5 Advice to Clinicians

5.1 Support group feedback

Posted on March 27, 2014

When I received feedback from the founder of a DID support group letting me know that they wished to use the book for a study group, I was delighted. This is exactly my hope – that members of the DID community would access the material for their own healing. To read the material in that kind of safe place – with others in a support community – is a wonderful way to protect oneself from re-traumatization while exploring the paths to healing that are presented in the book. This is something I had not previously considered. It is truly a great joy to hear about this and even more positive that the idea came from the DID community itself!

5.2 The Therapeutic Window

Posted on April 30, 2015

The concept of “therapeutic window” is discussed in detail in Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment by John N. Briere and Catherine Scott. The therapeutic window, as presented by Briere and Scott, refers to a psychological midpoint between the inadequate and overwhelming activation of trauma-related emotion during treatment. It is a hypothetical target where therapeutic interventions can be most helpful. Psychotherapeutic interventions within the therapeutic window are neither so trivial that they provide inadequate memory exposure and processing; nor so intense that the client’s balance between acceptable memory activation and overwhelming emotion is tipped towards the latter. In other words, interventions that take into consideration the therapeutic window are those that trigger trauma memory enough to promote processing but do not overwhelm internal protective systems such that untoward avoidance responses take over.

To put it another way, interventions that “undershoot” the therapeutic window are ineffective and a waste of time. Those that “overshoot” the window constitute re-traumatization. In the former, the client may avoid returning for further treatment because they feel nothing is being accomplished. In the latter, the client may avoid returning for treatment because, having been retraumatized, they are frightened.

The therapist must remain completely attuned to the client, their verbal, emotional and physical presentations give you the keys to see how far to go and how not to go farther. Each encounter between the therapist and client should be more powerful than the titrated exposure to the trauma within that therapeutic window. In that way, each time a client comes to therapy they will leave feeling just a little bit better than when they came in. This is critical to encouraging their hope for recovery and their further establishing of a therapeutic alliance with the therapist.

5.3 David Yeung Comments on Psychiatric Times SRA article

Posted on March 25, 2014

This is in response to a recent article denying all aspects of Satanic Ritual Abuse.

Clinicians should be wary of being drawn into this debate. The real issue is the impact of past trauma into present experience. One should not be sidetracked by a debate about the ontological aspect of SRA and therefore miss the point about Dissociative Identity Disorder.

War veterans reliving PTSD flashbacks are not interrogated as to the accuracy of their traumatic memory, while victims of child abuse are met with scepticism and disbelief. The purpose of psychiatry is to treat patients, not to cross-examine them as if their treatment sessions are taking place in a court of law.

Patients traumatized in childhood decades ago, by powerful abusers and under inescapable circumstances, have difficulty reconstructing their experience from non-declarative memory. In converting that experience into words, it is understandable that they will express it as a memory of satanic ritual abuse. After all, if someone who is conventionally seen as your protector violates you in unspeakable ways, that is close enough to an archetypal satanic experience to be seen, at least, as metaphorically true. There may be no other words to describe this indescribable experience of betrayal. The false memory debate pre-supposes that there is only one “true” memory – one that can satisfy a judge and jury. Perhaps those who are fixated on denying SRA should watch Kurosawa’s Rashomon again.

To call it false memory because it might not survive a court challenge will prevent a psychiatrist from helping patients to heal. People abused in childhood are already convinced by their abusers that no one will believe them, no one will take them seriously. For a clinician to do the same thing is to reinforce that abusive imprint.

After years of scientific and liberal education, psychiatrists should understand the difference between factual and metaphorical accounts. The conversation between the fox and the crow in Aesop’s Fable surely did not take place in an historical provable event but it represents metaphorically a deep truth.

I would not dismiss the possibility of ritual abuse. The current unveiling, surely not complete yet, of international child pornography and child sex slave selling rings promoted throughout the Internet is not far removed from what a victim may say using language of SRA in an effort to communicate their experience.

5.4 The 5% Rule

Posted on May 28, 2015

I am glad that some readers are finding my books helpful, and that some therapists are open-minded enough to read them. For patients and their significant others, my wish is that they will find hope for healing in the material. For therapists, my wish is that whatever they find helpful will prove of benefit to their own patients.

I recently received a request for more detail on the 5% rule I discussed with my patients. In Engaging Multiple Personalities Volume 1 page 31, I suggested to a patient that she could try to limit her experience of pain to 5% of the actual memory of pain. In that way, she could begin to relate to the pain while remaining in control and avoid being overwhelmed by it. 5% seemed to give the pain a boundary of tolerability, regardless of that boundary’s illusory nature. Further, if 5% was too much to handle, at that point she could decide to only take on 2%. Again, the idea was to create a vehicle through which she could begin to process her trauma on her own terms -rather than being uncontrollably swept away by the memories.

The notion of 5% is a way of pointing out that a difficult task can be divided into small bits, so that each part can be handled successfully without overwhelming the system. In concrete terms, if one has to climb a tall mountain, it might seem impossible at the beginning. By dividing it into 20 sections, each part is only 5% of the whole. That small part appears on its own to be manageable. The next 5 % will be likewise manageable too, and so on. When climbing Mount Everest, even the professional climbers acclimatize by spending time in a series of Base Camps that are each a bit higher in altitude than the prior camp before making the final ascent.

When it comes to pain, one has to use some imagination. I once treated a patient with severe snake phobia. I applied the 5% rule in this way. I suggested that she could imagine 5% of the fear to be like imagining a snake placed in a locked cage, in a locked room in a locked building, situated in the next city block over. The next step would be for her to imagine allowing the snake to be brought in the locked cage just outside the locked room, but still being kept in the locked building in the next city block. This amounted to her feeling a certain percentage of the fear of the snake without succumbing to panic. In this way, she was able to have some measure of control. Step by step she was able to regain control of her reactions to snakes.

The important suggestion is that one can use one’s imagination to break down into fractions whatever it is that one is frightened of. As in all behavioural therapy, the key point is generating that sense of control in the hands of the survivor. With control, one is no longer a helpless victim. Rather than being a victim of an onslaught of debilitating memories, the patient (NOT the therapist) is then in charge of allowing whatever amount of the distress to come through for processing.

Even simply talking and planning such a technique with the patient in a secure milieu is in itself therapeutic. It is best to engage the patient to fully participate in the therapeutic procedure. The primary default response to a trauma is helplessness—a sense of loss of control. This approach gives the patient the tools to transform the default response of helplessness into a powerful controlled processing response.

5.5 Advice for Novice DID Therapists

Posted on August 12, 2015

If you are a therapist who has never treated DID …

Is there a point to deny, discount or argue with different alters in a DID patient? Bluntly speaking, the answer is no. While DID/MPD deniers will deny the existence of alters no matter what evidence or experience you present to them, I have seen and engaged many different alters in DID cases. Further external validation is unnecessary to proceed with treatment.

There are two key points to keep in mind when acknowledging the presence of different alters:

1. Alters feel strongly about their individuality. To insist that they are just one identity or personality is going to push them away from the therapist and destroy any possibility of a therapeutic alliance. I accept their way of thinking of themselves as separate individuals. I will not impose my own “unitary” concept of personality and try to convince them that they are deluded or simply wrong. This multiplicity aspect of personality is prevalent in all of us. It is only a matter of degree. When I play tennis, I am acting and feeling like a teenager, trying to hit the ball to the other side so that my opponent cannot return it. It is the “teenager” in me that is playing the game. It is a conceit to think that the teenage quality of me playing tennis is not part of the continuum of experience that includes alters in DID patients.

A therapist should never argue or try to convince a client that he/she does not have different alters. It would be akin to attempting to convince that a schizophrenic patient’s voices are not “real.” However, common sense and appropriate therapeutic demands dictate that clients’ alters should all work out a way to handle the practical aspect of day to day business. Alters should obviously find a way to live in a cooperative way because there is only one body – one cannot go to a party and simultaneously rest at home.

2. When treating a DID patient, unless a therapist acknowledges the presence of alters, treatment cannot even begin. Therapists cannot get anywhere if they insist on ignoring an alter because that means shutting down therapeutic communication. This is so basic but is one of the major obstacles in DID therapy for psychiatrists who have no experience in treating such patients. There is a strongly held but erroneous belief that if a therapist talks to an alter, it is going to make things worse. In fact, the opposite is true. Ignoring the alter(s) undermines the therapeutic alliance. The patient will close down this most important support and gateway for healing. It is the equivalent of telling a non-DID patient that the therapist does not want to hear what is really bothering him/her.

Once these two points are understood and agreed upon by the therapist, treatment of a DID client is no different from treating patients with most other psychiatric diagnoses. In DID therapy, therapists should focus on processing past trauma, and bringing together the alters so that they learn to live together in harmony and mutual support, like a team of athletes with different strengths and skills all pulling together toward the common goal of healing.

Sometimes a therapist who has never treated DID will be open-minded and even read my books to get started in treating DID. Claiming to have no experience is not a good excuse because DID is not rare. Sooner or later the therapist will see or at least recognize another case of DID. No therapist should deprive themselves of the opportunity to learn to treat DID.

If you cannot find a psychiatrist, any psychotherapist from other disciplines can work with DID patients. Social workers, psychologists and others can equally engage in treating DID. Anyone trained in psychotherapy can treat DID if one follows the simple principle of processing trauma and bringing together the different alters to work as a team.

5.6 Treating Massive Multiplicity

Posted on June 2, 2015

Chapter 5 in Engaging Multiple Personalities Volume 1 documents Ruth, who eventually told me that she had over 400 personalities. I treated the fact of such a large number of alters in a low-keyed way. In my approach, it didn’t matter if she had 4 alters or 400. The important point is that the therapy was not dependent on the number of alters – it was dependent on some key general guidelines regarding alters.

Alters usually demand to be treated as separate individuals. That is how they experience their own being. In therapy, integration was not the goal. The ultimate goal is to help all the alters to function as one cohesive unit, like a football team with a common aim of winning the game. I tried to teach them to aim for cooperation, communication, and coordination. The approach was for me to help them to respect each other and encourage them to help each other. This needed to be done without my denying their desire to assert their own individuality.

Initially, there are conflicts that are often expressed quite strongly by alters that are not interested in working with or befriending any other alters. There are usually those that are quite angry with other alters and wish to be violent toward them. This approach requires the therapist to proceed with sensitivity and tact. Without hurting their feelings or telling them to drop their individuality, I would point out to them the need to acknowledge that they should work for the common good because they are all sharing only the one body. This is one of the main tasks in DID therapy, to help alters come to terms with the idea that they have to work together, to sacrifice a small measure of their individual demands so as to be able to work together for the bigger and more powerfully functioning unit.

Eventually, after alters have processed their traumatic memory, the need to be separate individuals often diminishes. As a therapist, it is paramount to control one’s curiosity and undue inquisitiveness as to the individual alters’ personality and characteristics. I never said anything other than the truth that all the alters played a part in saving the system from destruction under the direct assault of the trauma and its after-effects. Therefore, all the parts needed to respect all the other parts.

One must conscientiously refrain from trying to treat each and every alter separately as if you have 400 separate patients. My contact with each of Ruth’s alters was limited to whatever and whoever arose in the here and now of therapy. If one alter was suicidal, I would encourage that alter to come out to address that one’s specific issues, without demanding that she come out. It is a delicate balance of neither denying their individuality nor encouraging their separateness. As the trauma is processed, the individuality becomes more and more of a non-issue.

On the other hand, therapy for a suicidal alter must be straight to the point. One can explain to the suicidal alter that she is angry and fighting against herself, whereas the real anger should be directed towards the abuser. It was the pain inside that led her into wanting to hurt herself. I then pointed out different things she could do to soothe and ease that pain. Critically important was to point out that she could use the anger itself as a powerful force for healing and recovery.

Empathy from the therapist goes a very long way. One can seek to motivate other helpful alters to rally to the task of facilitating the healing. Other alters may be assigned the task as co-therapists, or at least to hold the hand of the sad or suicidal alter(s) to let them know they are not alone.

While therapy has to be flexible and dynamic, it needs to be goal-oriented and task-focused. I conscientiously avoided socializing with interesting, colourful and engaging alters. Therapy is not a chit-chatting social event with alters over a cup of tea.

In this way, even with several hundreds of alters, I managed to complete therapy in 2 and half years with Ruth. It is worthwhile to note that in a follow up instigated by Ruth, she reported that she had not needed support from the mental health system since therapy over 20 years ago at this point. This is a far cry from her history prior to psychotherapy that involved 20+ hospitalizations (one of which lasted 5 months), multiple psychiatric emergency visits and ongoing and unsuccessful pharmaceutical attempts at treating her depression.

This is not to say therapy can always be completed in such a short time. There are tremendous individual variations. Nevertheless, this is a confirmation that DID therapy does not have to drag on for years and years.

5.7 Misdiagnosing DID

Posted on September 9, 2015

Psychiatric diagnoses are based on clinical features rather than laboratory tests as in organic pathologies. For example, a patient presenting with a fever might have a common cold, a kidney infection, pneumonia or many other illnesses. It is the task of the clinician to determine what disease the symptom, fever, is resulting from.

In psychiatry, it is necessary to maintain a proper index of suspicion in that same way. When a patient presents with depression, it could be that they are bipolar, it could be that they have borderline personality disorder, it could be that they are in the midst of a divorce, or perhaps they have DID. It is the job of the psychiatric clinician to be open to all of the possibilities as they commence the diagnostic investigation.

Psychiatric disorders according to DSM 5 are based on symptoms, just like fever in the case of Malaria. Treating malaria with fever lowering drugs is akin to treating the depression in DID, which are cases of trauma and dissociation, with prescriptions that do nothing to treat that underlying cause. Just as treating malaria solely by lowering the fever will not cure the malaria, treating depression with anti-depressants alone will not necessarily cure the underlying cause of the depression.

When a patient presents with depression, the answer must not always and simply be an anti-depressant. The therapist must understand, first of all, that depression may simply be a symptom, not a syndrome or disorder, and it is not always a pathology. It is often an appropriate human response to difficult situations.

In my practice, it was quite common to see patients referred to me by other psychiatrists with diagnoses of Bipolar Disorder, Borderline Personality Disorder, and Clinical Depression that have not responded to medication. For those patients, it was almost always because the diagnoses were in error. The referring psychiatrists had focused on one symptom rather than the patient’s overall circumstances.

I believe this is due to a failure in training – a failure that I was subject to for many years as a practicing psychiatrist. I had been taught that I would never see a case of DID because it was such a rare phenomenon. Most of my colleagues, all veteran psychiatrists, never had a case of DID either. Looking back over my 40 years of practicing psychiatry, I would correct that statement to say that most of my colleagues (including me at the time) had never recognized a case of DID. Indeed, many referrals I received included notations of dissociative features being displayed by the referred patient but a refusal to include dissociative disorders as a primary or even secondary diagnosis.

I still remember my encounter with a patient in an infectiously happy mood who came to see me for recurrent spells of depression. Applying the DSM 4 criterion applicable at the time, I could not have been more certain that I was encountering a case of Bipolar Disorder. No one could have convinced me otherwise. I had certainty in the diagnosis and felt greatly relieved. I knew exactly what to do, how to follow the well laid-out protocol of mood stabilizers and so on. With the diagnostic certainty, I was confident that my task was virtually accomplished.

As a result, I never even considered the possibility that what I was seeing in my office was an alter who appeared carefree and happy. A careful consideration of the patient’s life history and early incestuous abuse should have alerted me to the possibility of quite a different diagnosis. In fact, after seeing her numerous times, she disclosed that she had been abused by her father. Rather than raising my index of suspicion, as should have occurred, I simply said “Oh, that’s part of your personal history.” Although my response was in accord with the standard psychiatric practices at the time, it was an abject failure that I did not reconsider the bipolar diagnosis.

Thanks to the bravery of some of my DID patients, I can say with confidence that a more appropriate approach to the “hypomanic” part as a possible alter would have opened the door to healing. My conduct at the time, instead, confirmed for the patient that I didn’t think the abuse history was all that important in the context of the bipolar diagnosis – again this conformed to the standard practice of psychiatry at the time. This was ignorance, dangerous ignorance on my part, and a continuing regret.

I should have understood that her opening up that personal history to me was dangerous and frightening for her. It should have been met with gentle kindness and openness. It should have led me to reconsider the therapeutic approach. There existed an alter who could have connected me to the severe inner turmoil and complexity of a psyche suffering from complex PTSD. That would have further established and strengthened the therapeutic alliance. It would have enabled her healing to have proceeded in a safe, supported and appropriate way.

I believe that many therapists make the same kind of mistake as I did for the first many years as a practicing psychiatrist. One must always be aware of the possibility that by simply labeling a patient as Bipolar or Borderline may mistakenly lead the therapist toward concentrating on a pharmaceutical treatment that will only cover up the real pain of a badly traumatized individual. It is often worse than no diagnosis at all as the patient’s difficulties are both compounded and hidden by the cascading effects of psycho-active medications.

What do I suggest to the current and future generations of therapists? Pay attention to the following research statistics:

The incidence of DID is not rare. According to Lowenstein1, DID may occur at a 1% rate in the general population, which is close to that of Schizophrenia.

The prevalence rate for schizophrenia is approximately 1.1% of the population over the age of 18 (source:NIMH) or, in other words, at any one time as many as 51 million people worldwide suffer from schizophrenia. There is an almost identical rate of prevalence for DID.

Physicians and other therapists are all aware that schizophrenia is not uncommon. Let us raise our index of suspicion about DID as it is just as common, statistically speaking. Just because high functioning individuals with DID exist and are well known, such as Dr. Robert Oxnam, Herschel Walker and others, it is not a rare disorder. In my opinion, the diagnostic bias against DID is connected to the discomfort people have acknowledging the constellation of circumstances that give rise to it: early childhood abuse, dissociation, and betrayal.

5.8 Why some clinicians refuse to acknowledge DID

Posted on September 18, 2015

I previously posted on the danger of diagnosing a mental disorder based on clinical symptomatology alone. In that post, I discussed my own failure to diagnose DID in a patient because she presented what appeared to be a classic case of Bipolar Disorder. DID is rooted in early childhood abuse. It seems that many psychotherapists, and others throughout society, prefer to avoid the issue of the rampant abuse/molestation by people across all economic, religious, social and cultural boundaries. To acknowledge DID is to acknowledge the epidemic level of abuse that occurs in one’s own societal milieu.

The purpose of this post is to highlight other reasons for the failure to diagnose DID correctly and, in particular, why clinicians affirmatively choose other diagnoses over DID. During my years of practice, I received many referrals of patients that had multiple diagnoses, usually borderline personality disorder, bipolar disorder and schizo-affective disorders. In many, but not all, there were clear acknowledgments of dissociative qualities indications. Nevertheless, in the referral documentation dissociative disorders were simply not considered in the diagnoses.

I have long puzzled over the fact that there are deniers of DID even among seasoned psychotherapists. I think the crucial issue is that in the experience of many therapists, they have never encountered even one patient with DID. With that background it might be understandable why he/she would reject such a diagnosis. But that should not be the end of the inquiry.

In my experience, it is not that therapists, certainly the vast majority of those that referred patients to me, never encounter DID; rather, they simply fail or refuse to recognize it.

Human beings have a predisposition to perceive things in a certain way. In psychological terms, this is known as a perceptual set or a perceptual expectancy Numerous studies confirm that perception is highly influenced by what one expects to perceive. For example, because we are highly attuned to hearing our own name, we recognize it even in a loud and chaotic environment. In a similar way, if we believe that our key has been stolen we will fail to see that key even if it is right in front of us.

