David Yeung's Blog, page 8

The Therapeutic Alliance – Part 2: Genuineness, Acceptance, And Empathy

With a proper therapeutic alliance, the emphasis of the therapist on one side and the client on the other changes. It is shifted to the medium in which the communication occurs. It focuses not so much on what the therapist can do, but whether a milieu has been nurtured such that the client feels safe and trusting enough to take the hand offered, as it were, to get out of a difficult situation.

As therapists, we must bear in mind that we are not the only ones doing the assessment in an assessment interview. Your patient, after waiting for a few months to see you, has more invested in this venture than you. They are assessing whether they can trust you enough to share their innermost vulnerabilities, their most private concerns. If you don’t establish the ground for that therapeutic alliance, if you have not engendered the feeling of safety, space and time to open up, then it will not happen.

It is in this context that the effectiveness of CBT (cognitive behavioural therapy,) EMDR (Eye movement desensitization and reprocessing and DBT (dialectical behavioral therapy), all recommended therapeutic approaches for cases of trauma, dissociation, and borderline personality disorder, must be evaluated. Without considering the importance of a therapeutic alliance, it is misleading to say that CBT, EMDR, DBT or any other therapeutic model are the treatments of choice.

When a psychiatrist offers you an antidepressant pill for your depression, in the absence of the correct therapeutic alliance – even if it is an appropriate prescription – you will remain locked in your belief system. That will counteract the psycho-active effect of the drug. It is noteworthy that most people understand the placebo effect; the beneficial effect that cannot be attributed to the pharmaceutical properties of the drug itself and must therefore be due to the patient’s belief in that treatment. People are less aware of the nocebo effect, which is the opposite. The nocebo effect is that the patient’s disbelief in the treatment lowers the positive pharmaceutical impact of that drug.

Therapists take heed: One’s therapeutic effectiveness is directed related to quality of the therapeutic alliance we create in each and every one-to-one therapeutic session. It depends on how you say “hello” or even months prior to that, when and how the appointment was made.

The genuineness of a therapeutic alliance often explains how a history of early trauma is sometimes given to one therapist in the first visit, while other psychiatrists may have spent years with that same patient and still missed it.

This is the mechanism by which some world known professors and heads of major universities as, well as the chief editor of a major national journal of psychiatry, erroneously declare that dissociative identity disorder is non-existent, is a fake disorder or created by over-enthusiastic therapists. They assert it is impossible because they never have encountered one such case. In fact, the odds are that they simply failed to recognize those cases. Instead, they decided upon common misdiagnoses such as treatment-resistant depression (which should usually be more correctly identified as drug resistant depression), bipolar disorder(s) and borderline personality disorder.

With self-reflective insight, they might come to understand that they have never given the time, space and safety for their patients to show them their innermost pain and suffering. The fact is that when a patient feels safe enough during therapy, spontaneous catharsis happens without asking. Our duty as therapists in such an event is to protect the patient from inadvertent re-traumatization throughout the cathartic process.

Focus on the process of healing, not the detail of the trauma. As always, the right therapeutic alliance guides the therapist to be sensitive to the need of the patient.

Being a brilliant scientist is of no use if one forgets that one is basically human. Religion is not about arguing whether or not God exists, whether or not God has this or that quality. The men I have quoted in Part 1 of this post are all from different religious backgrounds. Ultimately, it is about being reminded that we are human.

I offer and will repeat to offer the following guidance of Carl Rogers’ emphasis of a person-to-person relationship between the therapist and their client, one that is characterized by genuineness, acceptance, and empathy. That emphasis is worth more than any diploma on your office wall.

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The Therapeutic Alliance – Part 1: Our Fundamental Humanity

When two people meet, be it just for a handshake or making a deeper connection, there is much more that takes place than what meets the eye. There is a kind of transaction that takes place, whether it is a mere acknowledgement or a meeting of kindred spirits. With this reference point, Eric Berne developed the concept and paradigm of transactional analysis. In that paradigm, all social engagements are seen as transactions between people in their parent-like, child-like, or adult-like ego states.

For me, the ideal state is when 2 people meet in what Martin Buber’s referred to as an “I-Thou” relationship for a soul to soul encounter. I imagine that was the experience when Martin Luther King met Thích Nhất Hạnh or Father Thomas Merton. Although they were from very different backgrounds, they related as brothers, soul to soul. What they didn’t bring into the experience was an ego defence barrier. They were completely open to one another without asserting or subsuming their background in the engagement.

Well, we are not all able to do that but we can see that as a most positive aspiration. But, let us find out what we ordinary human beings can do, as therapists and clients in a healing relationship.

