David Yeung's Blog, page 9

Countering the Far Reaching Effects of Humiliation – Part 3 Dignity, Humiliation, Respect

Dignity is the state or quality of being worthy of honor or respect. It is the inherent right of people to be treated with dignity. From a religious point of view, dignity may be seen as God’s gift to each individual. From a secular point of view, dignity can be seen as one’s human right to act and have their own agency in the world based on the simple fact of their human existence.

Dignity is displayed in a calm and controlled demeanor. But, it can be harmed through a humiliating experience or crushed through repeated humiliations. Dignity is a sense of pride in oneself, of self-respect. The polar opposite of dignity is humiliation.

Humiliation is the crushing of dignity by an outside agency – in the case of DID etiology, by an abuser attacking a young child. Unfortunately, dignity and humiliation are usually outside the language spoken by psychiatrists, or mentioned in diagnostic formulations.

Humiliation is mentioned a few times in the DSM 5, but not in the context of DID etiology. But, it remains undefined in the DSM so far as I have been able to determine. It is used (on page 703) in this way: “Sustained feelings of shame or humiliation and the attendant self-criticism may be associated with social withdrawal, depressed mood, and persistent depressive disorder (dysthymia) or major depressive disorder.”

This quote from the DSM infers that shame and humiliation are interchangeable terms, but that is not the case. They are not identical. Nevertheless, it should instructive to clinicians that the listed symptoms resulting from sustained (or one might say repeated) such feelings are often presented by individuals with DID. Despite this, such symptoms are instead usually seen as pathology markers on their own rather than in the context of a potential DID diagnosis.

While humiliation and shame both make a person feel bad about himself, it is important to distinguish between them. Humiliation is always provoked by someone else, while shame is connected to one’s own actions or simply chance circumstances. With shame, people mostly focus on themselves and how others might perceive them. With humiliation, there is the added traumatic factor that the other person is intentionally causing them harm. Abusers often seek to instill shame in those abused by blaming them for the abuse itself. This is true in early childhood abuse, in spousal abuse and in other abusive circumstances.

In short, we bring embarrassment upon ourselves and may feel ashamed as a result. But, humiliation is brought upon us by others. From a therapeutic point of view, it is clearly an abuser’s assertion of power over a child that cuts far deeper, leaving both scars and open wounds which show up as triggers in the future. Because humiliation is traumatic, it is kept hidden by the one humiliated while being simultaneously used as a weapon by the humiliating abuser. Fundamentally, humiliation involves abasement of pride and dignity, along with a loss of status both personally and socially.

Respect is something earned through one’s actions. Self-respect is a state of mind that is founded upon pride and confidence in oneself. It is a feeling that expresses itself through behaving with honour and dignity. Self-respect means proper esteem or regard for the dignity of one’s own character. This self-respect is part of both the path and a marker of healing.

We can easily trace many negative character traits to their origin in a loss in dignity, in those with DID and others whose negative conduct does not rise to the level of being pathological. This can happen when a child is under assault in the form of bullying or massively disproportionate and severe punishment. The result may be perpetually defending oneself even when one is not under attack, in excessive one-up-man-ship. It may show up in excessive social competitiveness, aggressive or even abrasive personality or social phobia and excessively passivity. Mistrust and paranoia can often be linked to pronounced early childhood humiliating experiences.

Alternatively, it can result in a child developing an overwhelming passivity. In the face of ongoing humiliation, a child may internalize the message of the abuser that the child as no ability to defend itself – even internally. In effect, such a child may end up adopting of an abuser’s weapon of humiliation as an adaptation of survival. By giving up any fight, the child survives another day with the abuser.

As noted in Part 1 of this extended sequence of posts, because humiliating experiences are not necessarily physically overwhelming, they may not be seen by an outside person – therapist or other adults – as being genuinely traumatic. This is a tremendous mistake. This kind of humiliation, this abusive power dynamic, is often no less damaging than physical trauma. But, it is easier for a therapist or other adult to ignore because the evidence does not show up externally – at least not immediately – the way one can see a broken arm or the bruise from a punch.

One must consider instead the fact that the damage may show up in the future as violence directed inwardly as self-harm or outwardly against others. When it appears primarily as a psychiatric morbidity, as depression for example, therapists as well as patients may miss the possibility of humiliation as a causative agent. The result may then be medication to suppress the depression rather than helping the patient process the early-childhood psychological trauma through therapy.

When anti-depressant medications don’t work, it may lead to a diagnosis of “treatment resistant depression.” I don’t consider treatment resistant depression to be an accurate categorization. Rather, in the current environment of prescribing antidepressants as the primary method of treating depression, it should be seen as drug resistant depression. When medication doesn’t treat the cause, and instead solely treats the a symptom, the cause remains intact. If the cause remains intact, it will continue to manifest in some way, shape or form despite the medication. The unfortunate result can often be over-medicating patients to the point that the medication causes dysfunction separate and apart from the cause of the depression.

With unresolved early childhood trauma, the antidepressants may have limited benefit but that does NOT mean that you should just stop taking them. Instead, work with your doctor to have meaningful psychotherapy with the antidepressant as an adjunct to therapy rather than the principle method. With proper psychotherapy, as you heal from the trauma, the medication should be able to be successfully and safely reduced. Because suddenly stopping a psychoactive medication has potentially quite a bit of risk, if you are on antidepressants, only stop taking them under your doctor’s guidance.