Applying that same expectancy analysis to psychotherapists and DID, if a clinician believes that DID is rare, its presentation in a patient will be missed. This happened to me on many occasions before I came to realize that DID was no less common than many other disorders. I needed to modify my diagnostic index of suspicion to include DID as a possible diagnosis as likely as bipolar, borderline personality disorder or schizo-affective disorders.

Another common reason for missing DID is that the DID is hidden behind some other presenting symptom. For example, many patients come presenting with depression. Others may be presenting with sexual or other addictions. Still others may present with difficult so-called character flaw problems like pervasive anger. Therefore, it is important to examine the problem of basing diagnoses on mere symptomology without an appropriate index of suspicion.

By way of example, malaria and typhoid are two different diseases but sometimes physicians are unable to diagnose them properly due to certain symptoms they share in common. In the initial stages, both may present with the following clinical features indistinguishable from each other: high fever, abdominal pain and lethargy. Yet they are completely different in etiology and demand. Typhoid fever is caused by a gram negative bacteria named as salmonella typhi whereas malaria is a protozoal disease due to different species of Plasmodium invading the red blood cells, transmitted via mosquito. Treatment for malaria will not help a patient with typhoid, nor will treatment for typhoid help a patient with malaria. Fortunately, some simple lab tests can distinguish between the two. However, there are no such laboratory tests to distinguish between most psychiatric disorders, such as between schizophrenia and DID.

So, again, one must not end one’s inquiry simply because one has seen what one expected. One can see bipolar disorder in mood swings, but the mood swings might also be different alters presenting themselves to the therapist. Depression may be a disorder, but it might also be an appropriate response to difficulties in life or it could be rooted in DID that is held by one or more alters.

Competent therapists need to examine their own index of suspicion. DID should be included in that index of suspicion when seeing patients with presenting symptoms that are found in common with other disorders, whether it be depression, addiction, schizo-affective disorders, bipolar or borderline personality disorder.

5.9 Alters are not the pathology

Posted on September 14, 2015

Many years ago, a fellow psychiatrist courteously wrote and explained why he disagreed with my therapeutic approach of speaking to the alters. He clearly considered this an error that would lead to “consolidating a pathology of dissociation.” He was taking DID as a disease in which the 6 year old alter speaking in a 6 year old voice was seen as the illness rather than a symptom. Effectively, he saw the alter as the pathology that needed to be eliminated. Thus, he viewed engaging in dialogue with the “voice” (the alter) as clearly an unwise practice that would only consolidate the problem rather than eliminate it.

In fact, the correct analytic approach should be to consider that the unprocessed trauma is the pathology, not the alter. The alter needs to be brought back into harmony with the other parts because they are all pieces of the same psychological system.

The treatment of DID is to engage the patient’s experience of having an alter as a separate part. Talking to an alter, acknowledging its presence, is a necessary step to draw that split-off piece of the self back in order to bring the whole system into a functioning unit instead of a group of perpetually conflicted and competing parts (alters).

This means that the therapist must be open to the fact that a 6 year old alter in the body of a 46 year old adult is not a symptom to be eliminated. Rather, it is a separated part of a wholeness to be healed, like a fragment of broken bone. With a broken bone, it is the fracture that is the pathology, not the bone fragment. And just as with a fractured bone, the broken piece that manifests as an alter is not garbage to be excised and thrown away. Treat the brokenness, which is the unprocessed trauma, don’t denigrate it.

A fractured bone can become quite strong and functional once it is healed – although never exactly identical to the bone that has never broken. It doesn’t need to be. In that same way, once a DID system is healed, it can likewise become strong and functional – although never exactly identical to a mind that has never been fractured in that way.

I learned over the course of 40 years of practicing psychiatry never to ignore or try to get rid of an alter. This is true however vicious an alter may initially present. Even the most angry and self-destructive alters can be seen as a repository of highly charged energy, worthy to be engaged and brought into harmony, not eliminated. Often they hold the keys to the knowledge of how the system protected itself under the pressure of the trauma as well as clarifying the path to healing.

All of the alters hold gems of insight. With a proper therapeutic alliance, they will show the therapist those gems without interrogation, prodding or challenge. Kindness and connection open the doors to healing. It is the task of the therapist to invite the patient through those doors. Just as setting a broken bone in its proper position will allow the fracture to heal, creating the proper invitation to the alters will allow that fracture the is DID to heal.

5.10 DID and Schizophrenia – Part 1

Posted on October 1, 2015

This is a short theoretical and philosophical discussion concerning whether or not there is any difference between DID and Schizophrenia in terms of classification, diagnosis or treatment. There are not necessarily any confirmed definite answers, but I believe there are guideposts to consider.

Schizophrenia is traditionally classified under a group of functional psychoses while DID belongs to a group of neuroses. In the traditional understanding of psychosis, the patient may lose touch with reality. In neurosis, the patient retains some acknowledgment of his illness. From this traditional perspective, Schizophrenia and DID are two entirely different kinds of mental disorders.

The term schizophrenia was conceptualized by Eugene Bleuler and further refined by Kurt Schneider (1959), a German psychiatrist whose delineation of “first rank symptoms of schizophrenia” remains widely adopted. Unfortunately, Schneider’s primary criterion for schizophrenia is the experience of “hearing voices.” Hearing voices is how those with Dissociative Identity Disorder – especially pre-diagnosis – often describe their experience of alters expressing themselves internally. It is crucial to consider as an analogue the fact that having fever and abdominal pain are symptoms common in both malaria and typhoid. In other words, just as malaria and typhoid are two completely different physical illnesses with symptoms in common, Schizophrenia and DID are two distinctly different mental disorders with symptoms in common.

The first rank symptoms of schizophrenia are summarized in the following mnemonic of ABCD:

• Auditory hallucinations: hearing voices conversing with one another, voices heard commenting on one’s actions;

• Broadcasting of thought: a form of auditory hallucination in which the patient hears his/her thoughts spoken aloud;

• Controlled thought (delusions of control);

• Delusional perception.

Patients with dissociative identity disorder may report “hearing voices” even more commonly than patients with schizophrenia. If one is trained to presume that hearing voices is always an hallucination, then most therapists will jump to the conclusion that the correct diagnosis is schizophrenia. They will mistake the auditory manifestation of internal conflict between the alters to be an auditory hallucination that comes from nowhere, points to nothing understandable in any context, and is completely disconnected from reality.

Spiegel and Loewenstein have commented on the considerable overlapping of the symptoms of the DID and Schizophrenia. But, if we follow Schneider’s diagnostic criteria with that presumption, we will have to come to the inclusion of DID within the group classification of schizophrenia. This is despite the fact that they are as different as apples and oranges in terms of classification (psychosis vs neurosis), diagnosis and treatment. In my experience in treating both schizophrenic and DID patients, the hearing of voices in DID is quite distinguishable from the auditory hallucinations of a schizophrenic. This and other mistaken applications of the ABCD as applied to DID patients are discussed in Volume Two of Engaging Multiple Personalities.

A crucial difference between the two disorders is that schizophrenia usually causes the patient to be highly impaired in his/her thinking. Schizophrenic impairment is generally quite pronounced and leaves the individual severely dysfunctional. In the case of patients with DID, some can be extremely high functioning, while others can barely get along, but most have alters that are usually quite capable of relating to the outside world. Nevertheless, they may be impaired in other ways, such as having co-morbidity of drug addiction and/or alcoholism in one or more of the alters. As a side note, this may be why many DID individuals come to the realization that they may have DID in the course of addiction treatment – whether at AA, NA or at addiction treatment facilities.

Generally, specific diagnostic criteria are followed in making a diagnosis, This is necessary for consistency and uniformity so that treatment guidelines can be applied correctly. It is a key tool for clinicians but like all tools, one must know when and how to use it. When one fails to recognize that there are many psycho-pathologies that display identical symptoms to DID on first, second or even third encounters, the clinician will have failed to use the tool of the DSM properly. This highlights the importance of maintaining a proper index of suspicion for all illnesses having common symptoms – physical and/or psychological – until one or another has been definitively excluded or confirmed.

Simply put, a patient presenting with “hearing voices” may be schizophrenic but, based on the percentage of incidence in the general population, may be equally likely to have DID. This highlights the limitations inherent in relying on one or two symptoms alone in making a diagnosis for mental disorders. One must examine the entire milieu of the presenting patient. This is completely analogous to the danger of diagnosing either malaria and typhoid based on fever and abdominal pain alone.

It is an inconsistency in logic to force a psychiatrist to choose whether to follow Schneider all the way and call DID a true schizophrenia with dissociative features, while understanding that in nosology (classification in medical science,) Schizophrenia is a form of psychosis while DID is a form of neurosis. At the moment, I am merely explaining the dilemma in psychiatry. While I have no definitive answer to that dilemma, I do have my experience of treating patients with both disorders that I relied upon in my practice.

I can say, definitively, that when the logical inconsistency is ignored, psychiatrists are more and more led down an incorrect path of treatment for individuals with DID. This has dire consequences that may take years to play out, investigate and correct. Unfortunately, for many patients, the dire consequences mean more trauma is inflicted in the attempt to heal as a result of the psycho-pharmaceutical blinders the incorrect diagnoses place on the therapists, in the patient files, and on the patient directly. Having a schizophrenic patient talk to the voices he hears will exacerbate his Schizophrenia. Having a DID patient engage in communicating with the voices of alters is part of the necessary treatment of his DID disorder. So, it is crucial to be able to distinguish the two in order to properly treat, and not harm, the patient.

5.11 DID and Schizophrenia – Part 2

Posted on October 1, 2015

Colin Ross, a pioneer and authority on DID, proposes to consider DID as a type of schizophrenia with dissociative features. He made this decision because “two thirds of people with DID meet structured interview criteria for schizophrenia or schizo-affective disorders.” (p. 131 Trauma Model Therapy, Ross and Halpern (2009).) While this approach enables one to conform to the DSM Criteria, in essence it is making a DID diagnosis more palatable to the general community of psychiatrists who are more comfortable identifying patients as schizophrenic than dissociative.

Despite my view presented in part 1 of this topic, of the logical inconsistency of merging a disorder that is classified as a neurosis (DID) with a disorder classified as a psychosis (Schizophrenia), there may be other tangible benefits to Ross’s re-definition of DID as a schizophrenia subtype. Such an inclusion of DID as a subtype of schizophrenia may prove effective for heightening awareness of DID within the psychiatric community. As such, it may be very helpful to DID patients, so long as the therapy is correctly targeted to the DID rather than the conventional (and drug treatment related) approach to schizophrenic patients. Without that refinement in treatment understanding, this may prove difficult for practitioners to truly grasp and implement. Below, I have paraphrased Ross’s explanation of this view, and as such, any error in the paraphrase and explanation is entirely my responsibility.

1. “A proposal of having a dissociative subtype of schizophrenia facilitates the technique of talking to the voices, otherwise therapists will never talk to the voices.” This is a reasoning that may have wide benefits in the treatment of DID, if it enables psychiatrists to grant themselves the permission to indeed engage directly with alters.

2. “A large number of schizophrenic or schizo-affective patients do not respond to conventional treatment using medication. The ethical burden or political barriers of talking to the voices are reduced when conventional treatment has not worked.” This is a subcategory of 1 above with an important added benefit of a specific criteria indicating the need for directly talking to the voices – that the medication that has been proven to work with schizophrenics has not worked for the patient in question.

3. “Talking to the voices often works.” As I said before, the proof is in the pudding. It seems to me the main purpose of including DID under the broad rubric of schizophrenia is to remove mainstream psychiatry’s roadblocks to the technique of direct engagement with alters. It is my hope that the more psychiatrists experience the treatment benefit of speaking directly to alters, the more they will understand the efficacy of that approach in healing the trauma that is at the root of DID.

Returning again to the ABCD of schizophrenic symptomatology, when speaking to the voice(s) respectfully, a genuine schizophrenic will likely respond with a statement that indicates a wide gap in his connection to reality while DID patients respond with contexts that make the content understandable in that specific context. The statement from the patient could be as simple as “ There is no way I can speak to you.” A true schizophrenic may give an explanation along the lines of “The clouds this morning were shaped like pumpkins so clearly I am unable to communicate with you.” No matter how you go at that kind of response, there isn’t a bridge to enable understanding. A DID patient would say something quite different that does indeed give a context that enables understanding.

This example comes from a DID patient that trusted me enough in our first meeting to tell me, unprompted, of her abuse history. Then, in a somewhat different voice, shd immediately said that she couldn’t continue therapy because there was no way she could speak to me. This made no sense as she clearly had just spoken to me on an extremely deep level revealing core trauma issues. A few moments later, when I asked why she felt she couldn’t speak to me, she gave the context: She had been abused by someone named David. Therefore, she (or one of the alters then presenting) simply could never trust me nor anyone else with that name. I immediately understood the issue and did not argue. Instead, I referred her to another therapist with a different first name.

Nevertheless, I could have mistakenly convinced myself of an ABCD analysis fairly easily. I could have presumed that the different sounding voice telling her she could never trust me was an auditory hallucination she was simply describing out loud, the non-trusting voice was broadcasting thought to the “actual” patient, the non-trusting voice was asserting control over the thoughts of the “actual” patient, and finally that the “actual” patient had the delusional perception that I was irrevocably related, solely through the link of my first name, to an abuser.

While this ABCD analysis may seem trivial or specious, I saw many such analyses in patients diagnosed as schizophrenic that were referred to me – even as their files indicated strong dissociative features. The impact on such patients of the incorrect diagnosis followed by the impact of inappropriate medications – often over long periods of time – was incredibly harmful to the patients and their families.

I included a few examples of success using the approach of speaking directly to alters in Volume One of Engaging Multiple Personalities. I also included failures when that approach was not used. Without talking to the voices, the patients who succeeded in healing would not have stood a chance of any recovery. In Volume Two of Engaging Multiple Personalities, I make recommendations to therapists concerning implementing the technique of direct engagement with alters.

Again, it is my aspiration that more therapists will at least explore directly communicating with alters in patients with DID, or suspected cases of DID, so that they will have their own experience to consider. They can then make their own assessment as to “the proof in the pudding.”

5.12 Characterizing DID: Illness or Injury?

Posted on October 19, 2015

Language has power. Whether you examine it from the point of view of ordinary communication, advertising, or threats, words and how we use them have tremendous impact – some of which is intentional and some of which isn’t. This is because the words are chosen based on the experience of the speaker/writer while the impact of the words is based on the experience of the listener/reader. For those with DID, words are tied intimately to the body language of the abuser. For people without DID, they often fail to understand the power that words have to trigger retraumatization – because they fail to understand the physicality, violence and/or threats of violence, that accompanied those words.

Given that a word may have one meaning to one person and be experienced quite differently by another, I want to look at the use of the terms illness and injury in DID. I had not thought about this before, but in a DID Facebook group, one member defined himself as injured, not ill. In considering the refusal to consider himself ill, going against most therapeutic models, he was quite clear: he had been injured. He advised me that this distinction came from a therapist at Del Amo’s National Treatment (Trauma) Center. I believe this critical distinction is both accurate and subtle.

Illness and injury are often used as synonyms. Conventionally speaking, this is not usually a big deal but while they can sometimes be used interchangeably, they are not exactly the same. An illness is something that people understand to be bacterial, viral and, at least subconsciously in almost every circumstance, potentially infectious. An injury is something that is the result of some external force exerted on a person, whether deriving from a fall, a chemical, or something done by one person to another. This is not something that people, even subconsciously, generally view as potentially infectious.

The truth is that the trauma of child abuse is not an illness that arises due to a microscopic life form such as a bacteria or virus invading one’s body. Those attack one at a cellular level. The body’s defenses rise to fight the illness, sometimes successfully on its own as in a common cold, and sometimes successfully with medicines.

Child abuse is an external force – physical, psychological or, often, both – that attacks and injures the child as an entire individual. In situations of child abuse, there is no cellular defense that can rise to fight the abuser. In the case of trauma resulting in DID, the mind’s defenses rise in the form of multiplicity to survive the external force of the abuser.

When someone breaks a child’s arm, the broken arm is classified as an injury. If the bone protrudes from the break and becomes infected, the infection would be considered an illness but the broken bone would continue to be classified as an injury. In fact, the root of the illness (the infection) was the injury. We must keep this distinction in mind when examining the etiology and resultant manifestation of DID.

Characterizing DID as an injury, rather than an illness, has the potential to benefit those with DID as it is a more accurate classification of the source of DID. Thinking of DID as an illness implies, conventionally speaking, that one needs rest, medicine and homemade chicken soup. But, no patient with DID got it because someone sneezed near them in a crowded bus, or because they ate at a restaurant where the chef didn’t wash his hands before cooking. No patient got DID because they stepped on a rusty nail. Patients manifest DID as a result of very real injuries that are unrelated to the microbial world.

This re-characterization may enable those with DID, and those without it that engage them – whether therapists, family, friends – to see them the same way one would see a person who has a broken leg. That person, perhaps with a cast, needs extra help. They need to be protected from anything or anyone banging into the broken leg intentionally (an abuser continuing the abuse) or by accident (a non-abuser unaware of interpersonal triggers). Just as a bone takes time to knit as part of the healing process, DID takes time to process the trauma as part of its healing process. Let us understand the injury so that we – patient, therapist and supporters – understand the importance of protecting both the mind and body during the course of healing.

5.13 The Body Keeps The Score

Posted on November 5, 2015

If someone breaks a leg, is burned, or is otherwise physically injured, it is easy to see. It shows right there on the surface of their body. Maybe they are wearing a cast, or have a scar, or some other clear sign of damage. But when someone has been traumatized, it is not always so easy to see. Nevertheless, it is there – locked in the body. Often you can see it in someone’s posture, in the way they flinch when a sudden noise surprises them, or in the way they try to hide from a gaze.

We all lie to ourselves and to others, usually in small ways that are not a big deal like, “I am walking out the door right now” when we are still inside getting on our shoes. But we are capable of lying in ways that are quite dangerous, to ourselves and others. Why is this important to understand when dealing with trauma? It is important because lying is conceptual, it is manipulating thoughts and strategies. While the mind can do that quite easily, the body cannot. The body doesn’t operate like that. When working with trauma, remember that words can be deceiving. Words can misdirect the attention both of the patient and the therapist. Instead, trust the body. The body doesn’t have the capacity to lie. The truth is locked into the body, and the body will confirm the words that are true.

Memories of early childhood trauma usually do not come in logical, sequential verbal narratives. This is because it is mostly implicit memory rather than explicit, demonstrative memory. Explicit memory is simply not available when abuse happens in infancy, when it happens to you as a toddler, or when you were a young child. In other words, when the abuse occurred before a child’s developmental unfolding of logic, of conceptual grasping of reality and thinking, one cannot expect to recall it as if describing last night’s television show that you watched as an adult. Abusers count on this, knowing that the child will be unable to express a logical, sequential and, for the most part, fact-checkable explanation of their pain – now or in the future.

As a psychiatrist, my primary concern was with treatment, with healing an injured patient. For both the patient and therapist, my advice is to refrain from searching for a logical, sequential, and verbal expression of the abuse experience. This is personal experiential stuff. If your body is telling you that you were abused, that is the foundational truth. Searching for confirmation of details is not nearly as important as trusting the truth held by your body.

How it happened, when and where it happened, are less relevant unless you are still in the physical orbit of the abuser. Trying to force the implicit bodily memory of abuse into an explicit narrative memory will likely cause further confusion and doubt. The body will allow access to the implicit memory when the patient feels safe enough to permit it, or when there is enough stress that the patient’s ability to suppress the implicit memory is overwhelmed.

When the implicit memory arises, don’t dissect or argue with it. It is true on its own foundational terms. Appreciate the wisdom of the body in keeping a record of the trauma, and the wisdom of the child to have survived the abuse. Allow the memory to be as it is, to be expressed as needed, but this time in the safety of the therapeutic environment. This enables the patient to start to experience the distinction between an explicit memory of the past and the present discharge of implicit memory.