I cite the religious and philosophical thinkers above because in being practitioners of science based medicine, we somehow often forget we have souls. In that forgetting, we turn away from our fundamental humanity. But, that fundamental humanity matters most when we are dealing with crisis, trauma and healing. It is the key to a successful therapeutic alliance between therapist and patient.

In looking at books regarding different approaches used in psychotherapy, I find that little time is spent discussing the very basic fundamentals of psychotherapy. Perhaps they are so self-evident that authors and teachers assume it is unnecessary to restate them. I disagree. It is always necessary to return to and remind ourselves of the foundation of therapy, empathy, which is integral to our humanity.

I respectfully request that you not let my use of a word like soul, or to speak of religious thinkers, discourage you. I use these words for that which I am unable to communicate using conventional language. Most of our speech refers to concrete things such as a chair or a pound of butter. While such materialistic terms are necessary to our everyday existence, they are inadequate in communicating the wider sense of our experience.

When we use words like compassion, empathy, and understanding, we cannot use materialistic terms. You cannot scientifically measure the love you have with your significant other. You cannot scientifically measure the pain you experience when someone close to you passes away. So, we start to use words differently. For anything beyond the materialistic world, we need to use poetic language and often metaphors.

So please allow me to use words like love, humanity and God in that way. The way I use the word God, God is not an object I can pinpoint or describe in any literal way. For example, I cannot say, “God is here, not there.” I cannot place God in a location. As with love, God has no color, no size or weight. What I reference as God is not confined by time and space. It is in that same context that I speak about “soul” as in “meeting of souls.”

Carl Rogers emphasized the critical nature of a person-to-person relationship between therapist and client/patient. That is the environment which can provide the patient with genuineness (openness), acceptance (being seen with unconditional positive regard), and empathy (being listened to and understood). To me, this is the necessary and basic requirement for the foundation of a proper therapeutic alliance, from which healing is possible.

Time and time again we are shocked when we encounter practitioners of healing professions that are lacking in such qualities. I mentioned the meeting of souls as the highest ideal. It is one that we seldom achieve. But, that is the lodestone we aspire to in seeking to create the person to person therapeutic alliance so critical to healing.

These days, patients need to make a great deal of effort to see a therapist. One must spend the time and energy getting a primary referral from one’s doctor. And then, one must phone for an appointment and often experience an automated recorded voice saying something like:

“Please hold……If you wish to speak in English, press 1. If you are a new patient calling for an appointment, press 2, if this is ……. press 3. If …………..press 4.” After days, weeks and sometimes months on the waiting list, you finally arrive at the psychiatrist’s office. Then when you see the psychiatrist, all he does is acknowledge that you are not doing so well. It can be along the lines of: “You are depressed. You need to take this medication. It usually takes up to a few weeks to work, so be patient. We will start with this dose and then see from there.” Does it sound like a therapeutic relationship, a space in which healing will take place?

All the years of learning in university are irrelevant unless we keep in mind that we absolutely must connect with a patient. Without that connection, we will be unable to help them work with their trauma. Expertise can make a difference to the outcome but if, and only if, it is leavened with empathy, with compassion, and with openness.

That is why I believe the most fundamental issue is to create a field for healing to take place. It is like sowing seeds, some fall on to rocks, and others to concrete ground. Only those seeds falling onto suitable ground, with the right amount of moisture, the right kind of soil mix, and the right amount of sunlight that will enable the seed to mature into a plant. This suitable ground for healing, this fertile milieu, is what we call a therapeutic alliance.

It is the foundation of a relationship between a healthcare professional and a client (or patient), hoping that their engagement will effect beneficial change in the client. This relationship is the milieu, the soil from which will facilitate the sprouting of a seed that will grow into a healthy plant reaching down into the earth for nourishment and up toward the sun to flower.

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The Devastating Clinical Consequences of Child Abuse and Neglect

The subject of this post is a paper I just read online published in the American Journal of Psychiatry. I usually only glance at the subject lines of articles and dismiss them, because they are usually about psycho-active drugs. This time the title focused on the roots of mental illness. The link included an interview by Stephen M. Strakowski, MD. with the authors of the paper entitled:

The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

For the DID community, and for society in general, this is a critically important topic. The title of the paper speaks for itself. I have been fighting for years to elicit recognition of this. As of the date of my reading, there were 52 comments at the end of the article, representing a fair cross-section of psychiatrists today.

As noted in my previous post regarding progress in the DID community, and the (mostly) lack of progress in the therapeutic community treating DID, it is of grave concern to me. I wanted to know if psychiatrists of this generation have moved on. Or, are they still dismissing the serious consequence of early childhood trauma and neglect like my contemporaries. Because I have been retired for more than a decade, I try to follow this issue in journals.