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Countering the Far Reaching Effects of Humiliation Part 2 – Elements of Humiliation

Humiliation is not a defined term in the DSM 5, although it is used in a few isolated instances. This presumes a common understanding of humiliation which is unlikely to be as common as people may think. But, like other forms of trauma, particularly those lacking an initial specific motivation occurring out of callousness or lack of empathy, the way humiliation is experienced by the one harmed dictates their future pathological responses.

Generally speaking, there are 3 elements to humiliation in the abuse context:

[1] Denying the status of the victim through a subjugation that undermines the pride, humanity or dignity of that person.

[2] Reducing the victim to passivity as the method for rendering them powerless. It uses a gross power imbalance in subjugating the will of the victim, of even their experience of self-hood.

[3] Violently destroying the personal boundaries of the abused, leaving a damaged psyche. The end result is the decimation of their self-confidence. The person is dis-empowered, often with life-long disabling consequences.

Stepping back, consider the role humiliation plays in the case of corporal punishment. Caning in schools, or in the family, immediately establishes a hierarchy of physical power, with the one who administers the punishment over the one being punished. For the child, if inwardly rebellious and able to silently remain angry, their buttocks may be bruised or scarred, but damage to their psyche is mostly spared. In those circumstances, humiliation is countered by refusal to identify as a powerless victim. Such a child faces punishment with a fighting spirit, rather than surrender.

But contrast that with a critical factor in DID etiology – that the abuse occurs at an extremely early age. For those with DID, humiliation in connection with abuse (physical, sexual and/or emotional) often occurs before the child is old enough to have established a psychological structure with enough stability to even envision fighting their abuser. It is here that the real damage to the child happens, when there is such an intense subjugation as to prevent the child from establishing the foundation for any sense of safety in life. At the same time, the dissociative response often enables the arising of angry alters whose importance to healing is critical, as is discussed in Part 4 of this extended blog post.

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Countering the Far Reaching Effects of Humiliation Part 1 – Disempowerment

To humiliate someone is to make them feel ashamed or stupid, to make them feel like they have lost, and are undeserving of, the respect of other people. Humiliation is a common tactic abusers employ to subjugate a child. It is accomplished by debasing a child’s status, through breaking their spirit and pushing down their ego to the point of abject submission.

Humiliation is always connected with a power imbalance. In short, an abuser is communicating that “I am stronger than you/I have authority over you/I will overpower you. Therefore, you will submit to me/my wishes/my demands.”

The result of humiliation is dis-empowerment. And, as with any experience of dis-empowerment, the consequences ongoing traumatic humiliation are far reaching.

Michael J. Fox said, “One’s dignity may be assaulted, vandalized and cruelly mocked, but it can never be taken away unless it is surrendered.” For an adult, there may be a choice to not surrender, or to surrender only in part. An adult can decide to fight it out, or to maintain a spirit of rebellion when there is no possibility of physically fighting back. In other words, an adult can choose not to surrender (in spirit) or to physically fight back, rather than to silently accept defeat and fully accept the role of being a victim. An adult may, perhaps, blame him or herself. They may feel guilty and deserving of the humiliation, but they have adult tools to fight back with or to work with those feelings.

Now imagine the gross confusion and bewilderment that arises when humiliation is heaped upon a child. Imagine, as a child, being forced to participate in the obscene act of being sexually violated, being physically beaten, or being otherwise abused, and to accept that humiliation in a spirit of submission. Escape through dissociation is likely the only logical or even possible outcome.

For a young child being abused by an adult or older child, surrender is not a choice but is rather an inescapable outcome. For very young children, survival through submission is the only option. When early childhood abuse and humiliation is a repetitive experience, dissociation becomes the default response – regardless of age.

Keep in mind that humiliation is not the sole goal of the abuser. Crushing the spirit of the victim is part and parcel of establishing the power dynamic that permits the abuse of that child in the future when and as the abuser may wish while limiting the possibility of genuine push-back from, or exposure by, the child. Humiliation enables this by the piecemeal or violent erasure of personal boundaries by the abuser, normalizing the humiliating conduct and eroding further a child’s sense of having any place in the world.

Many of the difficulties people encounter in daily life can be traced to experiences of humiliation; in adults, in children and in society. The impact of humiliation seems to include a baseline, different for each individual, beyond which a person will be unable to pull back from its clutches. When a person’s spirit is crushed in this way, unremitting depression sets in. The choiceless acceptance of humiliation is often followed by powerless rage.

Consider the intensity of that choicelessness coupled with powerless rage. In so doing, one might get a sense, a glimmer, of the importance of angry alters. They keep open both the chance of survival and the healing potential of the system. The trapping of rage in those angry alters keeps the system alert to identifying potential dangers, albeit often hyper-alert with its attendant difficult consequences. At the same time, trapping that rage in the angry alters allows dissociated submission that enables survival while experiencing abuse.

Humiliation is often be a non-physical assault. Some people may think that because it is not necessarily physical, it therefore is not so big a deal. However, looking forward, it can have the extraordinarily destructive result of setting up an abused child for ongoing future assaults both psychological and physical.

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The Sensation of Touch

In the previous post regarding weighted blankets, I spoke about the importance of experiencing safe touch and that the use of a weighted blanket may, for some people, be a safe way to re-learn that experience. Most people usually think of touch as a pleasant or painful sensation, but rarely a highlight of life in the absence of the heightened experience of touch related to sexuality or pain. Touch, more than merely the interface between our bodies and the outside world, is probably the most misunderstood sensation.

The sensation of touch may be differentiated into several categories: light touch, deep sense of pressure, temperature and pain, vibration, proprioception or sense of position in space (such as joint sense ) and others. It is said that there are 20 different types of highly specialised receptors associated with touch. These are sensory neurons found in all parts of the body except the brain. They vary in density and sensitivity to stimuli.