Practice the “here and now” formula. In short, you are, at the time of this one breath in the therapist’s office or in your protected place at home, safe and whole. In the midst of implicit memory, breathe. You are breathing anyway, so why not pay just a bit of attention to it. In the moment of this very breath, one can access a powerful feeling of stability. Practice just experiencing that feeling without trying to extend it, manipulate it or otherwise hold on to it. Why not try to hold on to it? Because it is now the next moment, the next fresh breath, the next opportunity to experience safety.

The more often you can experience the safety of a here and now moment, the more that experience – on its own – will leak into your everyday life. Work on creating the habit of noticing your breath when any past difficult memory starts to arise, implicit or explicit. Each time you connect with that safety in the breath during the remembering, whatever happened in the past begins to weaken its present grip on you.

It is a process of very small steps. The past will not suddenly lose its power, but it will begin to do so gradually. With processing the trauma gently, slowly and safely, the past will cease being so potent. It will become more and more like an ordinary memory, with limited impact on the present.

As the trauma is processed in therapy, the body will shift just a bit, letting go a little bit. What I said to my patients was that I wanted them to leave my office feeling just a little better than when they came in. In that way, there was no pressure to have a giant breakthrough with the attendant pitfalls of loading such pressure on them. Instead, my patients would make small gains without retraumatization. It was with gratitude that I could see a patient walk out of the office a little more gently, a little more erect, and feeling a little more safe inside, than when they entered.

This is not to say that patients were on a continuously uphill trajectory of healing. Everyone’s life has ups and downs. This is true whether seen over the course of days, weeks, or months but also over the course of minutes, at times. So, each session with a patient was a new starting point – how did they come in that very day and how did they leave.

The body keeps the score, and communicates it every moment. Be open to its messages.

5.14 Guidelines for Therapists On First Encounters with a DID Alter

Posted on December 9, 2015

I am writing this because, in my psychiatric practice, I made many mistakes over the course of learning to work with DID. From the perspective of having been retired for the last 9 years, I have reviewed my patient histories so that others may learn from those mistakes. This is the core of my purpose in publishing Engaging Multiple Personalities Volumes 1 and 2.

The education and training I received as a psychiatrist gave me no clue as to how to identify and treat DID patients. In particular, there was no guidance or even discussion of how to relate to a DID alter that might appear in a client session. Because the first encounter with an alter is critical to establishing the necessary therapeutic alliance required for treatment, psychiatrists and other therapists need to be aware of the pitfalls of not being prepared for such an event as well as the benefits that can arise from proper preparation.

In general, DID is rarely diagnosed during the first many therapeutic sessions. According to various authors and studies, most DID patients are only diagnosed after cycling in and out of the mental health care system for several years. This is because, unlike other disorders, DID cannot be discovered through questioning or “digging out” information from the patient.

The foundation of therapy is understanding that the diagnostic procedure is a mutual process: The therapist is assessing the patient just as the patient is also assessing the therapist. Until the patient feels safe with the therapist, and thinks the therapist is or may possibly be trustworthy, the patient is not going to share their innermost secrets or confidential material with the therapist. The DID patient, in particular, due to amnestic barriers between the host and alters, will likely be barred from even being able to access that information. Through decades of experience interacting with people, alters are hyper-vigilant in evaluating who is likely or unlikely to understand their plight. They will not risk being ridiculed by someone unlikely to listen with empathy, although they may conduct themselves with aggression if they feel threatened by the therapist and/or therapeutic environment.

In the event that the DID system deems the therapist worthy of being shown an opening to those innermost secrets, an alter may suddenly “jump out” in the middle of a therapeutic session. In such a case, at least for me in every case in which this happened, the therapist will likely feel “a shiver up the spine” sensation. It is a somewhat indescribable experience. To see a little boy suddenly appear in the body of a 45 year old woman in a business suit, with a young boy’s posture, manner of speech, and emotional presentation, amounts to more than a simple surprise. I developed a code of behavior for myself to follow when first knowingly encountering an alter.

These are the rules I established for myself (the therapist) in such a situation. I hope they will be of benefit to others.

1. I shall remain stable in my own mind, calm and non-reactive.

2. I shall treat the alter with respect and appreciation that he/she is willing to be seen by me and to talk to me directly.

3. I shall contain my curiosity and refrain from asking for a complete personal history of the alter as that could be interpreted as an interrogation.

4. I shall just wait in a silence of empathy. The alter will likely tell me all he/she wants me to know, with minimal leading questions.

5. The ultimate guideline of decorum is that I behave as if I were being introduced to a new person at a social event: I metaphorically shake his/her hand and sincerely say, “It is nice to meet you.”

The most common mistake therapists make is based on the idea that getting rid of the alters is the prime goal of treatment. In fact, the therapist should realize that the appearance of an alter is a golden opportunity to access and clarify the confusion created by the dissociation. The alter is the main path, the highway so to speak, to access the information needed to enable the alter(s), and the system overall, to process the trauma. Because of amnestic barriers, in many cases the host is not even cognizant of the abuse history. The alters hold the keys to the mystery of what is hidden behind the compartmentalization of the alters, what is being blockaded by the amnestic barriers in the personality structure of the patient.

Avoid seeing the appearance of an alter as the pathology. The amnestic barrier of dissociation is the real pathology. The priority now is to get acquainted with that sequestered part, which is essential in the healing process. That part may hold much information about the abuse history. Be prepared that there may be an abreaction in detailing the abuse history. So, do not demand details of the trauma and do not provoke the patient to recount them. Letting the alters feel comfortable and secure enough to establish a proper therapeutic alliance is the best, quickest and safest approach to avoid retraumatization. With a proper therapeutic alliance, therapy can generate a positive cathartic experience. Without it, there is only retraumatization.

The first question to ask is not about the personal history of the presenting alter. Rather, it is to find out the age and function of this alter. The age is important so that you use language that is age appropriate to the alter. If the alter doesn’t wish to say their age, then take your cue from how they are speaking to you in terms of how you respond to them. In my experience, the alter will usually tell you whether he/she is, for example, a protector, a persecutor, or perhaps a fearful and suffering child still holding the abuse memory so that the system can function in some capacity without the constant burden of the trauma. The alters generally are quite aware of their function, and sometimes can phrase it exactly in that way.

It is critical to understand that an improper reaction on the part of the therapist can lead to disastrous results and will probably close off any future communication. The unwary therapist taken by surprise may make inappropriate demands when a 45 year old patient starts behaving like a toddler, and blurt out an admonishment like, “Don’t play games with me. Act your age. Go back and sit on your chair.” In other words, harshly denying the alter right in front of you! Such a reaction, spontaneous or otherwise, is negating the person-hood of what appears in front of you. There can be no therapeutic alliance if you deny that alter.

An alter sincerely considers him/herself a separate identity. Why not just accept the alter on his/her own terms, exactly the way you would when meeting any patient who first comes into your office? No therapist can dismissively brush off a client and expect to work with that same client in any genuine way. You are going to have to work with this alter so treat him/her respectfully. This is the first rule.

In chapter 1 of Engaging Multiple Personalities Volume 1, the suicidally-depressed woman patient in her business suit suddenly morphed into an arrogant and proud 5 year old boy, boasting about his bravery and dismissing me as an idiot. I reacted calmly, and respectfully thanked him for talking to me. I addressed him in a matter of fact way inquiring for his name and purpose in being there. The result was to establish a therapeutic alliance with that alter but also to all the other alters that were listening in and watching. It was the key to the system preparing to trust me.

Conventionally speaking, of course the boy is not a separate person. But we are not meeting the alter in a circumstance where a government ID is required for entry into our office. We are talking about meeting an alter in the context of psychotherapy. Psychiatrists should have the flexibility of mind to accept that if there has been severe ongoing early childhood trauma, DID and the consequent appearance of alters, is reasonable, logical and appropriate to the circumstances. In this context, it is ridiculous to hold on to some argument about whether or not alters truly “exist” at all!

Don’t argue with an alter, trying to convince her that she is really the host. You may be legally correct but therapeutically it will be a disaster. We need to remain focused on what works as therapeutic intervention for healing from such trauma rather than trying to force our understanding of our own experience onto the patient.

Therapeutically, the boy alter should indeed be treated as a person in need of healing in his own right. For those therapists that simply cannot wrap their head/mind around the notion of an alter, perhaps an analogy would be helpful. To refuse to treat the DID patient because the alters are doing the talking rather than the host that you think you should be speaking with is ludicrous. It would be like saying you won’t treat a mute patient because they can’t tell you how they contracted their illness. You would not feel justified in denying treatment to a mute because someone else in their household told you they were running a fever, vomiting and sobbing all night long.

Please respect the bravery of the alters to come out and communicate directly. Anything other than that will ruin the therapeutic contact. Treat the alter as if he or she were a completely separate identity and the result is that you will benefit all the others, including the massively unhappy frightened host.

The other common mistake is to be anxious to learn the details of what is hidden. In the past, therapists were so focused on getting that information, on an almost gossip level, that injections of sodium amytal, hypnosis, or outright interrogations were used. Instead, by preparing the alter by letting him/her know that you are ready to listen, and providing a milieu of reassurance and support, a cathartic experience will naturally follow. You will get all the information you need to conduct psychotherapy.

There is no need to push. A cathartic experience is only therapeutically useful if done in a secure environment making sure the patient is not re-traumatized in the process. It should be done in a gentle way, as if the therapist is holding the hand of a child revisiting the trauma scene. The role of the therapist is bearing witness to a crime often committed decades ago, guiding and comforting the survivor as he/she goes through the journey once more, but this time with the critical difference being that he/she is no longer going through it alone.

Another task the therapist has to perform is to gently remind the survivor that the “here and now” is where safety is found. This has to be repeated many times until it hits home. There are all kinds of ways to convey this message. Mostly I would point this out through the “touch sense” (the kinesthetic sensation), reminding the alter that the traumatic experience happened in a different place, at a different time, and with people that are not now in the room. Often the alter is stuck in the past, usually decades past, and feels surrounded by the enemies that were the original abusers. Replacing the palpable fear of the past with a comfortable bodily sensation of warmth and relaxation, of heaviness in the limbs and so on, is often quite helpful. The therapist is now helping the system process the PTSD symptoms. This pointing out of “the past and the present” is essential. I would use all kinds of signs and clues to point out the passage of time and the difference in location.

Trust your own experience but be prepared so that you remain stable should an alter jump out to meet you. Know that it is a sign that the patient is showing his/her trust in you. The alter is giving you, the therapist, the chance to prove that you understand and will treat the alter with respect and acceptance, that you will not laugh at him/her, and that therapy will now take a positive turn. The alter is sharing with you a deep secret. Don’t waste this golden opportunity for therapy. Do the right thing!

5.15 When Patients Present Memories of Abuse

Posted on December 29, 2015

For most people, and for many therapists encountering DID patients, the first question that comes to mind is whether or not to take the reported memories of abuse to be truth or fantasy. But, there is an even more fundamental question that is at the heart of the matter: Why is that the first question for so many people, whether they are trained as therapists or not?

In my experience, it is because most people simply don’t want to believe that another human being would do something so evil to an infant, to a toddler or to any small child. People don’t even want to believe such things when it is adults doing evil to adults. This is clearly shown by the disbelief during World War II of the initial reports of the concentration camps, of the genocide in Rwanda, and of the Cultural Revolution in China – among other horrific events. And so, people continue to suspend belief, and such horrors continue without protest, until the evidence overwhelms the bias against looking at the evil of which human beings are capable. The same is true with child abuse.

The raw unvarnished truth is that the abuse of children, physical and sexual, happens. The raw unvarnished truth is that such evil has happened in the past, is happening in the present and in all likelihood will happen in the future. The terrible consequences echo throughout the life of the child with ramifications in future generations in that family and for all of society. This is clear for anyone to see, if they are willing to actually look at the abuse and its cascading effects.

Consider the inclusion of fantasy as part of that first question arising when one hears a tale of abuse. To the abused individual, the use of the word fantasy, whether it is said out loud or is expressed in the subtext of a therapist’s body language, can only sound offensive and demeaning. But still worse, it is a confirmation of the ongoing fear ingrained by their abuser that no one will believe them that such things happened.

It usually takes months of waiting to see a specialist, after perhaps years of gathering the courage to tell a doctor one’s innermost private and excruciating history of early sexual abuse. How would you feel if you were finally able to disclose even a hint of the trauma, and then consider how you would feel if the person you are looking to for healing and support, the person in authority evaluating your trauma history, is hesitating as they consider whether or not your memory is some kind of fantasy. It is important to know that they are generally not hesitating because they think you are lying. That is a second step. They hesitate because they simply don’t believe that another human being, particularly a parent or close family friend, could or would do such a thing.

But, no therapist can establish a genuine therapeutic alliance with a patient if they cannot listen deeply to such trauma material, remaining present without judgment. This means keeping one’s own mind stable without doing an on-the-spot calculus concerning the details of the patient’s recounting of abuse. Forget the calculus, you will get the truth of the trauma far more directly and accurately by remaining fully present and grounded for the patient. In that way you can see the totality of the context, presented verbally as well as in body language. The assessment needs to be about whether or not there has been trauma is the point, not the details.

My advice to therapists is to sit still and project genuine empathy, empathy based on understanding that any individual talking about being abused has experienced trauma. As with any memory, traumatic memory does not need to be 100% accurate in its detail because it will be accurate in its context.

Look at an ordinary memory, for example my memory of my childhood bedroom. I remember it as being quite large. There is no doubt that if I were to walk into that bedroom today, it would appear to be quite small. But no one would challenge my memory of that bedroom as being fantasy. It would be taken for granted that when I was a small child (the context of the memory), I would definitely have experienced it as much larger than I would experience it as an adult.

So, when listening to a patient’s memory of trauma, particularly a flashback of trauma, don’t be stuck on proving or disproving “fantasy.” To proceed with therapy, it is enough to know that there was trauma that is reaching into the present and trapping the patient in its past.

The use of the word “fantasy” can be traced back to the very beginning of psychoanalytic theory. When Freud formulated his theory of neurosis by the end of the 19th century in Vienna, he had already encountered many patients who talked about early sexual experiences with their fathers. He privately wrote to a friend that it was a highly significant discovery, like discovering the source of the Nile. The discovery suggested, for the first time, that there was a causal link between hysteria and early childhood sexual molestation.

When Freud delivered his first lecture on this causal connection, the academic and medical authorities were quite unreceptive to this discovery. He explicitly used the terms incest, rape and gross sexual abuse in describing the experiences related to him by his patients. Krafft-Ebing, then one of the most prominent physicians of the time who was senior to Freud both in age and professional stature, described Freud as “spinning a fairy tale.”

Having felt the ice-cold response to his discovery, Freud then changed his theory and used the term “fantasy” to describe the recounted sexual experiences he heard from his patients. He then postulated that it was a kind of wishful thinking that infant girls had for their father.

There have been many explanations for this change in his view: Was it beyond his imagination to believe that these molestations in fact took place? Unlikely, as his original presentation was quite explicitly about molestation, not imagination. Did he change his words and his mind to ensure the survival of psychiatry in the harsh intransigent academic world of Heidelberg and Vienna which at that time was the center of science and medicine in the Western world, or perhaps as a way to preserve his own reputation in order to be able to continue his work? Possibly. Was he afraid to force a confrontation with leading lights of society whose daughters told him of having been abused, a confrontation he might easily lose? Quite possible given that this is something that continues to happen up to this very day, when people are terrified to confront abusers that are leading lights of today’s society.

Regardless of why he changed the theory, and whether or not he then reverted to his original view, his use of the terms “seduction” and “fantasy” enabled society and the abusers to infer participatory intent in the abused children instead of forcing an acknowledgment that the abuse was exactly what it was – rape, incest, and assault, just as he had originally characterized it.*

Later, much later, psychiatrists like Judith Hermann, in her extremely clear and invaluable book “Father-Daughter Incest” published in 1980, elaborated the truly sinister aspects of such early childhood sexual abuse experience.

Today, we should correctly appreciate Freud’s discovery of the link between hysteria and the psychological experience of a patient’s childhood. At that time, it was well beyond the imagination of others. People were then, and many still are, stuck on searching a biological root for the phenomenon which, in Freud’s time, was called hysteria. There are still psychiatrists obsessively denying the impact of early childhood abuse on adult patients as they search for a biological cause of the mental phenomenon that results, whether it be deemed hysteria, DID, PTSD or other diagnoses.

Based on my clinical experience, the odds are that Freud’s patients were indeed victims of incest, sexual assault and abuse. As the studies and news reports continue to highlight the ongoing patterns of molestation across religious, cultural and ethnic lines, it is a phenomenal disservice to patients to presume as a therapist that there is a burden of proof a patient must meet before the therapist is willing to try to establish a therapeutic alliance. The moment such a burden is placed on the patient, the ground for a therapeutic alliance is likely poisoned.

Sit still, be kind, project empathy. A patient will experience anything else as the therapist assigning himself the role of judge and jury. Remember that no memory is foolproof, no memory is incontrovertibly accurate in all details. But also remember that the heart of the matter, the energy of the memory, is accurate in context. Don’t fear acknowledging the context; sit still and listen deeply.

• “Assault on Truth” by Jeffrey Masson (1984) has some convincing alternative explanations of Freud’s views on abuse as well as the development and possible repudiation of the seduction theory.

5.16 Roots of Psychiatry: The Reality of Childhood Trauma

Posted on February 26, 2016

The first thing that often comes to mind for a patient as well as for the therapist is whether memories of early childhood abuse are truth or fantasy. Often such memories are dismissed automatically as being untrue – even by the adult who had been abused as a child. I believe that the reason for this is that people don’t want to believe that horrific abuse of a child can or has happened – to themselves or to others. This societal issue played out in the earliest history of Psychiatry. It may be helpful to examine the background for the use of the term “fantasy”in psychiatry.

Human communication presupposes that people, in general, present themselves and are taken pretty much at face value. In ordinary conversation, one generally does not assume that what one hears is fantasy. The only time one considers something spoken to be fantasy is when it is explicitly stated to be so or when the content is simply beyond the belief of the listener. The crux of childhood trauma is connected most definitely to the latter.

The use of the word fantasy in psychiatry is tied to Freud’s “seduction theory”of hysteria. But it is important and instructive to note that at the beginning of his work, prior to propounding the seduction theory, he used various words interchangeably in an 1896 paper entitled “The Aetiology of Hysteria” to describe “infantile sexual scenes”: Vergewaltigung (rape), Missbrauch (abuse), Verführung (seduction), Angriff (attack), Attentat (a French term, meaning an assault), Aggression, and Traumen (traumas).” All these words explicitly characterize sexual violence directed against the child by an adult. The infantile sex scenes were not characterized as fantasy according to that original work.

Many of Freud’s patients were suffering from what was then termed “hysteria.” Those working with DID, as patient or therapist, will recognize that the common denominator in all kinds of hysteria discussed at that time in psychiatry is dissociation. Freud’s patients were often daughters of prominent men in society, or even of his colleagues. It may or may not have been beyond his imagination to believe that the sexual misconduct of his own upper class community was factual, although clearly in “The Aetiology of Hysteria” he did not doubt that the molestation memories his patients presented were truth. Nowhere in that paper does he raise the question of the memories being fantasy.

However, having formulated his theory of neurosis at the end of the 19th century in Vienna, he had to find an explanation for the sexual memories that was acceptable to his colleagues, the Viennese circle of eminent neurologists and neuropsychiatrists who dismissed his early work.

