint of danger, or not complying with the demands telegraphed by those hints from the abuser, meant that the abuse cycle could roar into action in a heartbeat.

As I have written many times before, the solution is not to attack the hyper-vigilance as bad. Rather, it is to begin by acknowledging the importance of that hyper-vigilance to the child’s survival. Then, the path of healing moves toward dialing down the hyper-vigilance to more ordinary levels of vigilance. This limits the risk and depth of re-traumitzation while maintaining a needed protection that everyone, with or without DID, must have. Step by small step, important progress can be made

As a result of hyper-vigilance, one might never feel safe crossing a road because a car could come out of nowhere at 100 mph and hit you. Even if you look both ways again and again, you might miss it because it could come so quickly while your head is momentarily turned. This is hyper-vigilance seeking to protect you by paralysis. If you don’t move off the curb, you will not get hit by a car careening out of nowhere at 100 mph.

At the same time, you must be vigilant to look both ways before you cross a road because there are indeed cars that might be coming.

But how vigilant should one be. Again, the therapeutic intention should be to dial down the hyper-vigilance based on the current present circumstances, not the abusive past. Hyper-vigilance should be maintained if you are in a wartime situation, because that is warranted by the present dangers. Back to crossing the street near your home, less intense vigilance is needed when crossing a street at a crosswalk and walking when the signs say it is ok. Look both ways, and go across.

But, if right turns are permitted on red llights, then a bit more vigilance is required. One always has to look to the left and right when crossing at a crosswalk, but you have to also look a bit to the left and behind to make sure no one is making a right turn into you because they are in a hurry and not paying attention to you in the crosswalk.

Once again, the idea is to empower individuals with DID to re-engage the spectrum of their capacities for vigilance, not freeze or diminish them.

As one gains confidence in appropriate vigilance, then trust in oneself and the environment increases accordingly. While triggers will still exist and perhaps engender flashbacks, the ability to correct the level of vigilance to the present circumstances will help diminish the power of those flashbacks.

The result, the goal, is to bring together vigilance and trust as to oneself as well as the environment. It is possible. It is a healing in and of itself that can allow you, step by step, to re-learn how to safely engage the world.

Best wishes

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The Role Of The Significant Other In DID Therapy – Part 3 of 3

As mentioned in Volumes 1 and 2 of Engaging Multiple Personalities, years into my retirement I accidentally bumped into Ken, the husband of Joan, one of my former patients. Joan’s healing journey remains successful and ongoing more than 15 years following the conclusion of our treatment time together.

With her permission, Ken and I met many times to work on Volume 1, trying to put the pieces together of the healing journeys of Joan and several of my other patients. I wanted to include journeys that were successful as well as those that were not. The intention was to create a book that would provide a context for understanding DID, whether one is a patient, a spouse/family member, or a therapist. I had the perspective of decades as a psychiatrist working with trauma including some specific cases of DID.

Ken had the perspective of a spouse, trying to support someone he loved that had DID. I was particularly interested in Ken’s view as the significant other of a DID patient prior to, during and post therapy. These notes were part of a discussion exploring Ken’s experience participating in Joan’s journey of recovery from severe Complex PTSD symptoms. I believe it will be of benefit to others.

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D (David): Looking back, I was very reluctant to allow you to participate by sitting in on Joan’s therapy sessions. On the other hand, I could not see a way out, not to get you involved, given that Joan insisted on you being present in the first and all subsequent sessions. Having seen alters emerge during those sessions, when an alter appeared at home, I could not ask you to ignore her.

K (Ken): I think I was absent for one session when I had to be out of town. As to ignoring the appearance of alters at home, I could not hit a pause button to wait until the next time she saw you. When an alter appeared, it was often connected to something that needed to be related to immediately; a potentially re-traumatizing flashback.

D: By and large, there are many elements governing the emergence of an alter, some of which are not predictable. Correct me if I am wrong, but it seemed that alters felt safe to come out to you because you responded with genuine support and understanding.