Touch is a fundamental part of our daily experience. The sense of touch gathers information about our surroundings as well as being a means of establishing trust and social bonds with others, both people and animals. It is crucial to creating our unique human experience. No wonder we use phrases such as calling something a “touching experience”, saying someone is “touchy”, or feeling “soft-hearted.” We often use the word “feeling” to reference emotional states rather than solely the sense perception.

The human brain has two distinct but parallel pathways for processing touch information.

[1] The first pathway is sensory, which conveys some dry facts: vibration, pressure, location and fine texture. It can tell you if someone is stroking you, up or down your arm. That part of the sensory pathway is a brain region called the primary somatosensory cortex, which is the first region to be triggered by the experience of touch.

[2] The second pathway processes social and emotional information. This pathway identifies the emotional content of mostly interpersonal touch using different sensors in the skin. This pathway activates brain regions associated with social/psychological bonding, pleasure and pain centers.

Touch is critical for child development. This is something researched for many decades, such as Harlow’s experiments on monkeys.) We know a parent’s touch, whether positive or negative, is a crucial factor in a child’s development.

Most people wouldn’t have difficulty distinguishing between a friendly touch of social support and a touch involving sexual suggestion or seduction. An arm around the shoulder coming from a person will change the way you experience that touch based on your relationship with that person. Our brain processes the sensorial experience with information about the social context from other parts of the brain. Usually the social context enables us to tell whether the gesture is genuine or insincere, whether it is straightforward or perhaps cloaks a hidden agenda. Identifying a gesture as insincere or containing a hidden agenda then appropriately triggers the need for further investigation.

Therapeutic Touch

A large body of research suggests that therapeutic massage can be helpful for a number of physical and mental ailments. These include pain relief and addiction recovery, as well as maintaining emotional equilibrium, cognitive function and mobility among an aging population. Other have also suggested that massage may be an effect way to treat anxiety, insomnia, headaches and digestive problems.

The popularity of therapeutic touch has not received its due recognition. This is partly due to the dominant status of the pharmaceutical approach and partly due to the lack of vigorous scientific proof of its efficacy. However, those with trauma in their background must remain aware that it may be difficult to identify the very moment that touch may change from a healing procedure into a sexual transgression. Always be as clear as possible about your personal boundaries and in maintaining them. It may be a good idea to tell your massage therapist at the very beginning that you have very strict boundaries that must not be crossed. Doing this may avert the danger of the massage therapist inadvertently or even intentionally blurring/crossing the ethical boundary between the therapist and the client being touched.

I am especially interested in establishing healthy self-soothing practices in our daily routines. Self-soothing happens when we need to be soothed. We use all kinds of methods to be soothed – some are safe, some are unsafe and some are neutral, depending on how they are applied. Given the general phenomenon of addiction related to nicotine and alchohol along with the uncontrolled use of comfort foods (especialy sweatened foods), and their attendant unhealthy consequences of obesity, diabetes, high blood pressure etc, safe self-soothing options are critical. Advertising for alchohol, nicotine and processed foods are designed to seduce us without concern as to their negative attributes.

In my experience with DID patients, grounding and self-soothing are part and parcel in healing those who were subjected to early childhood trauma. Helping them re-experience the literal sensation of “safe” was critical to therapy. Learning to self-sooth, the self-empowering process of being able to generate that sensate of safey is an essential part in healing.

It is in this context that I wrote an earlier post on the therapeutic potential of weighted blankets. I think any self-soothing practice that does not cause harm is worth very serious consideration. Consider comparing the negative aspects of self-soothing with drugs or alcohol (or any other addictive behaviod) with simply resting under a weighted blanket. If the weighted blanket works for you then there is no contest.

 

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Weighted Blankets and the Sensation of Safety

There is a general bias in identifying a pharmaceutical agent as a better, effective, or more scientific way to overcome a symptom than a natural method. In addition, it is extremely difficult to apply for a research grant to prove that such a natural method may be better than a pill for insomnia. Certainly not from the pharmaceutical industry! So, I doubt if grants are available to study how effective a weighted blanket is compared to a pharmaceutical agent for insomnia. On the other hand, there are now many anecdotal reports on the benefits of weighted blankets.

When I first read of the use of weighted blanket as an aid for sleep, decades ago, I thought it would make sense if it helped people with insomnia. I seldom have insomnia, so the idea of purchasing one never came to me.

Recently, I read some postings in DID Facebook groups that reawakened my interest. I also found out that weighted blankets have become a common commodity. I just stopped into a shop that specialized in things that promote sleep and bought a weighted blanket. It is 15 pounds; the recommended weight for someone my size. I wanted to explore the first hand experience of using one. Here is my report after using it for 3 weeks.

In the beginning, I felt mildly resentful because I felt restricted in my movements due to the weight. It seemed to be a hindrance to moving around in bed. I quickly realized that what I was seeing as an impediment was a mistaken understanding. It was an obstacle to manifesting my agitation physcially in bed. But when I stopped fighting that sensation, it seemed that what it was actually generating was the sensation of safety a baby might experience being “tucked-in.” So, I imagined I was a baby in a “wrap.” Sleep came over me soon. True to my expectations, I did experience a positive feeling as if I were being held and hugged while under the heavy blanket.

Three weeks have gone by. My sleep, in general, feels deeper. The number of times I wake up to use the toilet has decreased. In the evening, I look forward to the experience of going under the heavy blanket. I feel more refreshed in the morning. I cannot rule out that it might just be a placebo effect. Placebo or otherwise, with the blanket, I quickly settle into sleep regardless of any sense of resentment at the restriction caused by the weight.