I remain disappointed. While the article, interview and research are spot on – highlighting the deep and ongoing impact of trauma, many readers of the article are still harbouring, defending and promoting their old ignorance. They remain committed to their mis-understanding of psychological trauma, about the nature of traumatic memory, and fail to see the presence and impact of trauma in their daily clinical work. I have addressed the common questions, listed in quotations below, that readers of the article raised.

[1] “Most importantly, just how accurate are these reports? What are the biases present? Considerable research has shown that human memory is notoriously faulty.”

In assessing traumatic memory, we are concerned with the effect of the trauma on the patient’s current functioning. The fact that exact details are not accessible precisely is of no significance. If a child has been raped, I don’t care if her recall is not precisely accurate. The inability to accurately identify the culprit’s height and weight, or the crime scene’s exact detail. This is the nature of traumatic memory.

In my book series Engaging Multiple Personalities, I wrote, “It is dangerous to use our own ability to access non-traumatic memories as a standard against which we judge a trauma victim’s response.” Clinicians should not be bogged down worrying about individual minor details of the event, but instead should focus on the clarity of the emotional memory. Otherwise, they will continue to ignore the effect of the past trauma on their patient’s present functioning.

[2] “Do those answering questionnaires often do so subconsciously wanting to please or support the expert asking the question? Are those suffering in other ways predisposed to emphasize past negative experiences?”

There is this persistent charge that we help create false memories in our patients. It is no doubt left over from the 1980s which saw a sudden rise court cases of victims accusing their parents or care takers of sexual abuse. The pendulum does swing well over the median in any social phenomenon when it first arises, but that simply means we should examine our own biases as well as the statistical likelihood of abuse. We must maintain an appropriate index of suspicion – particularly when encountering depression that is drug resistant.

[3] “How often are accounts independently verified?”

This fails to acknowledge that most abuse occurs behind closed doors where the only witnesses are the abuser(s) and the abused. The demand for independent verification ignores the fact that the trauma can be identified enough to know that something bad happened by its impact on a patient’s current presentation.

[4] “As the preceding comments show, there is always an abundance of anecdotes.  What is needed is hard questioning scientific work and evidence closely scrutinized.”

It is common in challenging psychiatrists by dismissing what they do when they report on a single case. They call it anecdotal rather than “scientific” evidence. Anecdotal simply means that it is based on personal experience rather than formal research. Formal research is fine, just as the article that provoked these responses was based on a large study. Nevertheless, there is so much anecdotal evidence that psychiatrists should not wait to adjust their index of suspicion when encountering patients who likely have trauma in their background. If a patient experiences multiple treatment failure by psychiatrists who only used pharmacological agents, and showed recovery or significant improvement following psychotherapy, surely any inquiring mind would seek to find out the reason. Common sense, empathy and compassion suggests that therapists should at the very least start questioning the lack of humanistic aspect in merely prescribing psycho-active medication as the sum total of the therapeutic engagement.

We must reconsider the error of seeing all mental illness as a brain disease. In medical training, we all were taught that when considering a diagnostic formulation, we take into account, biological, psychological, social and noetic elements. It is amazing that today, in the name of “science”, psychiatrists have mostly turned into mechanistic pill pushers. This is science as defined by the pharmaceutical industry that has its own profit driven agenda – hence all the “off-label” recommendations they promote in Continuing Medical Education conferences. They infer that psychiatrists should feel proud that their work is “scientifically based” because they are prescribing pills to correct a “chemical imbalance.” This logic allows them to ignore social, psychological or spiritual factors in a patient’s life milieu. In fact, it is like prescribing insulin to pre-diabetic patients without asking whether or not they eat sugar saturated meals every day. There is only symptom management as the underlying cause is not being addressed. As a result, healing is not possible. 

[5] “Maybe the most distressing aspect of some of this is the arrogance of those who purport to know what really happened… and the judgments laid on many families just trying to do their best.”

This is not about corporal punishment by an overworked house wife or an over-strict father, following the Biblical admonishment of “Spare the rod and spoil the child.” This is about someone, not necessarily a parent, engaging in sexual molestation, physical abuse, neglect, and betrayal trauma. It is about abuse, not about “spoiling” a child.

With respect to corporal punishment used by parents to discourage certain unwanted behaviors, one should consider whether or not the child automatically learns a different lesson, that one should use force if someone disagrees with you.

The significant factor in analyzing corporal punishment that may actually be abuse is whether that harsh physical punishment is given in the absence of love. In the absence of other supportive and loving people in the environment, corporal punishment will leave a permanent injury to the victim. Alice Miller has written amply on effect of early child abuse and trauma. Her books are thoughtful and practical.

[6] “There are millions of traumas a year, including those to children. Trauma is the common cold of psychiatry. Around 90% of people feel bad for a week, then forget about the trauma. This is analogous to having a cold.” 