The result was the “seduction theory.” My understanding is that Freud used the word seduction to soften the tone describing sexual abuse. Using the word seduction implied a consent by the infant, that the infant consented to have sex in the context of seduction. Even that partial blaming of the infant was too close to accusing adults of abuse, so it was rejected by his peers. Freud ended up repudiating the seduction theory, characterizing the expressed memories of his patients as wishful thinking. In other words, there had been no actual sexual conduct. The fault was in the patient, having fantasized a sexual relationship with their father.

In this way, he made the expressing of memories of early sexual experiences with their fathers acceptable in the context of therapy because there was no actual accusation of molestation. In my opinion, the case histories described genuine examples of incest, rape and gross sexual abuse – not fantasy. The explanation given by the seduction theory was that such molestation never actually happened but rather came from patients’ wishful thinking. In this explanation, Freud chose to use the word seduction and fantasy instead of the explicitly violent terms “sexual assault” and “rape” that he used in 1896.

With Freud having characterized the memories as “fantasy,” the word became embedded in the roots of psychoanalytic thinking about early childhood sexual trauma that has dominated American psychiatry up to the 1950s and beyond. Here then, in the very earliest roots of psychiatry, is the repetition of society’s historical shifting of blame onto the victim and away from the perpetrator. It is a consequence of refusing to consider even the possibility that such evil conduct can be perpetrated on a child – particularly by well-to-do educated adults that are often at the head of the family or at the pinnacle of society. The critical impact of this repetition in psychiatry is that it gave a pseudo-scientific/pseudo-medical gloss to the denial and dismissal of molestation memories.

According to my clinical experience, incest and sexual abuse within a family is not uncommon but is often ignored and disbelieved. A 1988 Finnish study, carried out on 9000 15-year-old schoolgirls, had found the prevalence of incest to be .2% with biological fathers and 3.7% with step-fathers.1 Father-daughter incest is and was not as rare as many would like to believe, even today. In my experience, the rate of incest in certain communities is staggeringly high, such as in aboriginal communities suffering the aftermath of cultural genocide.

DID as the result of early childhood trauma is not uncommon and is almost completely ignored and disbelieved. I am confident that this kind of molestation is widespread. Being part of the upper strata of society, being of any particular religion or ethnic group does not impart any immunity to this. In short, I believe Freud’s insight at the very beginning was correct. It seems far more plausible that Freud’s patients were in fact victims of incest, sexual assault, and abuse.

Returning to the use of the word seduction, it is often misunderstood as not being part and parcel of violence. It infers that there is some form of participation by the child, or that there is a quality of love, as it is conventional understood, embedded in the seduction2. This is because seduction has a soft romantic connotation for most people. However, one must not forget that it has nefarious connotations in cases of fraud or of trapping people into sexual exploitation such as trafficking for example. There can be no “consent” by an infant or child to incest or other early childhood abuse – sexual or otherwise.

Let’s not continue any such misunderstanding. Considering the use of the term “seduction” when analyzing the relationship between an adult and an infant, toddler or other young child is wrong, dangerous and a critical warning that bad things are happening. Calling something seduction, when in the context of sexual contact with a child, whether it be an infant, toddler, or beyond is violent. While it does not necessarily physically injure the child, that is often the case. In all cases of which I am aware, it most definitely injures the child’s psychosocial development – at least through the first 5 stages as categorized by Erickson. Through seeing that injury in a child, one cannot avoid the conclusion that it was the result of violence.

Molestation in the guise of seduction is violence. Do not be deceived by it being dressed up in fancy clothes, fancy language, or accompanied by gifts. Seduction of a child is molestation. It is violence, full-stop.

I have gone into some detail because Freud’s seduction theory and characterization of expressed memories of sexual abuse as wishful thinking had been embraced for a century as a fundamental truth. It is only with the more recent findings of the severity, prevalence and universality of incest and sexual abuse that it is being questioned.

To me, the rate of occurrence of incest and abuse has been – and continues to be – grossly underestimated. Taking sexual abuse as a myth to be dismissed re-traumatizes all those who have been abused. Even as society now begins to acknowledge the violence against young children, in particular young girls, one continues to see the societal prejudice against acknowledging abuse and its effects on boys.

With respect to the statistics on DID, there is reported to be a 6:1 ratio of DID diagnoses for women as compared to men. It is my clinical experience that women tend more often toward direct self-harm and thus are shepherded into the mental health system while men are more likely to engage in physical altercations with the result that they are shepherded into the criminal justice system.

The tension over the question of declaring the memories to be fantasy or reality continues. It prevents many trauma patients from receiving proper diagnoses as well as proper treatment. In my psychiatric practice, after gaining a few decades of experience, it was clear that the body doesn’t lie3. Traumatic events may not be recalled with precision. Whether this is due to the age of the individual when abused or the intensity of the circumstances is irrelevant. The real tension should be understood as the difference between explicit and implicit memory. The body stores only implicit memory when conceptual faculties are not yet developed, or when they are overwhelmed at the time the trauma is inflicted.

Events that might have seemed phantasmagorical to Freud or to a currently practicing therapist may be explicit memory or it may simply be implicit memory being stored and subsequently expressed in archetypal forms. Simply because you cannot imagine the trauma does not mean that the trauma did not happen.

You know a large boat has passed in the ocean by its wake, you don’t need to know what country the boat came from, or how many people were on it, in order to know that it passed by. For treatment, the fact that trauma has occurred is the point to work with. As a therapist, you see the wake of the trauma, you don’t need to dig out the details. The details as expressed by the patient indicate the triggers and the impact of those triggers. They are not points for cross-examination by the therapist. I encourage therapists to avoid this as well as to redirect patients from cross-examining themselves in their internal dialogues.

5.17 On Calling Out Alters

Posted on March 24, 2016

Controlling the appearance of alters, how they seem to be switched on or off in a system, is a complex matter. I do not claim to know all the ways this plays out, but I suspect there are many different considerations that govern the appearance of any particular alter. It is likely that specific triggers govern certain appearances, but the overall control is based on an internal system of vigilance that is constantly evaluating the total environment.

The appearance of any particular alter likely depends on the system’s assessment as to whether an alter should come out to fulfill a function or, alternatively, is triggered to jump out in reaction to a situation. In the absence of specific triggers, there is sometimes an alter, often called the gatekeeper or having that specific function, with almost complete power to decide who may come out and when.

During the course of therapy, the therapist may eventually learn specific ways to invite out the appearance of particular alters. But, we should not take lightly the ability to “press the button” as it were, to call out an alter for therapy. This should not be done in the absence of extreme circumstances, such as the immediate risk of serious self-injury. Instead, let the system present the alters needing therapy in its own time based on its own assessment. Sometimes the presenting will be direct, as in an alter coming out and speaking to you about their issue in a session. Sometimes it will be indirect, when one alter starts talking about the difficulties of another alter or bringing in notes another alter has written down for the therapist to read.

I give an example of a mistaken approach I once took with the hope that other therapists will not repeat this mistake. I had a patient with one severely depressed alter. At the suggestion of the patient’s very supportive husband, I wanted to bring out this alter for therapy. He said that the specific alter was triggered to come out by the touching of her hair. Because the suggestion and encouragement came from her genuinely caring husband, I thought there was an implicit consent to this by the patient. That was not a correct assumption. Looking back, the touching of her hair was likely experienced by the patient, specifically that alter, as a kind of violation. I learned from that mistake, but it was a bitter lesson.

It is far more preferable to allow the system to choose, at any particular moment during therapy, to self-initiate therapy with a specific alter. In other words, it is for the system to control the appearance of an alter in need, not the therapist. Giving that power back to the patient is consistent with good psycho-therapeutic practice for patients suffering from early trauma and dissociation. I learned later in my practice that empowering the patient is essential. It is a foundational approach in therapy for survivors of early childhood abuse.

5.18 Is Depression Just a Chemical Imbalance?

Posted on May 3, 2016

For decades, in trying to persuade patients to take drugs for depression, psychiatrists have given them the rationale that the medication was to “correct a chemical imbalance in the brain.”

What is the evidence supporting that rationale? It started many years ago, when Pfizer, manufacturer of the antidepressant Sertraline (Zoloft), wrote that “while the cause [of depression] is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription Zoloft works to correct this imbalance”.

Because Sertraline (Zoloft) was known to be a serotonin re-uptake inhibitor, it was widely assumed that it worked by increasing the serotonin level in the synapses, or gaps, between neurons. This was predicated on the further assumption that depression was related to a low level of serotonin in this synaptic space. The term chemical imbalance then became a “go to” cliché in the psycho-pharmaceutical view of psychiatry. While this is presented as an assumption, in fact some patients genuinely responded in a positive way. But, not all do.

However, in the subsequent frantic race to produce other kinds of antidepressant, it was found that Bupropion (Wellbutrin) also works in the treatment of depression. This medication works by inhibiting nor-epinephrine and dopamine re-uptake. This antidepressant is devoid of clinically significant serotonergic effects. It has no direct effect on postsynaptic receptors as does sertraline. Again, some patients genuinely responded in a positive way. But, not all do.

The general idea is that a deficiency of certain neurotransmitters (chemical messengers) at synapses between neurons interferes with the transmission of nerve impulses, causing or contributing to depression. According to this view, it remains unclear whether either one or more of the monoamine neurotransmitters are responsible for depression.

The problem with this view is the failure to acknowledge the fact that while a drug reduces particular symptoms, that does not mean the symptom is caused by a chemical problem the drug corrects. Aspirin will bring down a fever, but it is too much a jump in logic to conclude that Aspirin is correcting a chemical imbalance in the body.

Similarly, one cannot loosely use the term chemical imbalance to explain a gonorrhea infection when the infection responds to a dose of penicillin. In fact, bacterial diseases such as gonorrhea develop resistance to medications. I point out the example of gonorrhea because some strains of that STD are known to be drug resistant. It is instructive to know that such drug resistance is not labelled “treatment resistant.” When anti-depressants fail to work, the depression is deemed treatment resistant. More helpful and more accurate would be to use that same label of the depression being “drug resistant.” Just as a drug resistant STD would send the physician looking for a different treatment, when a myriad of anti-depressants fail to alleviate depression the psychiatrist needs to see that their patient is not simply a chemical soup to experiment with. There are most likely other causes of depression for that patient that playing with chemistry will not overcome.

Further evidence throwing doubt to the hypothesis of depression as simply a chemical imbalance comes from the efficacy of a newly developed antidepressant, Stablon (Tianeptine), which decreases levels of serotonin at synapses. The fact is that many depressed people simply are not helped by these serotonin re-uptake inhibitors. In a 2009 study, Michael Gitlin of the University of California, reported that one third of those treated with antidepressants do not improve. Further, he reported that a significant percentage of the balance get somewhat better but remain depressed. If a chemical imbalance is the underlying cause of depression, and antidepressants correct that chemical imbalance, all or most depressed people should get better after taking them.

Neuro-imaging studies have revealed that the amygdala, hypothalamus and anterior cingulate cortex (specific parts of the brain) are often less active in depressed people. Some areas of the prefrontal cortex also show diminished activity, whereas other regions display the opposite pattern. When someone is under recurrent stress, a hormone called cortisol is released into the bloodstream by the adrenal glands. Long-term elevated cortisol levels can harm some bodily systems. It is well known that in animals, excess cortisol reduces the volume of the hippocampus.

Smaller hippocampus volume is also associated with people with severe childhood trauma. In PTSD studies of pairs of twins (not focused on early childhood trauma), where one had been exposed to trauma and the other has not, there is a significantly smaller hippocampi in the twins with trauma exposure when compared to their twins without trauma exposure. It is noteworthy that depression is almost always present in those with severe childhood trauma and it is almost always a part of the Chronic PTSD picture.

Thus far, there has not been established a clear or direct cause-and-effect relation between brain chemistry and depression. Chemical Imbalance is just a vague term to suggest that there seems to be some chemical disturbance associated with depression, and that certain drugs are known to alleviate depression in some of these depressed patients. The explanation is speculative and the proof is far from conclusive. It is not known if the depression generated the chemistry or if the chemistry generated the depression. Depression almost certainly does not result from just one change in the brain chemistry. A focus on any one single piece of the depression puzzle—be it brain chemistry, neural networks or socio-psychological stress (for example a recent or remote past stressor) is gross simplification.

From a clinical point of view, depression as a symptom began to assume the status of a disease. It is akin to classifying a fever as a disease, rather than as a body reaction to a stressor. Internal medicine has not taken that step: We still limit ourselves to documenting fever for investigation to look for its root cause. In psychiatry, that limitation of distinguishing symptoms from disease has gradually eroded to the point where we are bending the diagnostic criteria for making diagnoses. We can now “diagnose” the illness as “Major depression” or “Bipolar affective depression.” In short, we have selected a bunch of symptoms, put them together and call it a syndrome, a disease.

The psychiatrist may be eager to find a disorder that comes with a textbook protocol of pharmaceutical remedies. In fact, to make a diagnosis of either major depression or bipolar, the symptoms have to satisfy a stringent list as laid down in DSM 5. Often anxiety and agitation may be interpreted as hyperactivity mimicking hypomania. Bipolar is easier to “treat”, as there is a standardized algorithm to follow. Once diagnosed as bipolar, the main treatment approach is pharmaceutical.

Arriving at a DSM 5 psychiatric diagnosis does not and should not make therapists feel satisfied and over-confident to the point of ignoring other complicating and contributing factors influencing the clinical features. The danger today is the false confidence a therapist has once a bipolar label is established, the entire attention is focused on an exclusively pharmaceutical approach. One then has the protocol of waiting for the medication to work, which usually takes weeks. If the medication in adequate dosages fails to work after a few weeks, should one double the dose and wait again? That is certainly one part of the protocol promoted by the pharmaceutical companies’ guidance.

If the patient starts self-destructive behavior, does it mean her depression is worse, or she is feeling hopeless. Perhaps her children are being taken away for adoption because she is considered to be an unfit mother. Would that not be a reasonable, non-chemical imbalance based cause to be depressed? I have seen numerous examples of cases where once the focus is placed on pharmaceutical treatment, it is as if all socio-psychological factors impinging on the life of the patient can be and are ignored.

We know quite little about depression on a molecular level. Given the multiple reasons for the etiology of depression, to call depression a chemical imbalance in the brain is reminiscent of the classic story in which a group of blind men each touch just one part of an elephant to learn what the animal looks like. If one man happens to have touched the tusk of an elephant, he would swear that the elephant is like a cylinder of polished hardwood while another touching the elephant’s stomach would swear it was like a wall. The catchphrase “chemical imbalance” suggests a phenomenon associated with depression. But, association does not necessarily mean causation.

We really know very little about depression as a disorder. What we do know is that in patients with depression, less than half (roughly speaking) may have their symptoms alleviated by taking an antidepressant.

I am not against the use of antidepressants in treatment. I have witnessed effective and even dramatic responses to antidepressants in some patients. However, I am totally against mechanistically calling a symptom a disease and blindly prescribing a pill for that symptom – especially when the symptom is often a normal emotional response to real life circumstances. Such a course of action can keep a person dysfunctional for years. With that mechanistic view, treatment will be fundamentally limited to finding the magical antidepressant that works, or, at best, one that produces the least harmful side-effects.

While common sense and the history of psychiatry dictates that psychotherapy should be the first line of treatment when someone displays mental health issues, in their eagerness to expedite recovery, psychiatrists starting treatment with pscho-active drugs may lead them to ignore psychological factors for depression, such as severe childhood or other trauma.

Ultimately, which patient should be prescribed drugs as a priority is a matter that should be determined by an experienced and compassionate psychiatrist. To understand the causes of depression, we have to see the entire person, rather than just looking for a chemical disorder called depression. We have to maintain a strong index of suspicion for hidden or affirmatively ignored childhood trauma. It is imperative that we therapists always look at the patient as a person, with mind, body and spirit. Only deep listening and empathy can help to bring to awareness, in both therapist and patient, those significant factors that can manifest as depression. We should not attend to just the brain chemistry in a patient with depression. Just as when a car is by the side of the road, we do not just assume that the battery has died. It may be that the driver has run out of gas or is taking a nap!

Anyone can practice medicine if all he does is to prescribe aspirin for fever, a broad spectrum antibiotic for infection, a pain-killer for pain and a steroid as an anti-inflammatory. These are standard non-specific medications for common symptoms in general practice. Such a practitioner will help some people with some illnesses that those non-specific medications can benefit. He will cause harm to virtually all others due to this lack of insight and lack of a proper index of suspicion for the many diseases that actually affect people.

Depression is a common symptom for almost all patients coming for the first time to see a psychiatrist. Prescribing an antidepressant as soon as one sees depression in patients is a cop-out that can have enormously bad consequences. Psychiatry must be on guard against the brain-washing influence of both the pharmaceutical industry and the insurance companies as the payees of the health care providers. We must not embrace “chemical imbalance in the brain” as the answer to the question of depression. Far too many working in the Mental Health field have fallen into that way of thinking. We need to wake up and re-examine our basic understanding of human beings again. The obligation to our patients is their well being. Our depressed patients are not just simply pools of chemicals that are not in balance!

5.19 Working with Traumatic Memory: Practically Speaking

Posted on May 11, 2016

In psychiatry, and in fact for all kinds of counseling, all procedures start with collecting data from the patient. Starting with the individual’s history, finding out what is happening with the patient and learning the psychological background as well as social context, one then attempts to comfort, counsel and heal. This information gathering involves asking some questions but more important is listening to the clients’, and sometimes others’, account of the current and the past situations. Often past trauma is an essential part of the history. Thus, understanding the dynamic of traumatic memory is fundamental to gathering history, just as it is fundamental to proper treatment.

All police officers, judges, counselors, therapists, clinical psychologists, and psychiatrists must at least have some basic knowledge of this dynamic. Without it, grave misunderstandings may arise. The individual’s veracity may be questioned and incorrectly denied. Injustice may be the result based on misunderstanding of the dynamic and demanding a narrative of non-declarative memory. Such a demand simply won’t work. Non-declarative traumatic memory is simply not expressed as a narrative. That doesn’t imply that it is false. It simply means that one has to understand it without the crutch of a conventionally presented storyline.

Often, some past trauma is not remembered. Past trauma is not something anyone really wants to remember, especially if remembering it means, in one’s body, that one re-experiences it.. However, eventually past trauma will resurface. Not too long ago, there was a great deal of furor debating on this topic. The question was posed as to whether or not such “recovered” memory, memories that eventually resurfaced, especially during psychotherapy, can be accepted at face value.

“Repressed memory” is a Freudian term referring to memory that has been unconsciously blocked, due to the memory being associated with a high level of stress or trauma. The theory postulates that even though the individual cannot recall the memory, it may still be affecting them consciously.

A more neutral term, “forgotten or lost memory”, is often used instead. Some studies have shown that forgotten memory can occur in victims of trauma, while others dispute it. According to some psychologists, forgotten memory can be recovered through therapy. Other psychologists argue that this is in fact rather a process through which false memories are created by blending actual memories and outside influences. According to the American Psychological Association, it is not possible to distinguish lost memories from false ones without corroborating evidence.

So, if a patient begins to remember traumatic memories during the process of therapy, how does one know if such memory is accurate or iatrogenic, meaning that the patient has been misled by the therapist into creating a false memory? In psychotherapy, recall of the traumatic past during the process of psychotherapy is commonplace. This includes “dissociative amnesia,” which is defined in the DSM as “an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.”

It is well-recognized that “Traumatic Memory” resulting from massive psychic trauma may be associated with amnesia, as well as, paradoxically, hypermnesia. Hypermnesia refers to the unusual power or enhancement of memory, typically under abnormal conditions such as trauma, hypnosis, or narcosis.