Conclusion

[1] The simplest way for me to fall asleep has always been to be still, to stop tossing and turning. This heavy blanket is like a gentle reminder to me just to keep still. I believe “tossing and turning” is the most commonest reason people who have difficulty falling asleep get into a pattern of insomnia.

It is like the phenomenon of scratching an itch: The more one scratches, the more itchy one feels. Tossing and turning make people more restless, which makes them toss and turn even more.

[2] I can feel the sensation of being tucked-in and held. There is an immediate shift from the physical sensation to the emotional.

[3] Some people may resent the sensation of restriction of the blanket stopping you from freely tossing around, as I did initially and still do to a lesser extent. It is easy to get over this, because the sensation of being safely tucked-in, that good feeling, quickly takes over.

Considering this from the viewpoint of someone with DID, how might this be helpful? For someone with early childhood trauma, the sensation of being touched is often frightening – the opposite of being safely tucked in. This early trauma impacts those with DID for decades into the future. So, a question in therapy is how can the therapist help a patient re-learn the experience of that sensation of safety without touching the patient? Further, how can the patient experience safety at home, perhaps at night when it might be most needed? Knowing the difficulties DID patients often experience with close body contact with their partners, how can a partner help engender that experience of safety in a way that eliminates any trigger of sexuality? And finally, how can someone with DID that doesn’t have a partner experience that sense of safety alone in their home.

i want to be clear that I do not believe there is any approach to DID that will successfully address the problems of all individuals with DID. However, given that different approaches can be helpful to different patients, I thought it was both interesting and possibly important enough to post these thoughts. If readers of this post have read my books on DID, the Engaging Multiple Personalities Series, you will know that I believe that re-learning the experience of safety in the here and now, the experiential sensation of being safe, is a critical component in the healing journey. The question for therapists is how to deliver that sensation.

I have written in my books about using a large bolster cushion to push lightly against a patient’s chest to have them experience the sensation of a grounding safe touch without me actually touching them directly. There was always the large bolster between us both for ethical concerns and for avoiding potential triggers. The weighted blanket seems to serve a similar function, but can be used at home, alone or with your partner, and is in your control which has the additional benefit of self-empowerment.

I told the spouse of one of my former patients that I wanted to experiment with this.  He wrote back letting me know they had purchased one already. He wrote that the first night of use his spouse was irritated with the weight of the blanket. She commented that she really didn’t see any difference and didn’t like it particularly. Nevertheless, without prompting, she has used it every night since. No longer getting up repeatedly to use the washroom, no longer waiting for the spouse to fall asleep first before drifting off herself to sleep, and other positive results have happened.

So, in short, I think it may be of benefit. There are many versions and at different price points. I am not well versed enough to comment on which weighted blanket might be better than some other one. If people have tried this and had a negative reaction or no positive reaction, please post that as well.  It may be helpful for others in the DID community to get a sense of whether or not it is something that has a likelihood of being helpful to them.

I do have to add a disclaimer: I do NOT hold any commercial interest associated with sleep promoting products whatsoever. To my knowledge, neither my former patient nor her spouse has any economic interest in weighted blanket companies.

 

 

 

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Religion and Working with Trauma Survivors – Part 2

For me, religion is a worldview that relates humanity to life’s transcendental elements. My definition does not necessarily include or exclude an omnipotent deity. It includes all the religious traditions I have encountered in my life so far; including varities of Christianity, Judaism, Islam, Hinduism, and Buddhism as well as atheism.

For the therapist, when listening to a patient express their religious faith or lack thereof, the issue to consider is what enables this particular victim of horrendous repeated abuse to undertake the hard journey necessary for healing and restoration? Something is enabling them, or trying to enable them, or they would not be seeking help in therapy.

We know that resilience is the single most valuable attribute required in healing and recovery from past trauma. Accessing that source of resilience and protecting it from attacks is critical to successful therapy.

So, what is it that gives survivors the strength to persevere? For those who believe they have a personal connection to God, or an unnamed higher power, that connection can be used to their advantage in healing and recovery. Prayer can be extremely helpful and sustaining for those who believe that they can rely on that for their healing.

In such cases, irrespective of the therapist’s personal belief, it is only appropriate that the patient be supported and encouraged to continue in their spiritual path so they can benefit from that faith. I have seen survivors in religious communitie that are separate from where the abuse occurred. They have experienced a sense of sisterhood and brotherhood in those new comunities that gives them powerful support in an otherwise lonely individual struggle.

For those taking a path separated from religion on their healing journey, their motivating force might be the need to bear witness as a survivor. This is why I often spoke to angry alters about how important they were to the survival of the system. I encouraged them to see that their rage could be turned into fuel for the journey of bearing witness as a survivor.

This idea of bearing witness is a traditional element in many religious traditions but is clearly something that exists beyond any religious structure. The founder of the logotherapy, Viktor Frankl, was a Viennese psychiatrist who survived the Auschwitz concentration camp in World War II. He was trapped in a terrifying place specially designed to crush the human spirit, subjecting prisoners to a completely dehumanized environment. However, he had and held on to his reason to survive. That reason was for him to survive so as to bear witness to the fact that a people or “race” had been assigned for elimination through modern assembly-line methods. He believed it was necessary to bear witness that common people would lose their minds and individual will to participate in that elimination, and that they would obey orders to carry it out. Based on his experience in the camps, he indeed bore withness and used his experience to develop logotherapy, as discussed in his book Man’s Search for Meaning.