This reader should go back to the definition of psychological trauma, which means stress that overwhelms the system, leaving behind a gaping wound that refuses to heal by itself. The common cold does not devastate the patient. It is healed by one’s own healthy immune system. And yes, it is usually forgotten a few weeks later because its impact ends when your body finishes the healing process. The effects of child abuse and neglect last a life time. Even if it is not accessible to one’s declarative memory at any given time, the body keeps the score because the damage has not been healed. It often emerges in the form of symptoms like depression, rage, or self-harm rather than an accessible declarative memory.

[7] “Those who are affected by trauma have pre-existing conditions or genetic vulnerabilities to it.” 

This reminds me of what happens when patients are labeled as suffering from a personality disorder. This unfortunate and common practice implies that the patient has to live with the dysfunction or disability because of constitutional factors. Effectively, is it saying: “You are born with an inability to handle distress. You may as well learn to live with it. Just get over it.”

Finding a pre-existing condition to explain a patient’s vulnerabilities does not help. The main problem in understanding and accepting the connection of early abuse and neglect to their consequence of dysfunction in later life is the difficulty in finding a concise, easy to apply treatment – such as a medication. But, there are no medications that heal early childhood trauma. Psychiatrists perhaps feel threatened and insecure when we face a case for which we have to employ full empathy, exercise compassion and be fully genuine when facing another human being who is experiencing this level of psychological pain. Pharmaceutical companies and their affiliated conferences/training programs promote simple clear cut mechanistic approaches, as if the human mind is like fixing car or draining of an abscess.

Psychiatry is, or used to be, predicated on a deep understanding of the need to engage with empathy, a positive regard, and a genuine openness on the part of the therapist. Carl Rogers named the three essential attitudes necessary for a therapist to be of benefit: congruence (genuineness), unconditioned positive regard, and empathy. This comes with deep listening. It is far from a mechanistic cold surgical procedure or prescription pad.

I believe this view is much more important than EMDR (eye movement desensitization and reprocessing,) or CBT (cognitive behavior therapy), which are listed as the recognized treatment procedure for trauma based PTSD, for different kinds of dissociative disorder, and disabling emotion of depression, anxiety, panic disorder. In and of themselves, no doubt they are helpful for some patients, and more helpful in the hands of well trained and empathetic therapists. But, we should understand that EMDR and CBT are just tools. They are like scalpels: It is only in the hands of a skillful surgeon that a scalpel becomes a truly useful tool.

The real problem is the difficulty to finding therapists who understand the need to be grounded in empathy. Less important is the number of years of training or how many diplomas are in the office walls. Not enough attention is paid to the humanistic issues.

In medical schools we were all taught that when considering a clinical problem, we need to consider the biological, psychological, social and noetic roots. This has not changed and will not change in all worthwhile medical institutions wherever they are found. It is unfortunate that for many psychiatrists once graduated and licensed to practice, these consideration are soon forgotten. When such simple rules are forgotten, it is easy for a materialistic philosophy to take over. Financial consideration takes precedence and, as a result, one become more easily swayed by pharmaceutical company marketing.

Just consider a hypothetical child who is inattentive in school and gets a quick diagnosis of ADHD. If no one is interested in identifying his concern that his parents are fighting every night to the point of violence, is the critical diagnosis of ADHD all you need to come to? 

We must do better than this. Real advances in psychiatry will require getting back to its roots of empathy and compassion. Let us all push ahead step-by-step in the right direction.

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Progress in the DID Community – Part 2 of 2

In today’s psychiatry, medication has become the de facto treatment plan. Many colleagues are no longer even pretending to do psychotherapy. They are being trained by representatives of the pharmaceutical industry to see all mental disorders as brain diseases. While there are definitely therapeutic uses for psycho-active medications, using them as the wholesale solution to all mental health issues gives modern psychiatry a false air of scientific credibility.

This is a disaster in the 21st century. There is massive early childhood trauma throughout the world. This includes violence and sexual trauma in war torn regions as well as in refugee camps, not just in so-called healthy societies. There is no treatment focused specifically on those children because of the overwhelming nature of warfare and its consequences.

Make no mistake about it, the trauma is there and will become a massive problem that will show up in a few decades for those children whether we acknowledge it now or not. This is on top of the ongoing early childhood trauma that arises in the absence of war but in the realm of our own somewhat hidden and somewhat exposed plague of abuse.

The foundations of psychiatry include Pierre Janet’s classic papers on PTSD at the end of the 19th century. It also includes Freud’s original assertion in 1895 that incest was the root cause of several of his patients’ difficulties. That initial assertion was withdrawn by him following a withering attack from the medical community of the time. They were insulted at even the idea that professionals, men of wealth and power, or that men in general, would do such a thing. Although perhaps Viennese society was not ready to look at its own dark side, that initial assertion was likely quite correct.