A person may be so overwhelmed by a traumatic experience that certain aspect of, or the whole experience may not be registered. For example, many former inmates of Nazi concentration camps could not remember anything of the first days of imprisonment because perception of reality was so overwhelming that it would lead to a mental chaos. (Read Krystal: Massive Psychic Trauma (1968)) At the same time, some part of the traumatic memory may be extremely vivid as if etched in the psyche. An example of this is when a rape victim may retain in great detail the pattern of the curtain behind the abuser at the time of the assault with only the haziest recollection of the appearance of the abuser.

Therapists, police officers and other professionals, unfamiliar with this paradoxical phenomenon, may question the veracity of the victim if the recall of the trauma contains both amnesia and hypermnesia. They presume that, “If the woman was beaten and raped, surely she should remember correctly the color of the car that drove the assailant away.” 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.

Fundamentally, there are two kinds of memory: the narrative (explicit memory), and the non-declarative (procedural) memory. The former is involved in the straightforward narrative of an event while the latter is involved in memory that is often unconscious, sub-conscious or simply beyond verbalization. For example, this can refer to recalling an experience such as riding a bicycle (pertaining to motor skill), an emotional response, or a reflex action.

The conversion of the raw data of experience into memory is sifted through different neurological structures such as the amygdala and the hippocampus in the brain. Memory retention is often related to the valence of the emotion associated. Moderate to high activation of the amygdala enhances the long-term potentiation of narrative memory mediated by the hippocampus, while extreme overwhelming arousal disrupts hippocampal functioning, leaving the memories to be stored as affective states or sensori-motor modalities such as somatic sensations or visual images but as not narratives.

One tends to remember something very special, such as the phone number of a person with whom one is very much infatuated. But, in the immediate aftermath of a car accident, the color of the other vehicle may not be registered in one’s narrative memory because of the psychological shock experienced at the time. This is where the therapist (or police officer), in taking a history related to extreme trauma, may find patches of amnesia. One must never jump to hasty conclusions declaring such memory as false just because it has amnestic holes in the narrative. The paradox is that due to the overwhelming arousal, what would ordinarily be stored as narrative memory is instead stored as non-declarative memory.

The above is a gross simplification of the activity of some of the neurological structures that relate to trauma and memory. Because many people are not able to understand or even recognize this complex phenomenon of the impact of trauma on memory, victims are often disbelieved. They are challenged based on their “inadequate” narrative memory of the traumatic experience. But the narrative component of traumatic memory is typically like Swiss cheese, full of holes. It is adding insult to injury to demand a survivor prove his/her case of having been abused in early childhood as a narrative, after they have finally pulled together the courage to come forward to bear witness to their abusive experience. The victim, and their non-declarative memory, are not to blame.

Practical guidelines to follow when one suspects a patient history that includes trauma:

1. Avoid obsessive digging at the past. Do not interrogate a patient before a therapeutic relationship has been established. Even after establishing such a relationship, avoid demanding details. Remember that every question telegraph’s the questioner’s bias to the patient. By the choice of words and the affect associated with the question, one’s bias is revealed in the tone of voice, in body language, etc. Limit your presentation of bias to the extent you can. It takes special effort to phrase a question – including one’s own body language – in a neutral way. Make the effort. The goal is to permit the patient to allow traumatic memories, if they do exist, to arise in their own time and in their own manner of presentation. If you do this and such memories arise, they will arise with authenticity and be far more available to healing.

2. The less interrogation, the easier to establish a therapeutic alliance. In the absence of interrogation, in a container of stable warmth, it is far more likely that trust can be rapidly established. With that trust, trauma information will be forthcoming when and as needed. Usually, it is presented by the patient without any need for prodding by the therapist.

3. It is not important to know all the details. The task of the therapist is to help patients deal with the psychological and the physiological effects of past trauma. For example, is the patient able to bring her mind and body back to the here and now, or is she stuck in the past? Successful therapy doesn’t mean the patient must learn and acknowledges all the details of the past trauma. Success is demonstrated when the patient is able to live in the present experiencing safety unencumbered by the past trauma. The patient’s ability to control the disturbance of the memory of the past, to be able to come back to enjoy the present moment of safety and peace, is the hallmark of recovery. The patient will tell you what is important to work on.

4. You are not preparing a police report. The central issue is whether the patient is able to develop some detachment and objectivity of the experience. This means that the patient no longer experiences retraumatization, no longer becoming overwhelmed and re-living the trauma when the memory arises. As a therapist, the goal is healing – not building a court case. Neither you as the therapist nor the patient needs to prove the dotting of every “i” and the crossing of every “t”.

5. Understand Traumatic Memory. Traumatic memory consists of images, sensorial and affective states, and behaviors that are invariably consistent over time. These memories are highly state-dependent and cannot be evoked at will. They are not condensed to fit social expectations. Narrative memory is social and adaptable to the needs of both the narrator and the listener. As such, it can be expanded or contracted according to social demands.

Survivors of early childhood trauma are usually left with non-declarative memories of horrific past experiences that are locked in somatic and sensorial memories. These are usually terrifying as they survivors lack a narrative memory to help conceptualize frightening visual imageries. It is common that people are unable to accept these thoughts and feelings.

Once people become conscious of the intrusive qualities of the trauma memory, they are likely to try to fill in the blanks and complete the picture. The stories that people tell about their trauma are as vulnerable to distortion as are people’s stories about anything else. As a result, trauma history may be distorted when it is subjected to misguided leading questions from the therapist. However, just because trauma history may be distortable by its lack of narrative memory or by leading questions, does not mean that trauma did not occur. Let me reiterate the point – human memories are simply not 100% accurate. We are not computers or digital cameras playing back a recording.

6. Truth and Non-Declarative Memory. With non-declarative memory, accuracy to a third party’s conceptual (narrative) understanding of “truth” is not the point. Just as the host in a DID system may simply refuse to believe the truth of the non-declarative memory, that memory is accurate in its context. As I have mentioned repeatedly, the details are not necessary to the therapy. Once the therapist has determined that trauma did occur, let the patient assess the right time to disclose an abusive history in a form and context of their choosing. This is far more likely to produce benefits in therapy as compared to an interrogation based data collection that seeks to determine “exactly” what happened. For the therapist, it is preferable to simply accept the truth that when trauma occurs, details of the traumatic experience may not be recalled in exactly accurate narrative detail.

It is more important for the therapist (and the patient) to know whether or not trauma did occur, rather than the details of who did what when and to whom. There are some specific instances where some of the details may be critical, for example when the abuser is a primary caretaker of the patient and remains in a position to further abuse the patient or others.

7. Memories Held by Alters. Joan, my patient mentioned in Chapter 1 of my book Engaging Multiple Personalities, Volume 1, came to see me complaining of visual imageries and memories of her father abusing her – even though she did not believe it had ever happened. She was afraid she was going out of her mind, that she might be locked up as a crazy person for having such thoughts. Such amnesia, which in this case included the refusal to accept that abuse had happened, is typical of abuse memories when they are being held and expressed only by an alter. The inaccessibility of such memories to the host is exactly the safety dynamic that enabled the individual to survive the abuse at the time it was happening.

The function of such an alter is to spare other parts of the personality the burden/pain of the abuse. This is an example of true dissociated memory. Despite many papers which have argued against “repressed memory,” I have seen it vividly during direct interactions with patients. People who have been traumatized as young children will almost never be able to tell you about it when they first come to see you as your patient. Information gathered through some compulsory interrogation on the first patient’s first visit must be viewed with caution.

8. Genuine Therapeutic Alliance is Key. Those who deny repressed memory claim that to do otherwise invites false positives, abuse memories being presented because the patient thinks that is what you want to hear or that you have “implanted” such memories because of your own confused issues as a therapist. In other words, you have not established a genuine therapeutic alliance and therefore the idea of repressed memories is a vehicle for mutual delusion. The real issue to be concerned with is that one runs a far greater risk of getting false negatives because the patient simply cannot access the non-declarative memories in front of a stranger – which is what you are until a genuine therapeutic alliance has been established.

This post contains paraphrased material from Bessel A. van der Kolk’s book Traumatic Stress (1996)

5.20 Should Integration Be The Goal in Therapy?

Posted on September 20, 2016

Most standard texts consider a unitary personality, meaning the integration of alters into one single personality, as the ultimate goal and measurement of therapeutic success. I beg to differ. My criterion of success was and is measured in terms of social and relational function. If a DID individual is functioning with minimal internal conflict, like a well put together orchestra or football team, that is success in therapy.

It is not helpful to demand a unitary personality as the final criterion of success. After all, a DID individual is an expert in dissociation. For those with DID, Dissociation is strongly ingrained after being used for decades as a defense mechanism against overwhelming stress at the beginning of abuse, and potentially overwhelming stress one might encounter in the future. That habitual defense pattern will reappear as soon as the post-integration DID individual faces stress in the future that is greater than the strength of the integration.

I believe and maintain that the single personality ideal is a myth. In many non-DID individuals, although there are not amnestic barriers, there are clearly different parts that emerge when needed, whether it be the office personality, the romantic personality or perhaps the competitive athletic personality. So long as there is no undue internal friction, life can carry on even more in a colorful way with multiplicity.

There are many real life examples of highly successful DID individuals who are functioning in their multiplicity as a group of alters who have come to agreement of how to live together in the spirit of cooperation and collaboration within that one body.

5.21 Should Closure Be A Goal in Therapy?

Posted on September 29, 2016

Like forgiveness, discussed in an earlier blog post, the conventional understanding of closure is not necessarily a realistic goal in therapy. In my opinion, there should not be the presumption that is required for healing.

“Closure” or “Need for Closure” (NFC), the latter being often used interchangeably with Need for Cognitive Closure (NFCC), are psychological terms that describe an individual’s desire for a firm answer to a question and an aversion toward ambiguity. The term “need” denotes a motivated tendency to seek out information.

For my DID patients, the notion of closure was generally connected to seeking some outside confirmation that the abuse indeed happened exactly as remembered. In the therapeutic approach I took, the question of confirming the details of the abuse simply weren’t all that important for therapy. It was clear that my DID patients had been terribly traumatized. It was clear that they were, in the present, subject to tremendous fear, anger and dissociation. They all had triggers they might encounter in the present that, when activated, at any given point in time would pull them back into past trauma. The point of therapy was to limit the impact of the past trauma on the present.

To focus on getting some kind of conventional outside confirmation of the details of the abuse misses the point. The details are not something to be healed. Horrible as they were, they are historical experiences. there is no magic wand or magic pill to make them undo them. They are, simply and brutally, the traumatic experiences that resulted in DID. The problem to be addressed, and the injury to be healed, is the past trauma still affecting the patient in the present. No therapy – no closure – is going to take away the fact that traumatic events occurred. What therapy can do is support healing from the traumatic event(s) and reclaiming one’s life in the present.

It is instructive that many concentration camp survivors – even those that were liberated 70 years earlier – continue to be impacted by the intensity of their experience. Consider that society in general does not discount their experiences. Indeed, they are now usually honored as survivors bearing witness to horror and holding a critical collective memory. Yet, whatever support they receive, the survivors of the Nazi concentration camps still carry their wounds. How they carry those wounds, and how it impacts their lives, may be instructive for treating survivors of child abuse – whether or not they have DID.

Those that survived the camps seemed to be able to access a critical desire – the desire to bear witness. This bearing witness can often be linked to the anger they experienced in being tortured, in being treated as if they were not even human. It is the drive to survive and bear witness that has genuine power, but it is not based on a need for closure. From a DID perspective, I would argue that this highlights the importance of the angry alter(s), who often see fighting for survival as necessary to be able to call out, at some point, the perpetrators.

Those from the camps that continue to speak out in their nineties do not appear to be concerned with anyone outside confirming whether or not their memory is true. They have the confidence that the events happened. There is documentary evidence showing that such things happened. If anything, whether it is seen as spiritual or moral, they perceive that their obligation is to warn humanity of the danger of dehumanizing one’s perception of another person. This is quite different from conventional understandings of closure.

There are a few critical points that distinguish DID patients from concentration camp survivors. First, DID patients were usually assaulted as individuals by individuals close to them – not by others from outside their immediate community. Concentration camp survivors could see that their horror was something they experienced communally – no one denied their suffering in the camp.

Second, it was after the war, usually decades after the war, that holocaust deniers attacked survivors as liars. However, this was a minority that was confronted by the majority of outside powers. It is the opposite of the experience of DID patients where denial of their abuse history begins almost from the moment of the abuse. That denial comes from the abusers, from people they try to communicate to about it, and, based on the usually overwhelming positions of power of their abusers, the abused children themselves.

Third, concentration camp victims were of all ages while most DID patients were abused at an extremely young age – before their ordinary ego structures coalesced, before they developed conceptual defenses and abilities to process their trauma experience. Most very young children brought to concentration camps were killed quickly, as they were too young to be worked to death. This was the case unless they were singled out for use in medical experiments by the horrific Dr. Mengele.

In DID treatment, if one posits the therapeutic goal as closure, then the notion of closure must be framed as something attainable. It can be likened to survival and witnessing by the concentration camp survivors but in this case it is to warn humanity of the horrific danger and consequences of child molestation and other abuse. This appears to be happening, finally, as more and more victims of child abuse become willing to talk about their trauma history.

While there is likely no “closure” for the vast majority of DID patients in terms of external confirmation of the abuse, there is the very real possibility of hope, of joy, and of liberation in reclaiming one’s life. This hope, joy and liberation is the best and genuine closure.

5.22 Resetting The Nervous System after Trauma Part 1

Posted on June 15, 2017

I have paid close attention to the insights of Peter Levine ever since his book “Waking the Tiger: Healing Trauma” was published. He pointed out that while animals face being hunted down almost on a daily basis, they are virtually immune to traumatic symptoms. With that observation in mind, we have to take a fresh look at trauma healing in human survivors.

Healing involves understanding the role in healing played by bodily sensations, especially in the kinesthetic sensation. Through heightened awareness of these sensations, trauma can be healed. Levine’s approach does not fall into the prevailing practice of over-emphasis on pharmaceuticals even though he considers the problem to be a physical and neurological one.

These are my thoughts concerning his ideas. If there is any confusion or accidental misrepresentation of his work in what I have written, the fault is entirely mine.

The task of the therapist is to help clients by offering them an “island of safety.” It doesn’t have to be a big island, even a very small one is beneficial so long as it is safe. Then, give them a tool so that they can get to that island of safety by themselves. This is accomplished by teaching them self-soothing techniques.

The “island of safety” refers to a palpable, kinesthetic sense of comfort and security; an experience of safety and of being firmly anchored. This must be clearly communicated and demonstrated to the client in therapy so that the therapist conveys the experience, not just the idea.

As survivors of past trauma know, the consequence of the trauma is something that is deeply locked in the body. It is quite different from a conventional understanding of memory, which is narrative. It is unlike the memory of recalling what happened at the ball game yesterday. It is more like a computer that is stuck in a loop and must be re-booted.

“The body keeps the score,” is a phrase emphasized and coined by another trauma specialist, Dr. Bessel van der Kolk. Basically, the body has lost the ability to feel safe. The patient has lost even the memory of what “safe” feels like. This is something that comes up often in therapy.

Therefore, the task in therapy is to help the client to “reset” his or her hyper-alert response. Post trauma, patients are “jumpy” with easily triggered nervous system reactions. With therapy, the patient can realize that it is possible to re-learn and experience safety.

How is this possible? The path to healing is to teach the client that although terrible things did happen in the past, it is possible to experience feelings of safety and joy by living in the present. To a frightened or hurt child, pain and insecurity is felt in the body without narrative memory. The best remedy is to experience the mother (usually but not always) to “physically cradle the child in her loving embrace.”

The cradling by any genuinely protective adult has power. This is how healing is possible. But, as therapists we cannot cradle a patient for reasons that, although obvious, bear repeating:

1. It is prone to leading to transgressions of the therapeutic boundary.

2. Our client is not a child, even though the emotional feeling they may express is that of a helpless child.

3. The therapist, ideally, is teaching the client “to fish” rather than being given a fish as a temporary measure. One aims to teach the client self-healing rather than dependency on the therapist or a pill.

The procedure is teaching the client to generate a sense of self-reliance, of learning what constitutes comfort, security and physical stability. The most immediate goal is to bring the client to the relatively comfortable and secure environment of the here and now through actual experience rather than through words or pharmaceutical intervention.

Words do not create bodily sensations and often run the risk of unknowing retraumatization. I have had patients whose abusers repeatedly used the word “relax” as a prelude to the abuse. For such patients, to suggest that they relax is one of the worst possible things to say. While retraumatizing words have immediate bodily sensations for the patient, they are the opposite of what you need to convey. They remember the feeling of trauma, they do not remember the feeling of safety. Therefore, mere words are often empty of meaning for patients.

There are medications that can temporarily quell emotional distress. However, there is a clear difference between the actual experience of safety and the experience of suppressing distress through medication. The actual experience is tangible safety. It nourishes the patient and undermines the power of the traumatic events. Quelling the emotional upheaval through medication that suppresses the distress is not the experience of safety. It is simply the apparent absence of upheaval. These are quite different things. I use the term “absence of upheaval” because the distress will re-appear the moment the medication’s suppressive effect weakens.

We must be careful to ensure that our work will not be re-traumatizing, so pre-therapy contracting work is important here. The therapeutic alliance is basic and fundamental to the process. It needs to be cultivated and sustained through empathy, positive regard and congruence.

5.23 Resetting the Nervous System after Trauma – Part 2

Posted on June 15, 2017

Levine suggests two very simple physical procedures. One is to ask the client to put one hand in the opposite armpit, creating a physical sensation of containment of warmth and gentle pressure, directing one’s attention to something immediate, tangible, and palpable in the body. Note that these words convey healing by simply directing the client’s attention to feeling their own kinesthetic sense (sense of touch) in their body. Note how much more immediate and real the experience is of such instruction than if a therapist says the words: “try to relax” to the client.

Levine also suggests asking the client to put one hand on their forehead, the other on the chest. Feel the sensation. Or self-tapping their whole body. In general, these techniques help the client to define their bodily boundary which helps them gain a feeling of security.

The practice of tapping, as in the Emotional Freedom Technique, or gently tapping all over the body to provide physical stimulation and redefining physical boundary, creates a gently directed attention to the body in the “here and now.” This bypasses the emptiness of words when one is dealing with traumatic memory. Words sound hollow both to the therapist and the client when the therapist speaks to a highly agitated client.

Remember, traumatized clients are on permanent high-alert having been induced to a hyperkinetic state by the traumatic memory. The only way of reaching the psyche of such a client meaningfully is through bringing their attention back to their body.

Alternatively, the therapist could gently push a large cushion against the chest of a client and ask him/her to take a slow deep breath, hold the breath, close the eyes and slowly exhale. Use only a large cushion slowly and gently. This is to ensure that there is no physical miscommunication about the intent of the pushing.

Sometimes therapists overly rely on the use of words. I once used this method on a 59 year old man. It aroused an immediate emotional response and linking to a memory without any verbal intervention on my part. If you can assist a client to get in touch inwards, you don’t have to do a lot of talking in psychotherapy!

If these kinds of exercises are done within a trusting therapeutic relationship, the client cannot escape the physical sensation of gentle pressure against the body. This bodily experience enables them to feel the comfort of relaxation. This is what is meant by grounding, or resetting the nervous system. It is teaching the client the beginnings of re-learning the experiential feelings of comfort and security. The client is induced to re-learn that long lost sensation of good feelings in the body.

I always relied heavily on the therapeutic alliance as a pre-requisite to any procedure in trauma therapy. Then, any instruction was more likely to reach the client physically, rather than merely through words. The simplest way for me to help the client to reach a state of grounding was through that kinesthetic sense, coupled with the attention to the breath.