On the other hand, alters also pop out when some circumstantial situation serves as a trigger. For example, when a situation is perceived as dangerous, a protector alter may jump out. I think alters appeared in my office because they felt safe there, and sensed that I was willing to listen to them. Your presence in the second session of therapy, when SW emerged and you didn’t deny or otherwise protest his presence, must have generated enough confidence in your openness of support to test you further at home, to see whether or not you would deny the alters or what they said.

K : Yes, first SW came out in your office and I passed that first test. I think I also passed your test of me, in that per your instructions my role during the sessions was limited to simply being there without saying anything or otherwise reacting, other than to repeat more loudly Joan’s softly spoken comments.

In fact, after we left your office, Joan asked me if there really was a little boy that came out and spoke. I confirmed that he had, and that it was ok. Then, when he came out at home the first time, that was a much bigger and more intense test. The first time, in your office, SW had the possibility of triangulating the two of us, giving him the possibility that at least one of us would listen to him. It was more dangerous for him to emerge at home, just with me. If I had dismissed him, denied his presence, or denigrated him, that would have been a true setback, I think.

When I listened to him, and we connected directly at home, his energy shifted completely. I was moved from being seen as a likely enemy to someone he could speak with almost as a friend. Other alters followed; at first slowly but then rapidly as each alter that emerged was given that same acceptance by both you and by me – whether they came out enraged, sobbing, or otherwise. It seemed that when some alters saw that I didn’t deny or cut off the alters that did emerge to speak to me, they felt that it was worth the risk to see if I was truly safe for them as well. They tested me to see if I would acknowledge them on their own terms, and whether I would be open to hearing their pain, anger and/or fear, without judging them or pushing them away.

D : Tell me more about how and when they usually come out.

K : For the first few months of therapy, some alters that hadn’t come out during that day’s session would emerge about 10 minutes after we left your office. First, there would be quiet when we got into the car. Then, a few minutes later, Joan would start to seem uncomfortable. I would pull over to stop in a park in case my undivided attention was needed by her. We would walk together and I would pretty much just listen. She would complain about a pain behind her right eye, and then out would come a very angry alter. Then, just like during the sessions with you, the alter would soon announce that they were very tired, and then they would disappear. Joan would re-emerge and ask if someone had come out.

Not too much later on during her therapy with you, because evening time was when the abuse had generally taken place, it was not a surprise that alters would come out late at night once they decided it was safe to do so with me. I wasn’t initially prepared for the intensity and duration of those conversations. I think that was a product of the trust that had been created during the sessions with you coupled by the fact that I was an ongoing witness in those sessions.

D : The emergence of alters at home after initiating therapy must be a common phenomenon. I wonder why in my reading I have not come across any discussion on this topic.

K : Once they decided they could come out to me, many times it was with overwhelming energy. They came out night after night, usually when I was about to fall asleep. I think they felt that I was more vulnerable due to my exhaustion at the end of a long day, which became exaggerated exhaustion from staying up with them night after night. Once they were out, I had to remain awake and present for them.

Because I had to go to work the next day, it was not such a great thing for my health or efficiency. But the pain they expressed in flashbacks was so intense, there was no choice but to be there for them. As a basic message to other SOs, I think it is really important to remember to eat well, take care of yourself and rest when you can, so that you have the strength to be there for them when they need it.

The impact of ensuring that they feel safe has two consequences: 1) they can begin to process their trauma; and 2) you experience joy unlike any other that you were able to make someone you love feel safe – possibly for the first time in their life. As they process trauma and your experience that joy, your self-discipline and stability must be maintained to ensure that you are not subconsciously seeking to validate yourself informally as a co-therapist. When I recollect that joy, it is more in the nature of seeing a child take its first steps. The joy is simply an expression of your love, nothing more and nothing less because those steps are part of the child’s self-actualization; not a validation of you as parent or witness.

Without having been in the therapy sessions, strictly bound to only listening and staying still, I would not have had the understanding or the tools, from watching you interact with alters, to actually be genuinely helpful when alters emerged, fully expressing their pain or fear or anger, with me at home.