The early leaders in psychiatry pulled back from identifying early childhood sexual trauma for what it was. We should not do that, nor should we countenance others doing that. DID is a specific consequence of early childhood PTSD. We can be honest about that. That is the path forward. We can also use the acknowledgment of DID as a special sub-classification of PTSD to move forward the conversation and treatment of DID.

The common understanding of PTSD in soldiers was acknowledged throughout human written history. Physicians characterized it as “nostalgia” as early as the 1600s, “soldiers heart” in the US Civil War, shell-shock in World War I, “battle fatigue” in World War II, and PTSD in the DSM-III. By the end of the Viet Nam War, PTSD was being seen correctly as not a failure of will or defect of personality, but a product of trauma.

It is this understanding of the wartime foundation of PTSD which is the key, in my opinion, to bringing awareness of DID to the professional community. They accept PTSD. We should use this acceptance to highlight and identify DID as the product of (early childhood) trauma which it is, just as (battlefield) trauma results in soldiers with PTSD.

If you are someone with early childhood trauma in your background, or speak with someone who does, you will know that the analogy of battlefield trauma is spot-on. Any child who is being or has been traumatized early in their life on an ongoing basis experiences life as a battlefield. They live surrounded by potentially overwhelming adversaries seeking to harm them again and again and again.

Please continue to use whatever of my books and blog posts you think will help educate your own therapists to help you on your personal journey of healing.

I continue to hope that the small contribution the books and blog posts have made to support those with DID will ultimately produce a sea change in psychiatry away from automatic pharmaceutical intervention. I hope that they lead to the return of proper psychotherapy for the benefit and protection of those that were abused as children who are trying to heal now as adults.

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Progress in the DID Community – Part 1 of 2

Since the publication of Volume 1 of Engaging Multiple Personalities, followed by Volumes 2 and 3, many members of the DID community have written to me expressing appreciation for those books. They have said often, directly and in Facebook groups, that the material has been helpful to them as well as to members of their support network. In fact, many have brought copies of my books and blog posts to their therapists to help communicate their needs as a patient with DID. This feedback from the DID community allows me to continue to push forward to communicate the importance of correct diagnosis and correct therapeutic support.

I have even received some notes directly from therapists about how helpful the volumes have been in their own work with DID patients. That is the good, actually wonderful, news.

Almost 6 years have passed since Volume 1 of Engaging Multiple Personalities was published. Volume 1 reviewed patients identified as having experienced early childhood trauma and dissociation. Some of these had been treated successfully with psychotherapy as their antidepressants were simultaneously tapered off and discontinued. I tried to identify the reasons why some were treated successfully while others were not. From members of the DID community, there were expressions of relief both that their difficulties had a context and that healing was possible. A year later, Volume 2 was released which specifically focused on guidance for therapists.

Unfortunately, it seems that the psychiatric community still remains, for the most part, fundamentally unchanged in its view of DID. Copies I sent to colleagues failed to cause even a ripple in their consideration of DID and early childhood trauma. In my naivete, I expected them to be at least disturbed enough to re-examine their prejudice against DID diagnoses. I hoped to raise their index of suspicion when meeting patients with depression, self-harm and dissociative presentations to at least consider the possibility.

From colleagues, I got the uncomfortable feeling that Volume 1 in particular was treated as a book of curiosities. They were not so interested in the other Volumes either. Because my peers had not identified any such cases in their decades of practice, they ignored my suggestion that perhaps they had simply missed them.

Nevertheless, I was confident in this explanation. Why? Because in the many patient referrals I received, their files included notes identifying them as having dissociative tendencies and presentations without a primary or even secondary diagnosis of a dissociative disorder.

I am confident that psychiatrists see many dissociative patients in their daily practice. They don’t identify them as such because they are not expecting to see them. This is based on their own incorrect training mischaracterizing DID as extremely rare, Therefore, their index of suspicion is very low. Further, therapists are routinely distracted from the dissociative symptoms by their search for symptoms of depression. Why? It is because their index of suspicion is geared towards symptoms that will justify and support the prescribing of medication; i.e. antidepressants.

It is of ongoing concern to me that psychiatrists and other therapists are so stuck in their habitual way of looking at patients that they are not able to raise their index of suspicion to include dissociative disorders, despite overwhelming evidence.

Many years ago, a friend told me that he took a course on how to identify edible wild mushrooms. As soon as he completed the course, he suddenly started to notice just how many wild mushrooms were all along his daily jogging path. If only that kind of change had happened in the psychiatric community after we published the book(s). We can still work toward that.