There are therapists who decry religion within and outside of therapy. Those therapists should consider the success of Alcoholic Anonymous, which focuses on connecting alcoholics to a “higher power” in order to heal from addiction. It would probably be more appropriate to use the word spirituality than religion to describe that program, which brings hope to those helplessly addicted to alcohol. Comparing AA to both conventional psychotherapy and drug therapy in helping people with alcohol dependency problems, AA’s encouragement of working with a higher power has a well recognized success rate which is higher than either psychotherapy or medication. So therapists should not denigrate the power of spirituality of any kind in healing.

In the New Testament of the Christian Bible, St. Paul brought up Faith, Hope and Charity (agape or love) together, likening them to a three legged stool. With three legs, it is stable even on uneven ground. Most Christians believe that being grounded in faith, hope, and charity, allows them to remain on solid footing even when the ground beneath them is bumpy. I point out that this view is consistent with the path of any successful trauma therapy. The healing journey is certainly traversed over uneven and bumpy ground. Having the patient’s own connection to those three legs, within or outside of the Christian or any other religious tradition, is a most powerful resource.

Faith generates hope, and hope sustains us at difficult times. This is true whether you see faith through a religious lens or otherwise. Charity, again whether through a religious lens or otherwise, can be interpreted as being generous with love to those injured – including generosity to ourselves. Within the DID system, charity can be seen in some alters being generous to other frightened as well as hostile alters. This is something to be encouraged whenever it arises.

For those patients who disparage religion, therapists can focus on the spirituality of a beautiful sunset, the earthiness of a moss covered rock, the intricacy of a bird’s song, the nourishment of breathing in the forest after a brief rain. Regardless of the therapist’s own belief system, you must be open to the possible paths of faith your patients can access – even if that faith is limited to confidence that the earth will hold you up, that the sun will warm you.

In short, and this is the whole point: Abused individuals all have to be helped to give themselves a reason to wake up in the morning, to have a meaningful task to accomplish. Recovery from abuse is a deeply meaningful task.

This is something therapists can continue to remind their patients about. Begin with keeping the meaningful task of recovery split into quite small steps, like breathing in a warm sense of goodness even just once each day. In the context of patients who are religious, it is appropriate to encourage them to apply the tenets of their religious views of kindness and compassion to and between their alters. In the context of patients who wish to avoid religion, it is appropriate to remind them to be grounded in faith, hope, and love, and again to apply those qualities to and between their alters.

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Religion and Working with Trauma Survivors – Part 1

I have been hesitant to write a post on religion because it is a highly charged topic in virtually every setting, but it comes up very often in DID treatment. While religious faith can have a great positive impact in therapy, it can just as easily have a great negative impact on a patient should have been connected with the underlying trauma. As a psychiatrist, whether religion was brought up by my patients in a positive or negative light, I dealt with it based on that particular patient’s preferences only. I avoided making generalizations of any kind because each patient is an individual, and therapy must be geared to that individual’s experience.

I will restrict my comments to the impact of religion on the therapeutic approach one takes with patients. Appreciating its impact on each individual patient that brings it up is critical for establishing and maintaining the therapeutic alliance.

The therapist must not push back against a patient’s view of religion, regardless of the therapist’s own view. Otherwise, there is a serious risk of diverting therapy away from its primary obligation, which is helping the patient deal with trauma. Why is there such a risk? Remember that being told not to believe their own experience, their own perceptions, and the consequent feelings of being invalidated, are all common experiences of early childhood abuse survivors.

Should the therapist try to impose his/her own ideas about religion onto the patient, it can trigger distrust and retraumatization. It can become yet another replay of some terrible memory. To have any chance of a real therapeutic alliance, therapy cannot involve any demand by the therapist – direct or indirect – for the patient to have the same view of God or religion as the therapist.

In my work with DID patients that had specific views of religion, rule No. 1 was to respect the patient’s perception or idea of God, including the idea that God does not exist. The therapist’s own belief system does not apply here. I would never argue or disagree with whatever my patients’ religious belief might be. The only time to question a patient’s belief would have been if the belief was encouraging them to harm themselves or harm others.

For the DID patients I worked with, it was clear that harming themselves or others was tied to how they were dealing with the trauma and its aftermath, not to any religious view or lack thereof.

For patients that disparage and are frightened of religion, all that therapists who believe their own religious tradition need to consider in order to set aside their own belief system is the truth that throughout history people have performed sadistic horrors in the name of religion. They can remember that wars have been and continue to be fought in the name of religion. Critically important for those with early childhood trauma, abusers often hide behind the facade of religious piety. The fact is that people have hidden their commission of evil deeds behind many names and facades, religious and otherwise.

For patients that do have religious faith, therapists that disparage religion need to consider that faith, throughout history, has been a powerful source of strength that has sustained people as survivors. Faith can sustain people by nourishing their hope of survival and healing from their trauma.

It is important to maintain that open view so as to be able to consider both the negative and the positive experience of religion in patients. Why? Just as I have seen religion used to perpetuate early childhood abuse, I have also observed in some of my patients that faith can play an important role in helping heal those who have been severely traumatized. I have seen many patients whose therapists considered them “too damaged” to benefit from therapy. Nevertheless, they derived strength to fight successfully for recovery because of their religious faith. It was clear that their faith sustained them with hope, that most important element in the process of healing past trauma.