D: Did you feel comfortable talking to the alters? What would you say to a therapist who worries that you, as a spouse, have no training in psychiatry and should not be the one talking to the alters?

K: If you understand that the alters are part of your SO, then it is really just listening to someone you love cry out in pain. Of course you are there for them. Talking to them directly is not so difficult. Listening without judgment, remaining present and warm, and gently reminding them of where they are right now, what the date is now, who they are with right now isn’t so hard if you keep at the forefront of you mind why you are doing this. In other words, loving them and maintaining your self-discipline are not mutually exclusive.

D: Do you think patients would feel more secure if the SO is involved? In effect, it means that the SO ends up being some kind of co-therapist. I actually have more experience in encouraging alters to become internal co-therapists than having an SO take that kind of role. In fact, you are really the only one that I would characterize as a genuine co-therapist.

K: While I can see how an SO could be seen as a co-therapist, I think a better understanding of the role would be the SO as the deepest best friend. The risk of seeing oneself as co-therapist runs the risk of setting up a potentially dangerous power dynamic in the SO as therapist. By taking notes of all the evening conversations, with Joan’s permission, I remained as a witnessing scribe. By applying the grounding recommendations you used in the sessions, it maintained you as the therapist and, again, me as the witness.

I think the idea is not that the SO knows more than the DID individual as to what they should do to heal, but rather how deeply, warmly and stably the SO can listen. Also, I don’t think there is a blanket rule that all SOs should participate in therapy. It really depends on the wishes of the patient and the internal stability of the SO. If the patient gives permission, then the SO could be told at least an outline of the issues that DID individuals face, and that it would likely that those issues would come out at home. That would at least give the SO some guidance on how to conduct themselves if an alter appears.

D: If the SO is a lover or spouse, how can the SO address the take-over by a child alter who jumps out reliving a past experience of sexual abuse? It could be that an alter conflates the spouse with the original abuser. This is a very real possibility. The therapist has an obligation, sooner or later, to address this concern. I don’t see how it can be addressed properly if the SO is not participating in some way in the therapy.

K: I think the SO has to have the intention, self-control, discipline and understanding to use those opportunities as a way to empower the frightened alter. This was the essence of the exercises I did with Joan, insisting that the frightened alter needed to say “no,” to show her that she had that power and that I would absolutely stop on the spot. And further, that following that “no,” there would not be sexual activity for the rest of the morning/day/evening. This was true whether or not other alters came out with sexual intentions or invitations.

******

I invite readers to write to me about their opinion and their experience. I do not have enough large sample to form an opinion as to the general experience of involving the significant other (SO) in the therapy sessions.

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The Role Of The Significant Other In DID Therapy – Part 2 of 3

I have set forth below some simple rules I would recommend to therapists encountering alters in a session. They are also recommendations I have made to significant others who were seeking ways to be supportive of their DID partner when an alter appears at home. I did have patients whose significant others did not appear to be so committed to supporting a patient’s healing. I did not deem it appropriate in those cases to discuss anything about such patient’s DID or what to do at home. If such an SO asked me what to do when their partner began crying like a little girl in the middle of the night, the most I might say was “I think you understand that your partner had bad things happen to them when they were young and crying at night is probably her remembering those things. Try to be kind.”

The aim in therapy is not to get rid of the alters, but to establish contact with alters that may appear so as to create a space in which the complex PTSD symptoms can be eased. In this way, the goal is to engage that alter to be able to live harmoniously with the other dissociated parts.

[1] Stay calm when a DID switches so that an alter comes out. It can be very unnerving, especially when it is the first time you are facing an alter. Remember that all alters are parts of the person who is important to you. Understand that there are often barriers between alters holding different extremely difficult memories. Those barriers create the appearance of a personality split off from the person you know and love. The barriers came into being to protect that person when they were a child with no other defense to abuse. Don’t denigrate or deny the barriers, don’t try to break them down. Stay calm and accept this alter as a part of the person you love. By staying calm and offering appropriate support – usually and most importantly by listening – you are already being helpful for the healing of your significant other. It is through healing that the barriers will begin to somewhat dissolve, not through outside pressure.