One key point about breathing is that I never asked my clients to breathe deeply, it seemed too invasive. He/she might end up breathing in too deeply and beginning rapid hyperventilation! If the client was exhibiting agitation, breathing deeply was almost like asking them to breathe back in all the agitation they were putting out into the environment. In fact, they might mistakenly imagine them doing exactly that. The key guidance I chose to give was to ask my clients to breathe “slowly.”

If a therapist is essentially repeating to the client that they need to try to let go and relax, well it simply is not going to work. Give them a path connected to physical sensations they can generate by themselves within their body and you have set them on the course of self-healing. You have given them an understanding of the experience of feeling safe once again – an experience they likely thought would never exist for them again.

I have mentioned aspects of the healing process in various sections of my book series Engaging Multiple Personalities. I offer no apology for such repetition because the fundamentals of trauma healing, although quite simple, are very difficult to convey either to novice therapists or to clients.

We must reset the nervous system in relationship to the immediate physical experience of the living body. If we have been grasping a ball tightly, it is not so easy to simply let it go. We have to let go of our grip, muscle by muscle, making sure that we don’t begin to re-grip the ball each time we move to the next muscle. This is what we must teach clients to do with the tight grip with which they are holding their traumatic material. Small step by small step, with ongoing empathy and support, the resetting happens.

5.24 Complex PTSD – Part 1

Posted on December 13, 2017

Understanding PTSD and Complex PTSD

These days, most people are familiar with the general concept of post-traumatic stress disorder. Usually, they are familiar with it as it applies to returning veterans, and to some extent as it applies to others who have experienced overwhelming distress for which they were unprepared, like earthquake survivors.

It was not until 1980 that mental health professionals seriously acknowledged the long term impact of these kinds of trauma by coining the diagnostic label of PTSD. PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However, symptoms may not appear until several months or even years later.

PTSD is characterized by three main symptoms:

• Re-experiencing traumas through intrusive distressing recollections of the events, flashbacks, and nightmares.

• Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.

• Increased arousal such as difficulty in sleeping, difficulty in concentrating, feeling jumpy as well as being easily irritated and angered.

In 1992, Judith Herman pointed out that for the group of survivors of early child abuse, such as incest, the concept of PTSD does not adequately cover the injuries inflicted on these individuals. This inadequacy also covers cases of prolonged repetitive distress such as in cases of kidnap victims or political prisoners. Herman considers these cases as belonging to a special kind of PTSD that she proposed to call Complex-PTSD.

Complex-PTSD

Herman pointed out that these cases typically have a history of subjection to totalitarian control over a prolonged period (months to years). There are usually features of alterations in consciousness, including amnesia or hyper-amnesia related to traumatic events as well as other dissociative features.

The repetitive nature of the assaults inevitably deepens the effect of the trauma, making it an almost indelible imprint that is destined to be long-lasting. Deeper damage affects the person in the cognitive area. A common example is in the forming of almost delusional negative beliefs or expectations about oneself, others, or the world, e.g., “I am bad,” “No one can ever be trusted,” “The world is completely dangerous at all times and in all directions”.

Prognosis of Complex PTSD

Early childhood abuse is usually silent, hidden, ignored and/or being denied or dismissed, often even by professionals. They suffer alone. They are voiceless. Their primary fear is that their experiences are not believed. The implicit memory may be highly distorted or even forgotten. We have yet to develop a unified systematic approach in how to cope with such cases.

I have come across numerous instances among my peers that, despite identifying dissociative tendencies, have:

1. Expressed the attitude of “So what, the past is passed;” or “What can you do about it.”

2. Failed to pursue an analysis to determine whether or not there was early childhood trauma because the emphasis is on the constitutional factors, such as how many siblings or uncles are suffering from bipolar or alcoholism etc., and diagnoses that are treatable with medication.

3. Based diagnoses on perfunctory information gathering by simply filling in the blanks, neither yields accurate answers nor leads to correct diagnoses.

The prognosis for those patients from such colleagues is almost always bad. It is so bad that they avoided taking dissociative patients that were victims of early childhood abuse because there was no medication to prescribe. They just saw a long painful path of treatment failure and had no experience of positive outcomes. The solution for most was to note the dissociation, avoid the dissociative diagnosis and avoid working with the early childhood or other trauma material.

They often chose to diagnose such patients with Borderline Personality Disorder or Bipolar Disorder, diagnoses that would allow them to prescribe medications despite the fact that, though the failure to address the fundamental issues, the pharmacological treatment would fail. The result was often a diagnosis of treatment resistant depression – identifying the patient’s depression as the obstacle rather than their misdiagnosis and consequent erroneous treatment.

This kind of prognosis is a failure on the part of therapists. It becomes a self-fulfilling prophecy that further damages patients seeking to heal from early childhood trauma.

5.25 Complex PTSD – Part 2

Posted on December 13, 2017

Understanding the mind-body connection in Complex-PTSD

PTSD is more than a brain disease. Human beings are not simply a chemical stew that needs a little “salt here or pepper there” to fix them. Time and time again I have come across the knee-jerk reflex response of colleagues in trying to find the right medication as soon as they have identified a symptom, be it depression or anxiety. Their next thought is always trying to find the latest drug for depression or anxiety. We can do better than that. We must do better than that.

Treatment of Complex PTSD should include assessing the biological, psychological, social and spiritual aspects of a patient’s life. In PTSD, the entire body-mind system has been overwhelmed by a tremendously potent destructive force. The result is that the individual is dis-empowered. The dis-empowerment often manifests as an almost complete loss of confidence in coping with the ordinary ups and downs of life. Therefore, we must look at the entire life of the patient to proactively assist in their re-empowerment.

The neurological system of individuals with PTSD has been damaged. It has been reset to hyper-vigilance, like an alarm system that has been accidentally set to be hypersensitive. It is as if you are in a house with a motion-sensor that will not stop setting off the alarm. There are only a few small corners in which you can move without setting it off, because it is ready to go off with the blink of an eye. Imagine how difficult your life would be if you had to constantly suppress blinking your eye, and how terrifying it would be to know, as you uncontrollably blink, that alarm is about to start screaming. One shouldn’t be surprised at the speed with which flashbacks and re-traumatization occur.

Through the impact of trauma, PTSD is not only a brain (autonomic nervous system) disease. It is also a psychological disorder. Now in hyper-vigilant state, the tiniest cue will set off a huge autonomic storm. One’s bodily reactions trigger the traumatic state of mind just as the memory of trauma triggers one’s bodily reactions. Together, they mutually suppress, if not destroy, the memory of what it was like to feel secure and at peace.

The thought processes of the Complex PTSD individual are overwhelmingly preoccupied with fear, distrust and loss of confidence. The individual cannot perceive any hint that there is a pathway to even a moment of tranquility. The individual is constantly living in the past, poised to re-experience the trauma of being attacked, or facing another earthquake or explosion. The whole autonomic nervous system is now detoured toward re-traumatization.

Meanwhile, the fundamental question of what is the meaning of life and its purpose is thrown out of kilter. Questions arise with only angst, not answers, like: “Why is this happening to me?” or, in a sick family, “ Why was my sister spared when I was chosen to suffer?”

Given the depth of the impact of the trauma at the root of Complex PTSD, there is no reason to expect that a simple solution, such as deep brain stimulation, or a magical pill is going to heal such a condition. While these things may help, we need to accept that more is needed to bring about healing in the individual. We need a multi-pronged approach.

5.26 Complex PTSD – Part 3

Posted on December 13, 2017

Integrating Approaches in the Treatment of PTSD

We have not advanced much from the old days of Descartes when the scientists started thinking in terms of either the material world or the non-material world. We still think in terms of “either-or.” We are still stuck to picking either the drug or talking cure.

There is a prevailing tendency to believe that talk-therapy is too slow to work or it is ineffective. We cannot prove that it works through a double blind control study to prove its efficacy. Yet in clinical experience we have come across cases where the right kind of listening and talking can achieve wonders. For example, when the diagnosis of DID is correctly identified, effective remedy is instituted, and patient’s useless medication is discontinued, the patient achieves rapid improvement.

However, such cases are dismissively labeled “anecdotal.” They cannot be reproduced in a laboratory. Without double-blind studies paralleling pharmaceutical research, it is claimed that they do not validate any particular approach. This disparages the history of psychiatry from its inception until the advent of pharmaceutical industry control over psychiatric training programs, insurance reimbursement, and the consequent denial of the impact of the many schools of psycho-therapy from Freud, Jung, Frankl and others.

An Integrated Approach to Treating PTSD

1. In PTSD, we identify the “hyper-aroused nervous system.” In that hyper-arousal, the individual is also robbed of his confidence. Why? It is because he is not in control of his own body, which suddenly and without warning transitions into a hyper-kinetic state.

The first goal in treatment is for the body to relearn the experience of remaining in the here and now, appropriate to the reality in which it finds itself. Putting it simply, if you are running, your pulse rate should be high. If you are resting for a few minutes, your pulse rate should reflect a resting state of the body. In the PTSD experience, the pulse rate skyrockets even when the body is not running. In fact, the body starts to move in response to the messages it is being bombarded with – message of danger. These messages come all the time, when there is no danger, when the individual is simply sitting at home.

Several of my earlier blog posts discuss grounding exercises to aid the individual to achieve this goal. Surely yoga and meditation make sense as a fundamental exercise to get in touch with the here and now body. Many experienced therapists advise their clients to do these exercises of yoga and mindfulness. The “scientific” therapists, perhaps more accurately the pharmaceutically trained therapists, shy away from such advice. Why? According to conversations I have had, it is for fear of being ridiculed since there is little peer-reviewed literature to support yoga and meditation as an adjunct in the treatment of PTSD.

2. We need to open our eyes and listen with deep empathy. We should be openly waiting for our clients to tell us what their concern in life really is.

I had a patient who was given ECT and kept in hospital for months. Her diagnosis was depression, accompanied by self-mutilating behaviour. No one seemed interested or inclined to listen to her story. It was as if her life of being abused by family and neighbors was irrelevant to her mental health.

Her children were taken away to be adopted out by relatives. She was trying hard to leave her abusive husband while her church insisted that she should try to reconcile with him. No wonder her depression never got remitted despite being seen by numerous doctors. No therapist ever came close to the Complex PTSD issue, not to mention the DID diagnosis. No one seemed to show any inclination to listen for the patient to communicate these problems in her life.

In short, we need to go back to square one. Therapists need to make sure they have a firm therapeutic alliance with the survivor, before they even begin to try to understand each and every case. There is no shortcut. Making a diagnosis of depression and prescribing an antidepressant is a far cry from thoroughly assessing and understanding the individual. The ability to write a prescription has little to do with learning about the nature of the trauma that is causing the disability.

The right direction

The National Institute for the Clinical Application of Behavioral Medicine [NICABM ] offers a good program in training therapists to do trauma therapy. The works of Colin Ross, Judith Herman, B, Van de Kolk and others are very important. There are several self-help groups of DID survivors that have organized themselves that have a lot of good information and some training programs.

But, in short, the therapist who only offers pills will not get to the heart of the issue. Medication can be an important adjunct to psychotherapy, particularly in an immediate crisis. It is never a substitute. Complex PTSD can be healed through the efforts of the survivor and the support of competent therapists.

5.27 Repeating Myself Again

Posted on November 25, 2017

I find that I am repeating myself more and more, perhaps because of my encroaching senility or perhaps because misconceptions die hard. I think it is because once the general public has been brainwashed, one has to repeat the truth again and again in order to undo the misconceptions.

1. Corrective emotional experience

A genuine experience of kindness and love may convert a victim of cruelty to a kind loving person. Whether it is portrayed in fiction, such as in Les Miserable, or as displayed by Pope John Paul, long before he became Pope, carrying a concentration camp survivor on his back because she could no longer walk, kindness is an incredibly corrective experience that changes people.

For individuals with DID, it takes time for many of the alters to be convinced of the genuineness of kindness, but it can happen. Corrective emotional experiences cannot always be created elegantly with a swift and fundamental impact. But, little by little, it is like a river cutting a new path through the ground.

2. The Time Factor for Therapists

I hear all the time that mental health workers have no time. This forces them to look for quick answers. The result, coupled with the intense marketing of pharmaceuticals, is prescribing pills for “quick” solutions. Psychiatric labelling and prescribing a drug instead of listening to their client is often the order of the day, “You are depressed, take the antidepressant.” Time constraint is not a good reason for looking for a short cut. Most of those short cuts have the grave risk of other problems that will obscure the root issue of trauma. Remember, we don’t just take cough syrup if we have a chest infection.

As always, a reminder that looking for evidence of traumatic childhood abuse does not mean gathering of details like preparing a police report. The client will find their right moment to offer clues of such trauma. The therapist must remain open to recognizing those clues, rather than trying to force them out. Healing starts when the survivor feels safe enough to express their experience, is believed, and is emotionally supported. When that happens, the isolation they have felt since their early trauma starts to dissolve.

3. Leaving the Past Behind

Time and again I hear mental health workers say that traumatic childhood experience is something we should leave in the past, that it isn’t happening now, so move on to the future.

In the absence of processing the trauma, this is nonsense. I do not advocate dwelling in the past, but without healing, the past is like an old festering wound that refuses to go away. If we have an infection in our foot, we can limp along for quite awhile. We can do our best to avoid banging it against the curb when we cross the street. But when we accidentally hit the curb, we might scream in agony. We can ignore the infection for only so long until it spreads further and our whole being is under attack.

Leaving the past behind without healing the trauma is like that. We need to heal the past that is encroaching in the present.

4. Out of Sight, Out of Mind

There are many phenomena that remain out of sight and, as a result, out of mind. We ignore them thinking that they do not exist, or that they are so rare that we simply will never run into them. Kind of like a “no harm, no foul” mentality.

The problem with that view is that in normal social interactions, we are primed to avoid the sordid and the painful that is not right in our faces.

Do not dismiss the evils of refugee displacement, gender inequality, abuse of power, cruelty to children, PTSD sufferers unable to heal, marginalization of the disabled and the disenfranchised. We can only ignore them to the extent that we believe they either do not exist at all, they are not in our sphere of experience, or are very rare.

We all have difficulty handling bad news and need to keep a sense of balance in order not to be overwhelmed by negativity. At the same time, we need to recognize that there is indeed pain and suffering constantly within, around and among us. These are not rare. Recognition of this needs to be accompanied by appreciating positive aspects of our lives. In other words, remain grounded with a balanced grasp of reality.

5. Practice Kindness

We are surprised when we are informed that a respected person in a position of power gets caught for abusing over a hundred of victims under his care over a period of decades. We do not need to wonder why these cases usually take decades to get exposed. Victims are trapped so as to remain in their position by design of the abusers. Let us increase our awareness, not be surprised, and practice kindness with insight wherever we go towards ourselves and each other.

5.28 Diagnostic Labels

Posted on March 22, 2018

A reader posted a question regarding the diagnostic label that might be applied to him. Apparently, his therapist read my Volume 1 of Engaging Multiple Personalities and decided the reader was not “multiple” but has “dissociative parts”. Not surprisingly, the parts see that as a statement invalidating their existence and significance. In short, it was taken as making the parts appear to be less than real – even though, as the reader put it, “we feel pretty darn real”.

This issue may be something of interest for the general DID community and its support networks.

I am not sure why, after reading Volume 1, a therapist would take the position distinguishing dissociative parts from multiples in that way. In Volumes 1 and 2, I do distinguish between parts that have executive functioning capability and those that don’t. But that distinction is useful only to identify which parts developed in ways that encouraged executive capacity and which parts developed for holding discrete pieces of trauma. This distinction has nothing to do with whether one part is more real than any other part – or any less real than any other part. If the individual has dissociative parts that feel they are not being fully acknowledged because they are not seen as “personalities”, but just as “dissociative parts”, then I don’t see how a true therapeutic alliance can fully form between the patient and therapist. If the parts feel they are separate individual personalities, who am I or any therapist to argue that they are not sufficiently distinct and separate to be given that classification? If you feel deeply about the sense that you are a personality, just like other alters, you should be acknowledged accordingly.

Diagnostic labels are just that – labels. They are just words. They are labels used to organize ideas and facilitate communication of phenomenon or experience. They should be used to promote healing, not conflict.

For example, some readers have complained that I use the words “multiple personalities” in the title of the series. Given the change in the DSM from Multiple Personality Disorder to Dissociative Identity Disorder, why do I continue to do that? It is because many DID individuals, and certainly my patients when I was in practice, prefer the word personalities. They feel the term to be more appropriate to how they, including alters, feel. That was more important to me as a therapist than the views of many people outside the DID experience, including doctors or therapists, who vehemently object to the use of the words multiple and personality together, who insist there cannot be more than one person in one physical body. One could have a philosophical argument about that but will it help process any trauma? No.

I do not have any problem if my patients or anyone else prefer to use the word personality instead of identity. These are just words, so use any word that you feel applies to you that communicates your experience. Of course, you have to pay attention to your immediate circumstances in choosing the appropriate words for that context. There is no problem explaining that you have 7 personalities or identities while in a therapy session but there is no point in expecting an immigration officer at the border to understand that there are 7 of you as you show your passport at the border.

In therapy, the focus is to process the past trauma that keeps on intruding into the here and now. It is to facilitate internal cooperation, communication, coordination within the system. The idea is to minimize the conflict among the alters because that conflict prevents processing the trauma and prevents you from reclaiming your life.

It is important for the therapist to concentrate on helping the alters to feel respected, validated and taken seriously, as they individually appear, so that a genuine therapeutic alliance can be established. With that, an environment of healing can be created. Everything else is of minor importance. If you have a therapist you can work with, I would not waste time fighting about a diagnostic label. It is better to simply tell them what you need. If it is too difficult for someone to say out loud, then written messages from alters that can be delivered in a therapy session may be helpful.

Diagnostic labels are created by theorists trying to describe observed phenomena. In my psychiatric practice, the guiding principle was not theory but rather practicality – how to help someone process trauma. Processing trauma is not theory. It is hard work. Its success is based on the efforts of the patient and the application by the therapist of psycho-therapy with kindness, compassion and empathy.

5.29 Inviting Alters to Therapy

Posted on April 12, 2018

A reader asked about working with alters that were afraid to present themselves authentically in therapy, even though at least some of them viewed their therapist as amazing. It seems that because they were fearful and wanted to remain safe, they were prevented from presenting by what was likely a protector. At least part of the system was afraid of “losing control.” It seems that there was at least one part that “filled with rage and seems to need to come out but can’t.”

Internal conflicts like this are a common phenomenon. With any such internal conflict, it is important to respect all the participants and, with that respect, to engage their different perspectives. Using the 5% rule as an approach may give some level of comfort to the protector that things will not get out of hand. That same approach may allow for an alter that is enraged to express a small piece of anger at a time and feel safer doing it that way.

The healing journey is actually quicker and deeper when one goes small step by small step. Anything more runs the risk of retraumatization. The protector is likely aware of and concerned about the risk of potential betrayal and/or abandonment. The risk of retraumatization is something perhaps the protector is also aware of and concerned about. Both are important functions of protectors. For healing, creating a path that protects from the retraumatization while allowing for engagement is best.

The second part of the question flowed from the first. It concerned the experience of alters in despair specifically because they would leave therapy sessions feeling that they had not presented truly or as they needed to. The result is that they leave feeling worse than when they came to therapy, feeling once again that they had failed. I think that this is also not an uncommon experience.

Making sure that everyone – all of the alters whether they are presenting externally or not – is invited to listen is an important first step. This can be done at the beginning of each session. Then, at the end of each session, everyone should definitely be thanked for listening, whether they actively participated out loud or not.

It is important to acknowledge the bravery of alters that are willing to show up even if they are as yet unable to express what they need to say. By inviting them at the beginning and always thanking them at the end, you demonstrate your willingness to let them decide if and when they feel safe enough to participate directly. By doing so, you demonstrate your appreciation for their desire to heal.