Is it worthwhile to repeat this ad nauseam? I think yes. Why? Because of the response noted above from the DID community itself.

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Correcting Misunderstandings about Recovered Memory – Part 3 of 3

The article continues, saying that “we can not know whether a memory of a traumatic event is encoded and stored differently from a memory of a non-traumatic event.” This ignores the foundational history of psychotherapy.

This mistaken view is a product of the following kind of bias: “If something like this ever happened to me, I am sure I would never forget it for the rest of my life.” It assumes that everyone’s experiences are equivalently encoded in memory. In many cases of traumatic events, the trauma is so overwhelming that the victim’s survival drive results in accessing resources that overwhelm one’s ordinary mental process in order to deal with the trauma, including dissociation. Trauma memory is both stored and accessed differently than ordinary memory, as discussed in the Engaging Multiple Personality series.

Here is an example from my own patient histories that is by no means rare in a therapist’s practice: A successful professional woman came to me with the complaint that she thought she was losing her mind. She said she had been having hallucinations or delusions that her father had sexually abused her. She was certain it never happened. Therefore, it must be that she was losing her mind.

All I said to her at the time was that she must have had “some bad experience in her past.” I purposely gave her a vague and ambiguous answer. I said it in a reassuring and supportive way. It is important to give people in need both support and hope that an explanation and potential resolution was possible for difficulties. At the next session, an alter jumped out and confirmed that the abuse memory was true, that she (the alter) was the one who had been holding the memory in order to protect the other parts of the system. While alters usually take a lot longer to feel comfortable and trusting enough to appear in therapeutic sessions, this quick appearance was not unique.

Why am I confident that the memory was correct? In fact, the father had been dead many years. No third party witnesses were around to confirm or deny the events. So the question might be raised as to how can anyone prove that such a memory is true?

Again, context and definitions are critical. First, the notions of “correct” and “true” must be understood properly. In early childhood trauma, most details are irrelevant. Why? An infant or toddler, any very young person, will not focus or remember the details of most any event. What they do remember is the feeling they have; love, warmth, irritation, and so forth. The experience of ongoing abuse of a child is an overwhelming mass of fear, pain, confusion and panic. That is the key memory that one can consider to be correct and true.

The size of the room, what the abuser might have been wearing at the time, or other conventional perceptions are irrelevant to the truth of such a memory. Witnesses in court cases that are not dissociative often err on such details and their veracity is then attacked. Do not be deceived about what you need to evaluate as true and correct in cases of early childhood abuse.

In the case of this patient, the proof is that after suffering from years of suicidal depression, despite being unsuccessfully treated with anti-depressants for years, the patient recovered through psychotherapy. By engaging in dialogue with the alters in the DID system through the psychotherapy, she was able to process trauma that they were holding within amnestic barriers, she recovered. She was rapidly able to eliminate anti-depressants.

Further, the ongoing physical pain she complained about as a constant in her life eased tremendously. Instead, the roots of the pain were identified by the alters because that pain was connected to memories of the abuse, not to muscle strains, over-exertion, or any other external factor. Dealing with the trauma of abuse eliminated the physical pain. One can say, “the proof is in the pudding.”

Why am I so focused on context and definitions, on asking the right questions? Just consider whether or not you would reveal a closely held personal secret to someone who has already said they won’t believe that whatever you say could possibly be true.

Recovered memory is not rare for those with DID. If it is being held by alters in a DID system, it will not be revealed to therapists who deny, do not understand, or do not accept the phenomenon of dissociation. The gateway to healing those with DID is engaging the alters, not dismissing them.

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Correcting Misunderstandings about Recovered Memory – Part 2 of 3

The APA statement continues with the claim that experienced clinical psychologists view the phenomenon of a recovered memory as being rare. In support of that claim, it notes that one experienced practitioner reporting having a recovered memory arise only once in 20 years of practice. Again, such a statement needs to be put in context: In my 40 years of practice as a psychiatrist, I received many referrals, from other psychiatrists as well as from family doctors, of patients with noted dissociative symptoms including alters. None of those referrals included a dissociative diagnosis despite their identification of dissociative symptoms!

Why would a referral that included dissociative symptoms fail to include a primary or even a secondary diagnosis of dissociation? I think that the referring physicians didn’t want to give such a diagnosis as there was no medication to prescribe for treatment. They didn’t want to run the risk of having a long term patient with a difficult prognosis. More importantly, they didn’t want, or they did not know how, to engage in proper psychotherapy.

As the article continues, it notes that memory researchers do not subject people to a traumatic event in order to test their memory of it. I understand that memory research usually takes place either in a laboratory or some everyday setting and harming participants is not part of any acceptable protocol. Further, DID arises when there is ongoing early childhood trauma, not just a one-time event. One time events can result in PTSD but I am unaware of any information indicating that one-time events can result in DID. So, how to research these questions?