[2] Never try to provoke the switching of the alters, but remain mentally prepared for a switch – particularly if there is a specific timing cycle for alters to appear, such as late at night.

[3] Treat the alter with gentle kindness. Talk to them in age appropriate manner. If it is a 5 year old, talk to her like you’re talking to a 5 year old. Consider how you provide solace to a child who has been deeply hurt: You listen to them and talk to them, gently and with kindness. It would be disastrous if such an alter is told to behave like her chronological age and adult station in life. If you do that, you will have lost a golden opportunity to establish rapport with that alter, a rapport which is a gateway to help a DID patient heal.

We have to avoid the simplistic view that treats alters as a pathology to ignore, dismiss or eliminate. Like healing a fractured bone, an alter should be gently held in place so it can grow back together with the other part of the fracture.

[4] Do not argue with an alter. As noted above, speak in a way that the alter will understand. For a child alter, always be aware of why the child talks the way he/she talks. It is the same for a teen-age or very old alter. Arguing with an alter will get you nowhere. Instead, it will re-confirm to that alter that you are not listening, not accepting that alter’s experience, and are laying on a blanket of suppression. Such confirmations of non-acceptance will further trigger memories of and responses to past abuse.

[5] The more you understand why the alter behaves in the particular manner, the more you can help him/her to heal. Healing means getting him/her back to the whole, like a football player going back to play the game with his team, instead of running off with the ball as part of his individual agenda. The successful football player works toward the common team goal of winning, instead of playing alone with no regard for his teammates as if they don’t exist. I always use this metaphor to illustrate how we should treat alters in DID patient. In that moment of encounter, you are making the essential steps to help the alter to heal and move towards living harmoniously within the system.

[6] Remember to comfort the alter. It is more effective to use the right tone in your voice rather than clever words – even if you believe those words to be accurate. Use physical methods, such as kinesthetically comforting a frightened child. For example, letting a fearful child lean against your body or, with permission, letting them feel the gentle pressure of your embrace. This can be more effective than a thousand words. A therapist is under professional constraints against using the sense of touch to comfort a client. Obviously, a significant other is in a better and appropriate position to comfort the person kinesthetically.

While sexual contact in appropriate contexts may be comforting, sexual contact may well be the specific contact that you should avoid. This may be true even if such contact is invited by an alter. The reason for concern is because the early childhood trauma that gives rise to DID is commonly associated with sexual abuse. It is dangerous to use that kind of physical contact for comfort because the ramifications of sexual contact to the various alters in the system is extremely difficult to control if you are engaging in it as a means to comfort your significant other. You need to consider what you would do if another, very frightened alter emerges during the sexual activity, one who may come out in a full blown terrible flashback related to early sexual abuse. I have asked the co-author of this piece, the spouse of a former patient, to go into further details of this aspect of comforting the frightened alter later in this post.

[7] Get support for yourself. Once DID therapy begins, you should expect to meet alters, or be able to identify alters more often with which you have previously interacted. You need to stay mentally stable and healthy. Speak to the therapist. Just as I recommended to my DID patients, the SO should similarly do a lot of grounding exercises. Have a friend you trust be on call to support you from time to time.

You do not need to learn any specific therapeutic technique because you are not the therapist. But it may be helpful to understand that alters, forged in the crucible of early childhood trauma, are by their nature generally unable to be considerate of your time or limitations in a way that you will find “reasonable.” The result is that the emotional demands that you will experience during the healing process of your DID partner requires you to take care of yourself in order to support your partner.

For example, an alter in need may keep you awake for hours at night without any consideration to your next day’s work obligations. Like a child in pain, your need to sleep is not a priority for that alter. Be prepared for that. But the reward, when you see that your care and support is helping the healing of your loved one, will be great .

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