The act of acknowledging alters is a powerful method of validating them because they have never been acknowledged before. Often, therapists are mistaken in thinking that alters should disappear, because they are seen as something pathological to be eliminated. This is a mistaken view.

This acknowledgment is critical. When a very hostile alter feels acknowledged and understood, something is going to shift. Sometimes it can be like defusing a bomb, and the DID system knows this. Remember, behind anger there is always deep hurt.

When one alter is able to engage in therapy, using the 5% Rule or otherwise, other alters will begin to feel the benefit. As one heals, the others will begin to feel safer and eventually participate in the healing process. It is a rippling effect, which often happens in DID therapy. When an alter presents and wishes to participate directly in therapy, they will do so if they are invited with genuine warmth and empathy.

Many alters will heal by witnessing the therapeutic process of other alters as they go through it. As one alter is healed, others may feel the therapeutic effect. Because of this, each alter does not need separate therapeutic intervention.

So be kind to everyone inside, be patient with them as you engage. With that kindness, with that patience, healing can take place.

5.30 Empathy For Therapists: Part 1

Posted on May 8, 2018

Empathy is something mental health professionals are assumed to have in abundance. We normally take for granted that anyone wishing to be a therapist would have that fundamental quality as it is the cornerstone of proper mental health assessment and treatment. But, while many therapists have sympathy, empathy is not quite so common, particularly in treating individuals with DID.

It is important to understand the differences between sympathy and empathy. Both are necessary to engender and cultivate a therapeutic alliance but they have separate functions and impacts on both therapists and patients. Sympathy is a feeling that engenders warmth in a connection while empathy is something far more active that provokes a much more personal and deeper understanding.

Sympathy is feeling compassion for the hardships that another person has encountered or is currently experiencing. It doesn’t require that you actually understand or can share in some way that person’s experience. It is more like you feel bad that they have had to experience something distressing.

Empathy is actually imagining yourself in the shoes of another person, getting a sense of what their pain might really be by imagining yourself in their circumstances. It is a deeper understanding because, to a greater or lesser extent, you are touching the feelings of another person – not just witnessing them. Sympathy is like seeing the other person’s experience from the outside whereas empathy is like touching the person’s experience from the inside.

While a therapist cannot truly experience the early childhood abuse of their patient, the therapist can seek to truly imagine themselves in the circumstances of their patient at the time of the original traumas. One has to consider as deeply as possible what the terror and pain was for the patient. To do this, you cannot imagine yourself now, as an adult, but rather imagine being a small child under attack by an abuser who is 10 times your size and controls every aspect of your being. Imagine that attacker threatening you or your siblings if you were to say anything about the abuse. Imagine that the attacker is the person who is supposed to be caring for you, the person everyone in the outside world assumes is protecting you. Imagining yourself like that, having only a small child’s limited verbal and physical development, and in that set of circumstances, is one way to generate empathy, to appreciate the intensity of the traumatic experience of a patient.

Doing this on an ongoing basis is a way to cultivate direct empathy for the patient. It is critical to being able to develop the capacity to communicate safety and understanding to the patient in the present. It is this capacity that enables the patient to begin to trust the therapeutic alliance that is so necessary for effective treatment.

In practice, empathy involves sympathy and compassion. So, it is important to enhance those qualities as well. It is not possible to have true empathy for someone injured in a car accident without feeling sympathetic towards their pain as well as feeling the desire to lend a helping hand. Many people, therapists and otherwise, can relate to car accidents and injuries that result from them.

Not so many people, therapists and otherwise, can relate to the circumstances that result in DID – which are much more terrifying. It is the terrifying nature of the abuse experience, happening in early childhood, that sometimes keeps therapists from being willing to fully empathize with their patients. For therapists, one has to be careful with these kinds of empathy exercises because there is a risk of vicarious trauma. I have discussed this further in Volume 2 of Engaging Multiple Personalities as I believe it is a real issue therapists must deal with in their own lives.

Remember that while empathy is the ability to understand another individual’s experience by putting oneself into the other’s place, the therapist must retain their own objectivity. Therapists must be introspective and assess their own reactions to what their patient may have survived. This includes being aware of the therapist’s own fears of vicarious trauma and perhaps fears as to how they themselves might have reacted had they been subjected to that abuse.

As therapists, empathy is perhaps the most crucial quality needed in the establishment of rapport, of a therapeutic alliance. Deep empathy helps our patients to be open to experiencing the therapeutic milieu as safe, as trust-worthy and as having integrity. This is the prerequisite for effective helping relationships, enabling the patients to share their innermost concerns with their therapist to begin and continue in the process of healing.

5.31 Empathy For Therapists: Part 2

Posted on May 8, 2018

The important role of empathy in a therapeutic alliance is seldom emphasized in training, particularly as the treatment focus has moved toward pharmaceutical intervention. Perhaps some teachers of psychotherapy feel it is self-evident and therefore there is no need to elaborate. However, in practice, this deficiency is often evident. It shows up immediately when there is the mistaken view that information can be gathered without paying attention to the unconscious currents displayed in how the patient presents during the initial interview, the initial contact where the therapist is gathering background data. This continues if there is the further mistaken view that therapy can be conducted in a detached, apparently scientific way, as if that appearance is, in itself, sufficient.

Novice therapists, particularly those whose training has focused on psycho-pharmaceuticals, sometimes are under the false impression that merely following a checklist will result in competent therapeutic intervention and guidance. This is foolish. To think that one can expect genuine healing of depression from merely a prescription of a drug, without awareness of the patient’s personal milieu and social background, the past and present contexts of their life, is both ludicrous and dangerous.

In the case of a cold or “too busy to listen” attitude of the therapist, relevant information is often not communicated or, if it is communicated, it fails to be identified as important. Results of intake assessment interviews can be biased if they follow a pattern of questions and answers according to what is solely the interviewer’s definition of essential data. A checklist style of interview presumes that one will end up with a complete and accurate sheet of information if only one asks the right questions.

Nothing is farther from the truth. That mode of interrogation may yield many false positive answers as well as many false negative answers. When there is a lack in empathy, communication often becomes meaningless. Novice therapists may miss the critical context of a response by becoming diverted over some minor detail. A simple and unfortunately accurate example is that missing a clue to early childhood sexual abuse is a mistake of vital significance in an assessment.

Empathy directs the therapist in the how, when and what to say in the history taking. The sensitive therapist will know when to keep silent, when to ask follow-up questions, and what to ask while remaining always tuned in to the emotional tone of the communication. This means that each and every intake assessment will be different, based on the presentation of the patient.

In other words, the therapist becomes sensitive to the voice of the individual’s unconscious. Conscious data and words are seen as only part of the picture. True reliable and meaningful data of the interview are obtained only in a positive therapeutic relationship. The foundation of that lies in the therapist’s empathic understanding. This highlights the fact that there is no clear line of demarcation between when an assessment ends and therapy begins.

Never forget that the patient is assessing the therapist during the entire assessment event. A patient that doesn’t see empathy from the therapist is not going to trust that therapist enough to make the assessment accurate. Further, without empathy, there is a very real risk that the interviewee will not return to become a patient due to that lack of trust. In other words, an improperly conducted assessment, without empathy, is already heading to a therapeutic failure.

Personally, I suspect empathy can be nurtured and developed in most individuals. But, there is a prevailing tendency to denigrate the importance of empathy, because it is not seen as true science. According to Carl Rogers (1977), three attributes of the therapist form the core part of the therapeutic relationship – congruence, unconditional positive regard and accurate empathic understanding. These are the only tools the therapist possesses, just as indispensable to the therapist as scalpels, anesthesia and the asepsis are to the surgeon.

Today, the individuals who are overly focused on psycho-pharmaceutical approaches may forget these critical attributes. In practice, some professionals are exclusively focused on accurate record-keeping Accurate record-keeping is extremely important for therapy, but is not so helpful if it is focused on primarily for the sake of practicing defensive psychiatry, the fear of litigation. A therapist with perfect record-keeping may have done everything in a legally impeccable way – always prescribing in accord with the manufacturers’ recommendations – but without empathy may be unable to successfully treat their patients.

In the absence of a warm “ready to listen” clinical approach, case after case can easily get misdiagnosed. How can that happen to good therapists? It can happen quite easily when therapists are exhausted and overwhelmed by their caseload. When the caseload becomes too much, those who only pay lip service to genuine psychotherapy will limit their success in helping to those who will respond to antidepressants. The very real problem with this then is that the carpenter whose only tool is a hammer will see everything like a nail to strike.

How often do psychiatrists go home to their double martini to relieve the distress caused by vicarious trauma? The burned-out therapist often unwittingly chooses turning off empathy as a way of protecting themselves from the emotional cost of providing therapy. The fact is that everyone wants to avoid pain, even if the pain belongs to the other person. However, therapists do not have that choice if they wish to truly benefit their patients.

Empathy requires the ability to handle psychological conflicts, including that of the therapist. It is much easier to turn off empathy and do one’s work mechanically, than to listen with empathy and feel the pain of the other person. But, the penalty for that is doing bad or useless psychiatry. Therapists need to protect themselves by caring for their own state of mind. In that way, they can expand their ability to care for their patients.

5.32 On Mapping Systems

Posted on June 27, 2018

With respect to mapping one’s DID system, if you find it beneficial, then by all means do so. In my psychiatric practice I neither encouraged nor discouraged my patients to map their systems.

With my patients, it was always important to return to the fundamental point of treatment of DID, which is to allow the system to process trauma. In my experience, this happens through engaging presenting alters in a genuine, empathic and trustworthy manner. Having a schematic of their systems was not necessary to do that.

Again, based only on the experience I had with my DID patients, mapping systems was not necessary to an efficient or focused therapeutic alliance. The problem is not particularly the mapping but rather that therapists who encourage mapping systems may infer, or sometimes outright claim, that you have to understand each and every part of the system before you can heal. Certainly, for systems with massive multiplicity, this runs the risk of turning therapy into a never-ending marathon.

Mapping also suggests that therapists need to have some detailed knowledge of the individual alters, almost like requiring a census of “who is who” including how they are grouped or related. Mistaking meticulousness for clarity, a therapist can be lured or distracted into trying to provide individual psychotherapy of each and every alter rather than simply engaging with alters as they present. In the case of Ruth, described in Chapter 5 in Volume 1 of Engaging Multiple Personalities, some alters’ problems were taken care of as a by-product of other alters who engaged with me as well as by other alters who acted as co-therapists or “preachers” rather than by me as the psychiatrist.

Alters functioning as both co-therapists and preachers made perfect sense in Ruth’s context as she had decided the way to solve her problem was to convert the “evil” non-believer alters into believers (of Christianity.) As her therapist, my task was to maintain my neutrality so as to enable the therapeutic alliance to be extended to all alters, whether they were presenting as non-believers or otherwise. This individual choice by Ruth was a very positive decision in her healing journey. And, as always, I was careful to not interfere in the system as to religious or other matters unless specifically invited to do so.

Ruth had about 100 known alters when she saw me, and continued to present many, many more over time. It was instructive to see how they often had quite separate handwriting styles that remained consistent throughout and then long after therapy had ended. Years later she told me she had hundreds of alters. I was never sure if the number had grown or that she had become more comfortable in recognizing their presence. If her healing was dependent on mapping an ever-expanding system, she never would have healed to the point of going beyond the need for ongoing therapy. The fact is that after a relatively short time in therapy, for all practical purposes, her self-harming activity ceased. She was able to live independently, care for her children once again, and make a fulfilling life for herself which continues to this day, some 20 years later.

Mapping is sometimes also used to encourage the idea that integration is the appropriate goal in DID therapy. It is as if a DID system is really like humpty-dumpty and mapping would allow the therapist and patient to find all the pieces so as to glue them all back together. Readers of my books and this blog already know that I don’t believe that integration is or should be the goal of therapy. Why? Because under stress, the integrated personality will again split both out of habit and the need to protect itself from danger. In my opinion, it is far better and safer to focus on healing, on eliminating the intrusion of the past into the present while training to remain vigilant rather than hyper-vigilant. If integration takes place in whole or in part, that is fine. If not, that is fine too.

The goal is to heal from the trauma. To claim that healing from the trauma requires mapping (or integration) is a false leap of logic. The point is to eliminate the power of the past to re-traumatize you in the present. That is not based on mapping or integration. It is based on engaging alters so as to allow them to process the trauma in which they are trapped, that they are repeatedly playing out, and that they likely continue to dissociate around.

My further concern is that focusing on mapping and/or integration runs the risk of driving some alters into resisting a genuine therapeutic alliance. This can undermine another goal of helping the alters function as a team with cooperation and finely tuned coordination. It is incredibly beneficial to shift from alters as a group of mutually antagonistic individual parts to parts working harmoniously together. So long as they are not in conflict, they can have a peaceful co-existence. Otherwise, time loss, competing for time out, or even self-harm, will continue to cause tremendous stress.

Here are some simple therapeutic guidelines:

1. Symptoms can usually be traced to alters getting triggered by repeated intrusion of past trauma into the present. These are flash-backs which turn the patient’s life upside down again and again – just like the original repeated early childhood traumas. So, the first goal is to stabilize the situation, to do a kind of trouble-shooting based on what alters are presenting to the therapist. It is PTSD treatment for the early childhood trauma. Essentially, it is figuring out what to do therapeutically on a kitchen sink everyday level.

2. Once activated, alters assert their right to be, to exist, to communicate. They can take over and cause havoc in the ordinary life of the DID individual. For example, chunks of time loss can occur which are very disconcerting and often very frightening for the host. At the same time, the alters who take over during those periods of time-loss for the host hold critical keys to healing. The immediate goal in treatment is directed towards quickly negotiating some kind of cooperation among the alters. It is focusing on turning the chaotic conflicted group into a disciplined team-like group with the common goal of healing. That is the ideal. While it is far more easily said than done, that is the target.

3. Engage whatever alters present and work with them. Remember that all of the alters are around when you speak with one, and make sure you formally invite them to participate by listening, by watching and by speaking when they so wish. Many alters can heal as they touch in or simply follow a more principal alter’s therapeutic journey. They do not always need to be called out or to be otherwise addressed directly. In fact, many just feel safer watching and listening. A corollary to this is that being mapped can be frightening to them. It might be seen as telling them they need to stop hiding when they are still not feeling safe enough to be identified. And frightening an alter can make them potentially uncertain about the therapist’s motives. That uncertainty can be a recipe for therapeutic disaster.

In my experience, the most important therapeutic tool is deep respectful listening. With that as the ground, inviting all alters to listen in, mapped or not, addressing their concerns and understanding them in their context becomes possible. Other tools I used were stillness on the part of the therapist, working with the practice of one safe breath at a time to connect them to the safety of each present moment, self-soothing techniques, grounding techniques and the 5% rule. Medication, if used as an adjunct to psychotherapy rather than the principal therapeutic intervention, can have clear benefits to support the patient.

5.33 Considering the Use of Drugs in DID Treatment – Part 1

Posted on November 7, 2018

This is the first of a series of posts discussing pharmaceuticals and DID treatment. The purpose is to encourage those with DID to avoid psychiatrists that have already made any kind of diagnosis before they have established any safe rapport with you. Hopefully, it will also provide some clarification in the somewhat muddy field of psycho-active pharmacology and its place in treatment of mental health issues.

I am not against the use of all psychiatric medications. I am very grateful for what modern pharmaceutical science has achieved in relieving suffering, including medication for mental health issues. But I do not believe we will ever solve all mental health problems with pills alone.

My general advice to dissociative individuals, is not to blindly go along with pills alone. Medication alone, without actual psychotherapy, won’t address underlying trauma. Pills may temporarily put out the surface fire so to speak, the symptoms, but they don’t put out the embers burning underneath, which is the unprocessed trauma. Without a doubt, the trauma and the symptoms will reappear so long as the trauma itself is not treated.

If your mental health professional recommends taking an antidepressant, set agreed-upon boundaries for tracking its impact. For example, you might agree that it is being used tentatively. That way you can get a sense of what happens as a result and whether or not it is beneficial. It may indeed help you and often does function as a temporary fix. If it is helpful, use the stability that results so as to take the necessary steps in psycho-therapy to process the trauma. But, don’t accept it as the exclusive approach for your psychiatric problem.

Instead, you have the right, and the responsibility to yourself – including all parts of any DID system, to assess your therapist. A therapist should be interested in you as a person. A chemical cannot express an interest in you as a person.

Assessing your therapist is the first step toward establishing a genuine therapeutic alliance with that therapist. It is that therapeutic alliance that enables your therapist to help and guide you in processing trauma. You can make a therapeutic alliance with a person, you cannot make a therapeutic alliance with a drug.

5.34 Considering the Use of Drugs in DID Treatment: Part 2 – Depression and Antidepressants

Posted on November 14, 2018

We often find these 2 words, depression and antidepressants, spoken in the same breath. Why is this a problem? Because always coupling them together erroneously implies that depression is a disease and antidepressants are the cure. It is dangerous to see them together so often because they begin to appear to be naturally identified as a pathology and its treatment.

Depression is not necessarily a pathology. It can also refer to a very ordinary state of mind triggered by some kind of loss, whether it be material or emotional. Depression is often part of the ordinary ups and downs of life.

Depression is a term used when a patient expresses particular feelings. It can be used for a psychiatrist’s observation in referring to the inner world of the patient. It is also the term used for a mental illness, a pathological disorder which is a clinical state.

It is easy for us to become sloppy with words. We use the same words in different circumstances without necessarily clarifying the different nuances we mean to communicate. We lump words together in ways that blur their meanings. These result in false logics that can do a great deal of harm. It has affected many people and created much suffering for patients.

In a casual conversation recently, a well-established psychiatrist shared the sad news of a mutual friend who lost a family member through suicide. He then commented that 1) young people today do indeed tragically commit suicide, and 2) they are notoriously resistant to taking antidepressants.

I was shocked. Why did he immediately associate the suicide to depression that would respond to drug treatment in such a linear way? The thought arose in my mind that the troubled young man perhaps might have been helped if he had someone to speak with at that difficult moment in his life, someone that would listen to him with understanding and empathy.

Medication would certainly not be the first thought that comes to my mind in such circumstances. To know a person is feeling badly and to then help him requires more than prescribing a pill. It is an inappropriate leap in logic to so completely associate prevention of suicide with a pill. Surely some mental health professionals are missing the point, the basic importance of listening deeply and always being kind.

5.35 Considering the Use of Drugs in DID Treatment: Part 3 – The Widespread Prescribing of Antidepressants

Posted on November 21, 2018

According to Paul W. Andrews, an assistant professor in the Department of Psychology, Neuroscience & Behavior at McMaster University in Ontario, Canada:

Antidepressant medication is the most commonly prescribed treatment for people with depression. They are also commonly prescribed for other conditions, including bipolar depression, post-traumatic stress disorder, obsessive-compulsive disorder, chronic pain syndromes, substance abuse and anxiety and eating disorders. According to a 2011 report released by the US Centers for Disease Control and Prevention, about one out of every ten people (11%) over the age of 12 in the US is on antidepressant medications (italics added). Between 2005 and 2008, antidepressants were the third most common type of prescription drug taken by people of all ages. They were the most frequently used medication by people between the ages of 18 and 44. In other words, millions of people are prescribed antidepressants and are affected by them each year.

This information is in keeping with most of the statistics I have read, which show that the percentage of adults using antidepressants in developed countries is extraordinary. It is alarmingly high to most everyone – except for the companies that manufacture and profit from them. In short, this is a major alert. We need to re-think the rampant use of these drugs.