While I cannot advise traumatizing animals as a test model, there are plenty of traumatized animals that can be examined. If you go to any animal shelter, you will likely find traumatized cats, dogs and birds that get triggered by certain input. In fact, many of them experienced trauma on an ongoing basis from infancy. One might do a behavioral analysis of those animals and extrapolate from there.

I am aware of a rescue dog that wouldn’t come out from under a bed for three weeks after he was adopted by a family. He gradually became a loving and positive addition to the household. Several years later, a grandparent visited. The dog had met this elderly man many times before without incident. But at this point in his life, something changed: the man now needed to use a cane to walk.

The moment the dog saw the old man with a cane, he ran under the bed and refused to come out while the man was there. One can assume with some confidence that somewhere the dog retained the memory of a man with a stick beating him. The cane triggered memories that overwhelmed memories of this specific grandparent he had been unafraid of until triggered by seeing the cane.

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Correcting Misunderstandings about Recovered Memory – Part 1 of 3

There was a recent Facebook post concerning a statement of the American Psychological Association (APA) on recovered memory. That statement reflects a misunderstanding of the etiology of DID. It ends with a statement that many researchers say there is no empirical evidence for even the idea of dissociation sheltering memories from ordinary conscious access. That misunderstanding continues to guide therapists (and their patients) in the wrong direction.

The APA statement asserts that certain questions “lie at the heart of the memory of childhood abuse issue.” The first question noted is: “Can a memory be forgotten and then remembered?” This question presumes that a traumatic memory is actually forgotten. That presumption is a fundamental misunderstanding of dissociation resulting from early childhood abuse.

A more correct question is a bit longer and more to the point. It would be something along the following lines: “Can memories be compartmentalized so as to be rendered inaccessible to the conscious mind so long as amnestic barriers created as a function of that compartmentalization persist?”

Why is this important? From the very beginning of psychiatry, it has been clear that there are many memories of events which are not readily accessible to the conscious mind. This is true whether you consider distinguishing between the conscious and subconscious mind or whether you are analyzing dissociative experiences involving alters.

This then puts the second posed question in its appropriate context: “Can a memory be ‘suggested” and then rendered as true?” Without the above re-framing of the first question, this second question sets up the false inference that recovered memories are equivalent to hypnotic suggestion.

Once again, context is critical to understanding. Yes, there are similarities between hypnotic states and dissociative states. Should one take from those similarities that hypnotic suggestion and dissociation resulting from trauma are identical? No. One should understand that human minds have the capacity to act in the world without those actions always being consciously accessible and controllable. Hypnotic suggestion is one way that can happen. Dissociation resulting from trauma is another.

Clarifying that this is a fundamental ability of mind should enable psychiatrists, therapists and others to understand why certain memories would be inaccessible for periods of time or only be accessible in particular situations. They are conventionally inaccessible, not forgotten. It should be clear that under the pressure of massive early childhood trauma, such a fundamental ability of mind would necessarily be used to allow a child to survive the abusive onslaught.

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Countering the Far Reaching Effects of Humiliation Part 5 – Healing From Early Childhood Humiliation

Alice Miller wrote:

“As long as they are loved, children can recover from abuse and even the horror of war.”

Humiliation is a form of severe child abuse when the child experiences it on a repeated or ongoing basis beginning in their childhood. The path to recovery from humiliation is through love. Love starts from the ability to accept love, from oneself as well as from others. However, it is extremely difficult to practice self-love in the absence of love from others.

The characteristics an individual displays depends upon whether a person is given love, protection, tenderness and understanding or experiences rejection, coldness, indifference and cruelty in the early formative years. These characteristics are not innate but rather are dependent on what stimulus a child experience. For example, the stimulus indispensable for developing the capacity for empathy is the experience of loving care.

When a child is forced to grow up neglected, emotionally starved and subjected to physical abuse, this innate capacity will fail to develop or its development will be stunted. It is important to appreciate that while the negative experiences of children from infancy to early childhood explain their later behaviour, subsequent positive influences can be effective agent for change.

Alice Miller also wrote that if a traumatized or neglected child can later come to know what she calls an “enlightened or knowing witness,” he or she can process the effects of childhood trauma with positive results.

While remaining open to the opportunity to experience love, or positive influence, one should continue to pay attention to one’s boundaries and protectors. At the same time, pay attention to the following in sequence:

[1] Become aware of the connective link between your styles of engaging with others and your childhood experiences of humiliation.