Confidence that it is possible to heal, that it is possible to be freed from the bonds of retraumatizing memories, is the key to healing. For some, abusers have twisted religious imagery and practice. These patients may find healing only in a life that is completely extricated from religion. For patients like that, a therapist might gingerly feel out whether it is safe for the patient to hear the view that one can have a spiritual view without any trappings of religion.

For others, even those whose abusers twisted religious imagery and practice as part of the abuse context, maintaining or even finding faith beyond those evil twists gave them the confidence needed for healing. Because that key of confidence is so important, it is inappropriate to judge another person’s religious faith as right or wrong or superstitious. Instead, support them with the view that what gives them confidence in their healing journey is of benefit.

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Treating DID – A Brief Summary of Key Points: Part 3

[7] Metaphorical hand-holding helps the frightened child who keeps reliving the trauma, helping them to process it in small digestible doses.

Treating PTSD involves metaphorically holding the hand of an injured and terrified child. It is comforting them so as to enable them to process the impact of the trauma in a way that protects them from being overwhelmed or re-traumatized. It is to enable them to process the trauma in small dose that are digestible and not overwhelming to the individual.

The therapist must resist the urge to learn the details of the abuse unless and until the patient wants to reveal details. And then, no follow-up interrogation of the patient. Avoid asking questions when they are based primarily on the curiosity of the therapist. All historical events of trauma must be seen as private to the patient. We only find out as much or as little as is required to get the patient over the distress. Remember we are not police detectives writing up police report. The details of the trauma is of limited therapeutic relevance except to the extent that an alter needs to express it. The need to express, and to protect from re-traumatization, is of therapeutic relevance – not the details that are expressed.

[8] “The body keeps the score” so help the patient connect with their body.

The memory of the trauma is kept in the body. Therefore, a physical approach rather than an intellectual approach is at times more relevant in therapy. Teach “grounding” techniques. Spend time to teach how awareness of the breath can impart calmness as can physical exercise and movement. Patients can use that awareness to ground and so neutralize the panicky feelings.

Flask-backs are best understood as a combined physical and psychological event rather than simply a psychological event. Some alters have severe PTSD features in the form of flashbacks. In a flashback, the alter is essentially reacting bodily to the memory of the past trauma. In other words, the past trauma is intruding into the patient’s present. He/she is in fact re-living a segment of the original trauma. The body is reacting/behaving as if it is actually facing that same trauma. Imagine if you had once been attacked by a man-eating tiger. The next time you see that kind of carnivorous animal, your body would no doubt flood itself with adrenaline. You might run as fast as possible in the opposite direction when you hear the roar – even if this time you see that the animal roaring is caged in the zoo.

The individual is frightened and confused during a flashback because they are experiencing a massively hyperactive sympathetic branch of the autonomic nervous system that is not in accord with their actual perceptions. The affected individual is not in control of his/her hyper-reactive physical state. Even though their sense perceptions are giving them the same information we interpret as no big deal, their nervous system is screaming danger. In other words, PTSD is basically a disorder where an individual experiences flashbacks of trauma that take away control of the body. The body goes into panic mode when encountering a trigger, like encountering a sudden storm when you are traveling in a calm sea. For those not triggered, it seems like the individual is completely panicking at the drop of a hat.

Treatment is essentially teaching the individual to take back the control of his/her own body. When flashbacks happen in therapy, if the therapist remains calm, there is a powerful transmission of that calmness to the patient. Simply teaching the patient that attending to the one’s breath in the present moment can be an effective way of giving them the skills to handle the flash back. Self-induced calmness means empowerment. It means that one has found a way to overcome this distress though one’s own effort. A self-generated sense of calmness is a skill that can be regained by the patient, the result of which is vastly superior to a tranquilized sensation induced by a pill.

Drug induced calmness, even as it works, maintains the patients in a dis-empowered helpless role. He/she is being trained to rely on the availability of the medication when the next panic attack or next symptom appears. This avoids addressing the real issue, which is the past trauma taking over the present experience. In other words, with medication, one remains in a helpless posture. Further, it is common to find the body needing a higher dose of medication, the next time panic or agitation arises. Exclusively administering drugs to treat PTSD symptoms is doomed to failure and runs the substantial risk of chemical dependency.

Treating DID is teaching an individual how handle the result, the consequences, of having had tremendous overwhelming and repeated exposure to early trauma. The mind is fractured. What is left behind is a system of split and conflicting parts forced to live together in one body. Prior to appropriate DID therapy, each part likley has only varying degrees of awareness of the split. Each part has its own agenda.

How to bring about a fragmented selves to function in a cooperative way is the task of the therapist. How to deal with flashbacks is the key skill to teach through communication, cooperation, and compromise. In the wider world, we need to learn to live with our neighbours. Within their systems, those with DID need to learn to live with the divided parts to learn how to control impulses and delay gratification when necessary. Both the path and result of healing is that we have to do it ourselves, not through use of an external agent, like a pharmaceutical.

[9] EMDR or CBT (cognitive behavior therapy), are only tools to use in the treatment of symptoms in PTSD.

If they are helpful to any particular patient, that is great. But, they are not exclusive tools for treatment. Therapists must know how to apply these tools, like surgeons knows how to excise a malignant tumour. But, just as surgeons know that there are often other options for treatment than surgery, therapists must be familiar with other options as well. Tools can be used but their limitations must be recognized.

Using an antidepressant for someone with DID is like using a cough medicine in someone who has chest infection. There are cases where a patient may have a true brain disease that has a fair chance of responding to pharmaceutical intervention. But, so far there is no laboratory method to diagnose these cases, to separate them from depression that requires predominantly a psychological approach for its healing. We rely on subjectively identifying a group of symptoms to fit into a diagnostic label.