The narrative used to support this widespread use is simple: Suicide is the result of depression and depression is a disorder amenable to drug treatment. It is a simple but quite muddy thinking that is pushed out to both the medical and general population. It comes from misinformation coupled with aggressive advertising by drug companies to the public as well as professionals. They advertise directly to the public, and promote it through continuing medical education events for professionals. All of this is paid for and promoted by the very companies profiting from the sales. They tell the public to rely on the doctors, and they tell the doctors to rely on the pharmaceutical company sponsored literature along with other information that is not subject to outside or peer review.

Here are a few points to consider:

1. Suicide attempts do not necessarily result solely from depression.

For some time, it has been noted as a potential side effect that some antidepressants actually lead consumers to suicidal behavior. The term “suicidality” has been brought into somewhat common use. The U.S. Food and Drug Administration (FDA) proposed that makers of all antidepressant medications update the existing black box warning on their products’ labeling to include warnings about increased risks of suicidality, suicidal thinking and behavior, in young adults ages 18 to 24 during the initial treatment. Initial treatment generally refers to the first one to two months of medication usage. The first question I have with this warning is whether the label is primarily for prospective litigation defense rather than for any other patient centered reason.

Suicide is a complex behavior that cannot be reduced to a pseudo-scientific term like suicidality. Not all depression leads to suicidal ideation. I believe suicidal behavior is a form of anger turned inwards. I have numerous examples of patients who harbored internalized rage. By turning and maintaining that intense anger inwards, the need to express that rage was translated into suicidal behavior.

Once, a suicidal patient was referred to me who was taking an overdose of drugs every other day. She would end up in the Hospital Emergency ward for weeks on end. Finally, some of the nurses in the ER suggested sending her to me because what her then-therapists were trying was obviously not working.

I saw her a few times. She told me that she was extremely angry at one of my colleagues, a psychiatrist who had a responsible position in the hospital. She was boiling in anger but had no way to complain about his conduct. Just listening to her and acknowledging her grievances was ventilated that smoldering anger.

The ritual of repeated hospital visits was her way of expressing her anger. The simple act of listening and acknowledging her with empathy abruptly ended her repeated “suicidal overdoses.” Someone with a psychiatry degree, me, bothered to listen to her. Listening and acknowledging her was all that was needed to change her behavior. She stopped coming to see me after a few sessions, and abruptly ended her pattern of overdoses and visits to the ER.

I was later asked what I had done to stop her suicidal behavior. I hadn’t done much other than recognizing that her suicidal behavior was simply her way of protest. It was how she was trying to tell the world how angry she felt being trapped in that authority/helpless victim struggle with a perceived authoritarian psychiatrist with degrees and status. She was a single woman in her 50s feeling powerless. I was confident about the importance of listening and acknowledging her because 2 other patients had already complained to me about that psychiatrist’s abrasive manner in their own encounters with him.

This was an example of a patient who perceived that their therapist was not interested in listening to her innermost concerns. Immediately, such a patient loses his/her faith in the therapeutic relationship. If the doctor’s primary goal is choosing a pill as the mainstay of treatment, that is a direct message to the patient. That direct message is not one of empathy or compassion. The patient may and will likely feel rejected, ignored, helpless, and hopeless. Anger should be an expected response. And anger will often be redirected inward or outward.

If the patient loses hope, suicide is often seen both as a way out and a statement of protest. It is a red herring to coin a new word “suicidality”, as if that is a reasonable scientific risk of chemical side effects. It is as deceptive as implying that depressed patients will most likely have their depression alleviated with magic chemicals labeled “antidepressant” and that there is a mix of chemicals/dosages that will make the problem disappear.

2. Antidepressant use is not an accurate reflection of the prevalence of depression.

The popularity of antidepressants in a given country is the result of a complicated mix of depression rates, stigma, wealth, health coverage, the degree of aggressive sales tactics of the pharmaceutical industry, the availability of treatment. It is also tied to the biological bias of the therapists toward chemical intervention rather than psychotherapy – most of whom are trained and marketed to by the pharmaceutical sales representatives.

Again, I want to be completely clear that I am not against the appropriate use of antidepressants as an adjunct to psychotherapy. I have done exactly that with some of my patients. However, the mind is not simply a box of neural circuitry where wires can cross and be uncrossed, where chemical switches can simply be toggled on or off. We must not forget our humanity. Do not ignore its powerful effect in helping to transcend despair. We must not forget the power of empathy, of compassion, and of hope in healing and recovery.

5.36 Considering the Use of Drugs in DID Treatment: Part 4 – Understanding the Clinical Presentation

Posted on November 30, 2018

3. When a patient has made repeated suicide attempts, that patient is often labeled with the diagnosis of depression as part of a Bipolar or DID diagnosis. As we have been discussing, the correct diagnosis is critical as there are medication protocols for treating bipolar whereas there are no medication protocols for treating DID.

Bipolar Affective Disorder and DID are diagnoses based solely on their clinical presentation. Unlike malaria, they cannot be confirmed in a laboratory. In the past, before microscopes, malaria was also diagnosed by its clinical presentation, which is a specific fever pattern. But now, it is diagnosed using a microscope that enables the parasite to be seen in a blood smear.

There are no laboratory tests for these psychiatric disorders. The clinical presentation alone is used to make a diagnosis of DID or Bipolar Affective Disorder. And the evaluation of clinical presentations is subjective. It is based on an interpretation of what is behind the behavior, of what is causing it. There is a risk of the clinician’s bias in that interpretation. If bias drives the decision, that can compound the risk of mistaking one diagnosis for another, perhaps correct one.

This is more common than is generally acknowledged because the same or similar clinical presentation can be seen as quite different illnesses. For example, one psychiatrist may identify something as a mood swing and decide this is a bipolar patient. Another psychiatrist might identify it instead as a dissociative event where a different alter is presenting.

Those who have difficulty in accepting the phenomenon of dissociation often choose the diagnosis of a Bipolar disorder to fit their patients into a pigeon hole with which they, the psychiatrists, are comfortable. These disorders often include depression and instability in mood states. With the identification of a behavior as a symptom, the correct diagnosis is critical because treatment is quite different for each of these disorders. A critical distinction in the diagnoses is that identifying the behavior as a symptom of bipolar legitimizes the use of drugs. This is because there are drugs approved for use in treating bipolar disorders while there is no drug approved for use in treating DID.

We do know that diagnoses having an approved drug for treatment mean short interviews with patients that are less emotionally taxing for the therapist. This means that there is a greatly diminished risk of vicarious trauma for the psychiatrist to go along with the convenience of a prescription based treatment rather than psychotherapy.

Despite the many papers published on brain amine metabolism and depression, we do not know exactly how these are truly related. Nevertheless, using drugs as the treatment means that instead of putting out the energy of empathy, and deeply listening to the patient, there is just the checklist of questions to ask. The questions are all versions of “are you feeling better?”

The answers are then coupled with trying different kinds of antidepressants, dosages and combinations. A diagnosis that has an approved drug treatment guides the psychiatrist to focus on the relatively simple task of choosing the right pill rather than on psychological and social issues. But if that diagnosis is incorrect, the resulting treatment plan will not address the problem. It will cause more suffering to the patient and often further mask the correct diagnosis.

So, the correct diagnosis is critical.

Evaluating clinical presentations means that the symptoms and signs are documented by selecting and interpreting those presentations. The problem, to give one example, is that a psychiatrist who is biased towards a bipolar diagnosis will see a behavior as hypomania. The result is that he will give a patient the latest mood stabilizer as the first line treatment. If that psychiatrist ignores indications of early childhood trauma or even remaining open to that possibility, he will simply not identify the behavior for what it most likely is – dissociation related to flashbacks of that early childhood trauma.

For that psychiatrist, a diagnosis of bipolar affective disorder and the use of a mood stabilizer will appear to be a sound clinical practice. The doctor and the drug manufacturer are protected legally from claims of negligence. It is the essential litigation insurance. It is difficult years later to prove that the doctor was wrong.

Identifying severe agitation or panic in a patient with a history of abuse as hypomania rather than recognizing it as an episode of flashback agitation is a mistake with real and difficult consequences. Flashbacks are not a feature of hypomanic behavior. But, I have seen it described as hypomanic behavior in patient files because of a clinician’s bias favoring a diagnosis of bipolar.

5.37 Considering the Use of Drugs in DID Treatment: Part 5 – Diagnostic Bias in Files

Posted on December 7, 2018

Few people outside the psychiatric and pharmaceutical communities know how common the practice of stretching and bending the meaning of words is in medical files. That practice is influenced quite strongly by the bias of the clinician. I have personally had client files sent to me that clearly were based on a liberal and intentional misuse of words. This misuse served the purpose of identifying an otherwise understandable behavior into a symptom. I am confident in saying this because many of the files referred to me included dissociative behaviors and events. In fact, the files actually used the term dissociation but failed to include any primary or even secondary dissociative diagnosis. Further, those files usually indicated pharmaceutical treatment failures and no application of psychotherapy.

For example, patients were referred to me that were experiencing agitation related to a flashback of abuse. In the files, agitation was interpreted as “a variant of hypomanic behavior.” Such misuse of language completely shocked me. Those patients had often lost years on a wild goose chase, with therapists trying to find the right pharmaceutical agent for “a variant of hypomanic behavior.” The correct approach should all along have been trauma therapy as it was their trauma that was being displayed in the symptoms.

It is common to see patients that are kept on antidepressant for years yet remain depressed. Although they are labeled as suffering from “treatment resistant depression”, it is more appropriate that they be labeled as suffering from Antidepressant-resistant depression!

If a patient on antidepressant(s) has not improved as expected, the correct procedure is to review the diagnosis, not just to persist in trying different dosages or a newer drug. There is no logical reason or peer reviewed study that would indicate that the depression symptom is part of a disorder that justifies the exclusive use of medication. In reality, that is the common practice – to increase the dosage or change of antidepressants. Instead, try listening to the patient. Or, at least, continue with the medication and try listening to the patient.

In Volume 1 of Engaging Multiple Personalities, there are several examples of patients I had referred to me that were labeled as having treatment resistant depression who made progress in their healing journey through psychotherapy. With psychotherapy, those patients were treated. Their traumas were acknowledged and often successfully processed. During the psychotherapy, they were weaned away from antidepressants successfully and fairly quickly. I only remember a very few DID patients who required antidepressants as adjunct to being treated with psychotherapy.

5.38 Considering the Use of Drugs in DID Treatment: Part 6 Determining Treatment for Depression in DID

Posted on December 11, 2018

4. As I have said before, I am not rigidly against the use of antidepressants per se.

Some of my depressed patients did indeed respond positively to treatments other than psychotherapy, often in ways that might be seen as miraculous. My disappointment and concern is that there remains no clear protocol that confirms what kind of depression will respond to which treatments. The result was that I used my own criteria when considering options for my patients, based primarily on my clinical experience.

I used psycho-pharmaceuticals in the past. I can attest to the fact that they do help some very severely depressed patients just as I can also attest to the fact that they do not help others. To this day, for me at least, there are no studies that satisfactorily define what kinds of depression respond to which chemical interventions.

It can be an assault on the patient to give them a small manufactured pill. How is that possible? Keeping a patient on antidepressants for years while ignoring psychological factors such as early childhood trauma, or recurrent ongoing trauma as the cause of the depression, is a chemical assault. Such an approach has the quality of trying to beat down the depression rather than cure its cause. Until we have an actual proven answer in identifying which depression would be responsive to which drug, we need to be extremely careful in using these approaches.

5. The term “Chemical Imbalance” has no real meaning.

It is a false assumption that antidepressants are generally both safe and effective. The truth is that all pharmaceuticals are substances foreign to our bodies, even when they are based on natural chemicals produced by plants for example. Pharmaceuticals are highly potent chemicals. They are specially designed to quickly alter our metabolism and interfere with it. In fact, psycho-active medications are designed to rapidly impact one’s existing brain chemistry. They are far more potent than the plants they may be derived from.

The term “Chemical Imbalance” is somewhat a sales device. The identification of the numerous serotonin-receptors in the brain has helped some, but so far has not cured the pain and suffering of all or even most depressed patients. The truth is that psychiatry in the 21st century remains an inexact science.

After almost a century of sophisticated biochemistry research, we are still generally operating in a fog as to defining exactly what is the chemical imbalance in a brain that expresses pathological depression. I do not dispute that psychiatric medications have contributed to the treatment of certain psychoses. They have, in fact, led to a reduction of the number of institutionalized psychotic patients in developed countries. However, we must accept that there are some unavoidable limitations in the purely pharmaceutical approach to depression. It is a false hope that we can trade pills for genuine psychotherapy in the name of saving time and man-power.

5.39 Considering the Use of Drugs in DID Treatment: Part 7 – Go Slowly

Posted on December 14, 2018

6. The best we can do is to humbly accept the limitations we have in striving for a more precise description of depression that may respond to medication.

DSM 5 gives a clinical picture that defines a depressive condition that would be appropriate to treat with medication. In one example, this includes a somewhat arbitrary time limit: If grief in bereavement is prolonged more than a certain number of days, then we deem it a pathological state. And, with that diagnosis, comes the implied appropriateness of trying some pharmaceutical intervention.

If a genuine therapeutic alliance has been established with the patient, I would have a clearer sense of the likelihood of early childhood trauma, or an assessment of potential ongoing trauma in the patient’s current life. Being able to identify trauma leads to one treatment path. Absence of trauma would lead to a different treatment path.

My approach is to look at a person’s depression. If it is there most of the time, when he wakes up, when he does not get cheered up seeing his loved ones, when he is socially withdrawn, when he cannot shake it off, that would satisfy my criterion of a form of depression where I might try antidepressant. But, that would only be as an adjunct to psychotherapy.

Depression that responds to drugs usually has a different quality than depression connected to trauma. It is more like someone who has lost interest in things that used to generate a positive experience, a positive response. A common description is of a patient that no longer enjoys his favorite foods.

Psychiatric textbooks describe true depressive symptoms in different ways. The term “True depressive symptoms” refers to depression as a syndrome, a disorder; in other words a mental illness that prevents one from living one’s life in a way that accommodates the ups and downs of ordinary existence.

7. There is a dangerous pattern in psychiatry to quickly conclude that a depressed patient should be on medication.

This kind of presumption is illogical, dangerous, and based on an inflated sense of one’s insight. But, it is inflated by the promotional materials of the pharmaceutical industry and the money that flows from it. I have heard this kind of nonsense from the press as well as from many of my peers. What is missing? It is empathy that is missing. It is the warmth of genuine compassion that is missing. Both of those should be tested before anyone is given a license to be a therapist – whether it is a license as a psychiatrist, a psychologist, a clinical social worker or perhaps even just an ordinary human being that deals with other human beings in trouble.

For the sake of billions of dollars of sales, pharmaceutical companies invest heavily in propaganda and brain-washing to promote the use of drugs as the exclusive means in solving the mental health problems.

Be aware of the erroneous assumption that depression is a disease curable by antidepressants. This is, at best, a half truth. We need to be alert to identify patients with depression that is amenable to psychotherapeutic intervention.

5.40 Considering the Use of Drugs in DID Treatment: Part 8 – A Sales Channel Is Not Therapy

Posted on December 16, 2018

8. Drug companies use a particular sales technique known as “off-label” marketing to expand the sales potential market of their psychoactive medications.

The technique of “off-label” marketing is selling the medication for a purpose that has not been approved by, in the US, the Food and Drug Administration. With this kind of marketing approach, we are being led to participate in a cold, money orientated mental health systemc who need help dealing with trauma or other mental health issues.

For example, a drug may be approved for treating psychosis, but not dementia. However, that drug may be marketed for “off-label” use for individuals with dementia. This is not at all uncommon. This kind of marketing is often done at seminars that are sponsored by the pharmaceutical companies seeking to boost sales. It is based on anecdotal information they promote rather than peer reviewed studies. You can look at past drug litigation, such as around the use of Risperdal, to see the dangers in this technique. This kind of marketing made Risperdal a multi-billion dollar drug despite harming many children.

This same danger was recently highlighted in a study of Haldol, a drug that has been marketed for decades as an anti-anxiety drug but established an enormous off-label use. That use was for “treating” dementia related anxiety issues. According to the study, there were zero peer reviewed research papers indicating a positive impact of the drug for dementia patients. Here is a warning from 2007 that is instructive, given that the medication had been in used for dementia patients for decades at that point:

“Haloperidol (Haldol, Johnson & Johnson) is approved for intramuscular use, off-label intravenous use of the drug is relatively common for treating severe agitation in intensive care units. However, due to a number of case reports of QT prolongation, torsades de pointes, and sudden death thought to be associated with this practice, the FDA has issued an alert to healthcare professionals. The prescribing information for Haldol, Haldol Decanoate, and Haldol Lactate has been revised to reflect the concern and potential risk when the drug is administered intravenously or at higher doses than recommended.”

Note that this warning doesn’t say you should not continue to use it for dealing with agitation in dementia patients. It is merely an “alert” that was likely issued as a prospective litigation defense.

In short, beware of off-label use of psycho-active medications. Perhaps the anecdotal information promoted by the pharmaceutical industry is accurate, but perhaps it is not.

9. Emotional difficulties have to be approached through first understanding the emotions involved.

All aspects of the individual have to be considered in therapy; the biological, psychological, social and spiritual aspects. There is no substitution for this by prescription. Prescriptions are not time-saving if that is all you offer the patient. Why? It is because missing the underlying factors that generate the symptoms will only cause delay and suffering – often for years – as a result of the wrong treatment. Should the wrong treatment include psychoactive medication, there will likely be an even more difficult path of undoing the impact of that medication before being able to address the actual issues.

Years of pharmaceutical experiments will ensue for the patient. The hunt for another therapist will eventually follow, often many years after the original misdiagnosis and corresponding error in treatment. It breaks my heart that this is so common. It is why I continued to practice psychiatry into my 70s and why, in retirement, I wrote the Engaging Multiple Personalities Series.

The case histories in Engaging Multiple Personalities Volume 1 were all of people that came to see me after being treated to no avail by other therapists and psychiatrists for years. For those I was able to help, it was not that I was a particularly brilliant therapist. It was because I actually listened to them. Without exception, their prior therapists either did not believe in dissociation or were too callous to pay attention to the early childhood trauma these individuals experienced.

An effective therapist speaks to the heart, not to the brain. We must never forget the humanity of our patients, or our own.

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

Posted on December 24, 2018

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 a “controversial” diagnosis, which is actually saying that they don’t believe it exists. Such misunderstandings continue to cause untold suffering in many individuals 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 overwhelmed 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 likely 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 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 cooperation 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.

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

Posted on December 28, 2018

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 continuous 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.

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

Posted on January 2, 2019

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 doses 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 reports. The details of the trauma are 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.

Flash-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 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 to 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 likely 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 know 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 results have been very disappointing when pharmaceutical methods are used exclusively.

It is unlikely that there will be a magic pharmaceutical agent that can exclusively be 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.

5.44 Religion and Working with Trauma Survivors – Part 1

Posted on February 25, 2019

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 it 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.

5.45 Religion and Working with Trauma Survivors – Part 2

Posted on February 25, 2019

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 communities that are separate from where the abuse occurred. They have experienced a sense of sisterhood and brotherhood in those new communities 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 witness 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 others 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.

5.46 Correcting Misunderstandings about Recovered Memory – Part 1 of 3

Posted on October 23, 2019

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.

5.47 Correcting Misunderstandings about Recovered Memory – Part 2 of 3

Posted on October 24, 2019

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.

5.48 Correcting Misunderstandings about Recovered Memory – Part 3 of 3

Posted on October 25, 2019

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.

5.49 The Devastating Clinical Consequences of Child Abuse and Neglect

Posted on February 4, 2020

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 a 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 in 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 considerations 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 becomes 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.