Repeatedly noticing, and paying attention to the causal connections, is the beginning of making changes. The more you pay attention to this, the more you come to realize that you are not alone. You will see that such experience (of humiliation) is a human drama played out unfortunately and repeatedly every day in so many situations for so many people. Looking at it this way, one begins to transcend the isolating aspect of humiliation’s personal pain and hurt – you are not alone. Eliminating that isolation is another foundation of healing.

One can to cultivate this through cognitive re-structuring. Reminding yourself of this in a daily quiet time. You can set up a regular time to do this, such as going out for a walk in the morning on a definite consistent schedule.

And again, remember, you are not alone.

[2] Learn to distinguish the past from the present. If you are standing on the bank of the mighty Amazon river and take two pictures a minute apart, each photo shows different water. The water in the first picture has already moved on towards the Atlantic, replaced by entirely different water – even if it looks pretty much the same. In just that way, we are not exactly the same person as we were a minute ago.

This shows that the future is not exactly the same as the past. Use that truth to healthily correct the hangover of feeling humiliated in the past. You can do this by training to focus on the present moment. As Tolstoy wrote, “Remember that there is only one important time and it is Now. The present moment is the only time over which we have dominion.”

By recognizing the impact of one’s difficult personal history and bringing one’s awareness to focus on the now, we can begin to wipe out the negative influences of the past.

[3] Protect others from humiliation, particularly children. Should you come across a child being humiliated, or perhaps on the edge of being humiliated, step in and say exactly what you would have wanted to hear so many years ago. At the same time, be protective of yourself as well and, if necessary, call the police or child protective services to the situation. For just that moment, be the protector for a child in the present that you needed in the past.

Learning that you can protect a child from humiliation is a path to healing for yourself. While you cannot travel back in time to when you were humiliated to undo the impact of the humiliation, you don’t have to. If you see a child being humiliated or abused, you can help that child right then and there. You will be letting that child know they are not alone, that there is protection in the world. You will also be giving that very same message to the child you were years ago.

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Countering the Far Reaching Effects of Humiliation Part 4 – The Power of Angry Alters

The best indicator of a positive prognosis for those with DID is found in those with defiant angry alters. In effect, it is those parts that say “You have no right to humiliate me. I will not surrender to your will. You have not subjugated me. I will fight you always.” The implication for those treating DID patients is to remind those patients that their angry alters are generally the ones that refused to simply surrender to their abuser. Even though they may only have the initial capacity to express their anger in ways that are frightening to others both internally and externally, a path forward to healing can be found through engaging with them in therapy.

Engaging the angry alters is the opportunity to access that positive defiance, that refusal to accept humiliation as defining them. Appreciating their strength and insight is a genuine method to develop support within the system so that alters can begin to work in concert rather than in conflict. In my practice, the patients with the best prognoses were those that were able to connect with their anger – which often meant engaging with those angry alters again and again. By ongoing engagement in that way, one invites their assessment and potential trust in the therapy.

A common and negative outcome for the victim is submitting to the punishment without harboring some internal rage. In short, succumbing to the abuser’s humiliation of them.

There are several possible changes in the personalities of people who emerge from significant childhood humiliation experiences. They range from inability to relate to others which may appear as awkward socialization to severe psychopathic behaviour.

In the worst scenarios, the victims of humiliation – in the case of DID it may be one or more alters – over-compensate. As noted in the previous post, they may develop a powerful urge to gain personal power to control all social interaction. The drive to control can be so strong that it eliminates any sense of sympathy and compassion for others – including other alters – as well as when interacting with other people. Extreme levels of self-protection take over. It is this manifestation that makes angry alters both powerful and difficult. But, please don’t see those alters as identical or inextricable with their difficulties. To do that will mean that you miss their capacities as keys to healing.

For many with DID who have had their spirit seemingly crushed through humiliation, instead of acting out for revenge externally, that rage against powerlessness is turned inward. Chronic depression may be coupled with generalized fear with the loss of self-confidence as the outcome. Social relationships, including familial and marital, are compromised because of deep inherent mistrust. To heal this, and it is possible to heal this, calls for powerful transformational changes.

Once again, humiliation crushes the child’s spirit. It is intended to undermine any possibility of self-confidence and to infuse the child with fear. It impacts the child by giving them a twisted perspective of human relationships. The result is often to eliminate the capacity for genuine intimacy. It attacks that human capacity for intimacy by convincing them to distrust all relationships that might appear safe.

It does so by convincing them that they will never be safe, certainly never from the abuser. It seeks to convince them that “Anyone trying to convince you that they are safe is only presenting an appearance of safety because safety doesn’t exist.”

This is a critical barrier for therapists to be aware of and to overcome in dealing with anyone with DID. In my practice, the only path to overcoming that barrier was to respectfully engage the alters including the angry ones and to always gently invite them all to participate in therapy even by simply listening in as I engaged others in the system.

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