In PTSD, whether the result of early childhood, wartime or other trauma, the brain is set to a hyperactivity mode, like a thermostat that is set a few notches off the scale. So far, purely using a mechanistic approach, like chemical or physical methods, has failed miserably. Witness the poor track record of treating veterans with PTSD, returning from the Gulf war and from Afghanistan. The result have been very disappointing when pharmaceutical methods are used exclusively.

It is unlikely that there will be a magic pharmaceutical agent that can exclusively used to heal the damage of early childhood trauma that results in DID. We must come to our senses to recognize that to fix the cause of a car accident, we cannot just focus on the mechanical parts of the car. We need to understand the whole car, driver, weather, and road conditions to actually understand what really happened. In that same way, we must look at the entire patient beyond a simple mechanistic view.

With empathy, compassion and a willingness to engage the alters, by both the therapist and the patient, healing is possible.

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Treating DID – A Brief Summary of Key Points: Part 2

[3] Treat the trauma, not the drama.

While the presentation of DID may appear to be melodramatic or overly complicated to the therapist, common sense dictates. There is no need to treat every alter as a full fledged individual who needs individual psychotherapy. Generally speaking, they don’t. The key is to just address the alter specific presenting problems in any session. Alters are extremely responsive to, and appreciate such individual attention. And despite their initial hesitation, they are usually highly changeable.

In my experience, alters were willing to take turns to have their problems addressed according to their severity. They can all listen in and learn from each other’s sessions. This allows the healing process to spread throughout the system a little bit at a time without the need for continuos individual treatment. Remember, a therapeutic alliance gives them hope for help in dealing with burdens they have been shouldering all alone for many years. Burdens that have never been acknowledged by anyone outside, and in fact were often terrorized into keeping those burdens tied up inside.

Eventually, alters develop empathy – some sooner than others. With gentle encouragement by the therapist, they will often try to start helping each other within the system. I was often astonished with the efficiency of the inner guide(s) or inner therapist(s), that develop to hasten the therapeutic process. I have attempted to encourage one alter helping another, or to even just be sympathetic to others in pain. Therapists have an important role in teaching alters empathy towards their fellow alters.

[4] Promote co-consciousness and communication.

When talking to individual alters, the therapist must understand that it is like speaking in a classroom to one student but in the presence of the entire class. Such awareness will optimize therapeutic effect, good will, and planting multiple seeds of hopefulness into the system.

[5] Be prepared knowing that there will be both trusting and mistrustful alters remaining quietly in the background watching the on-going therapy.

In extreme cases, hostile dictatorial alters may try to sabotage therapy. They take this position genuinely in the name of protecting the system from being hurt again. Given their history of trauma involving those with power over the patient, this is both reasonable and important to acknowledge.

Occasionally, such an alter may drop a note to the therapist warning them that she/he is watching, protecting the others from being fooled. Don’t be insulted or be defensive and try to convince that alter that there is no need for their vigilance. Therapists should know that this is completely in keeping with that alter’s protective function. I would always thank those alters and encourage them to continue watching me. This is a correct and polite response. While they didn’t need the encouragement to keep watching, such responses generate more trust and good will.

[6] Empowerment is essential for successful therapy.

Following such a “client-centered” approach gives the patient a sense of autonomy and empowerment. There is no better way to help a DID patient than empowering the patient during therapy. Always keep that in mind. Essentially, the trauma the patient has been dealing with all his/her life has been one of dis-empowerment, of being the victim. Abuse is ultimately a process of domination, of one person overpowering the other. If, in therapy, the therapist finds ways to enable the patient to reclaim their power as an individual, there is tremendous benefit in healing. And critically, that empowerment will begin to allow the patient to undermine the strength of flashbacks that otherwise re-traumatize the patient.

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Treating DID – A Brief Summary of Key Points: Part 1

Treating DID

My three small volumes of “Engaging Multiple Personalities” were written with the intention of introducing to the public to Dissociative Identity Disorder, the often forgotten and neglected mental disorder arising from early childhood trauma. Since early childhood trauma is often ignored by professionals and the topic trauma/dissociation often misunderstood, there is unfortunately an enormous pool of individuals at large suffering from these conditions. Often, they remain misdiagnosed by therapists and bounced around within the mental health systems.

Many people erroneously regard this condition as rare. Others believe it to be “controversial” diagnosis, which is actually saying that they don’t believe it exists. Such misunderstandings continue to cause untold suffering in many individual with DID, keep many therapists from considering such a diagnosis or caring for an individual who has been so diagnosed. In short, competent DID therapists are difficult to find.

Looking back on my career, I encountered these patients early in my practice but failed to recognize their plight. Even if I had recognized them at the time, I did not have the training or skill to help them – despite my medicine degree and protracted training in psychiatry at some of the best centres in London, England. For the first decade of practising psychiatry, I remained ignorant as to how to recognize and help patients suffering from DID.

Eventually, I learned the hard way – directly from my patients, from both my failures and successes. I learned from each one of them something of how to work with those suffering from DID. Eventually, I developed some skills in helping patients suffering from trauma and dissociation. I wished I had some guidance, a mentor, when I was struggling as a therapist to find ways to help the DID patients more than a decade after I was considered a DID specialist.

Although at this point in my life I cannot be a personal mentor to other psychiatrists/therapists, the Engaging Multiple Personalities series is an attempt to provide some guidance to those with DID, their therapists and their potential therapists.

Treatment of DID begins with the recognition and understanding of the psychopathology of trauma and dissociation. Digging deeper, one must recognize that trauma and dissociation can indeed begin at a very early age, a horrifyingly early age. Trauma like that can culminate in fracturing the mind of a child, resulting in the condition now called Dissociative Identity Disorder, formerly termed Multiple Identity Disorder. It is difficult to learn how to treat DID through reading textbooks. It would be somewhat like reading the Oxford dictionary to learn the English language. It is not completely impossible, but for most people, it is not a particularly helpful approach to learning a new language. Therapists dealing with DID patients must learn these key points. Otherwise, the therapist will be unprepared to handle the appearance of an alter in a patient suffering from DID. That lack of preparation will lead to a cruel failure in therapy and damage any potential therapeutic alliance.

Here is a summary of the guidelines I recommend in the treatment of DID:

[1] We can use empathy to understand.

DID is a condition with an extreme form of dissociation, with the mind fractured into parts that are referred to as “alters,” or “alternative identities.” The host personality is usually the patient that initially comes into the office. But, the host personality is part of a system of alters that each experience themselves as individuals separate from the host. They have a separate sense of self, and display a separate personality. Based on their experience, the alters insist that they are individuals inside the patient that either remain inside or sometimes emerge to take over the body of the patient. When they emerge, they function for a period of time – ranging from a few minutes to several months in my patients’ experience – like any other individual you might meet out in the world.

How does empathy help a therapist understand DID? First, know that the dissociation is a survival mechanism. It arises instantaneously so that the child can escape in some way from the experience of an insurmountable trauma. Without the dissociation, going through the traumatic experience as a whole, the child would have been over-whelmed and destroyed. Simply put, the immature developing ego has found a way to circumvent the trauma by dissociating from it. This manifests as the experience “this is not happening to me.”

In short, an alter goes through the trauma while the remaining parts of the system – other alters and perhaps the host – experience the trauma quite differently, something like, “I am hiding here safe and floating up towards the ceiling.” This is a verbatim statement made by one of my patients describing the experience of being severely beaten by her sadistic father when she was an infant.

While I don’t have the first hand experience of someone with DID, based on the communications I have had with my DID patients, this is how I envisage the way an alter is formed. Therapists with a limited capacity of empathy might think this is a theatrical way of exaggerating the suffering of an abused child.

We must consider the truly horrific nature of a helpless infant encountering repeated trauma to generate real empathy. Truly imagine yourself as an infant being beaten, again and again and again. There is no way to escape. If you genuinely listen to a patient’s experience of early sexual abuse, repeatedly with no way to escape, how quickly could you “get over it”? To presume that you could ever get over it without tremendous help and your own herculean effort, is an egregious and cruel lie.

[2] The slogan to remember is “Engage the alters.”

The alters are not the pathology, so do not think of ignoring them to hope they will disappear. They have the primary functions of protecting and stabilizing the system. One must always remember to treat each alter with respect and to appreciate their important roles within the system.

There are 2 ways such extreme dissociation generally cause dysfunction in later adulthood.

(a) Each alter may have their own issues that require therapeutic intervention. Many of them can be identified as suffering from PTSD. Those with self-harm or potentially violent acting out behaviour should receive priority treatment. The approach is simply determined by the urgency of the problem presented by the alters. Attend to each problem as presented by each alter, according to severity.

While each alter may have issues that might need therapeutic intervention, this does NOT mean that therapy requires directly working with each alter. It is not the case that the therapist needs to identify each and every alter, and seek to address each and every issue they may have. What has happened with my patients is that treatment of even one alter eased the difficulties of other alters who were watching, so to speak, from the sidelines. In other words, providing therapy to the presenting alter had a positive cascading effect on other alters. To seek to identify the trauma each alter may have, in the absence of a presentation by that alter, would like lead to retraumatization rather than benefit.

Alter generally have some PTSD flashbacks as traumatic memory rises to the surface. However, once a therapeutic alliance was established, I was always amazed that there was much cooperation among the alters as well as a sense of urgency to work hard in the healing process. It is as if the system truly appreciates it when, finally, it has found hope that healing is possible. The system of alters, both individually and as a whole, becomes ever more approachable and ready for change when they are listened to with respect by the therapist. It is often the first time in their life that any outsider genuinely listened to them.

(b) Many alters are secondary elaborations arising from the primary splitting. It is critical to understand that identifying them as secondary elaborations is absolutely not to diminish them in any way. They arise to perform their protective functions. They nevertheless can cause friction to a system by exerting each of their own individuality, which individuality likely has its own trauma triggers as well as its own quality of hyper-vigilance.

Seen in a narrow perspective, an alter may appear to be extremely angry, paranoid, mistrustful or controlling and dictatorial. They jealously guard their individuality, which makes sense in the context of their emergence in the midst of specific traumatic events as they are hyper-vigilant about the potential for similar trauma that might come up.

Most alters have never learned compromise or genuine cooperation. If X wants to go dancing, and Y wants to study, there may be an ongoing clash and confusion that is impacts the entire system. In the early phase of therapy, many alters share varying degrees of co-consciousness. Consider how often a conflict or clash will occur in one single body holding several sets of will and desire. It is no wonder that a single choice may take an incredibly long time, whether shopping for a dress or choosing where to eat.

Treatment can be likened to negotiating for some harmony and corporation among a group of different aged people housed in a single dormitory, who may be complete or partial strangers to one another. The therapist has to be resourceful, for example suggesting that the alters elect a director for shopping who makes the final decision of items being bought which director alter is required to ensure that all alters get their way occasionally. Therapists will be amazed that the alters do listen and appreciate help in this way.

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