October 2010 Archives

In the last couple of posts, here and here, I wrote about awareness and using specific skills that have helped me (and hopefully you too).

It was interesting that I also paid careful attention in those posts to say that the skills do not always work. Not working probably means many things to each of us at different times. For me, I am very specific. For me, it means that I have not been safe; that I have self-harmed. That is the case today.

I have to tell myself that it does not mean all that work I do means nothing. I have to tell myself that the skills really do help and it is expected that there will be setbacks. I have to tell myself that I will recover from today. I have to tell myself that I need to keep faith in myself that I will keep healing.

I will pick myself up and try again. I will try to be more aware. I will try to do more of what I know helps.

But this is not an easy time period for me. And I know for many others it is difficult too. In the US, Halloween is a major holiday. Well over a month ago, decorations were in the stores. We are surrounded by images and sounds. Images that never "seemed" to bother me in the past, now send me over the edge and reverberate all throughout my system. For the past several years, Halloween has been very hard.

It has always been a time of extreme activation of certain parts of me; the parts who deal with issues of living and dying, good and evil, and other scary things. And, each year, very specific scary memories always rush to the surface. My reactions seem off scale, but comparable to those I experience around Easter.

As I have healed, I have become aware of this unrest inside during this time. I have realized how sensitive I have become. How easily triggered I am. So, navigating through these weeks around Halloween is not ever easy.

I cannot even ride it out in peace because my wife has a huge Halloween party every year for all the neighbors and kids. It does not at all make sense to me. For several years, I have huddled in my bedroom, medicating myself to get through. I do not want to do that this year. I thought I could be involved in the party and have it be okay. I had a sense that things were going to be okay this year.

Until today.

11/2 Update: I just noticed that on Halloween, Dr. Kathleen Young put up an excellent article on the subject as it relates to child abuse survivors. It's worth taking a look at. See: Trauma Survivors and Halloween.

In my last post, Healing from a Place of Strength, I talked about many of the positive strengths I have available to me now, much of them attributed to a new sense of awareness.

Not to belittle that positive approach, but there is the reality that healing is not a positive linear progression. I failed to mention what is perhaps obvious to most, that there are many times when a positive outlook is simply not possible. There are many times when awareness falls by the wayside. There are many times when my mind is seriously fragmented and I am completely dysfunctional. Perhaps the most harmful outcome of this "other side" is when we resort to self-harm.

I still think, though, that awareness is the antidote. It is also a skill that we can cultivate over time. In much the same way that dissociation has been an automatic response for many of us for so long, we can learn to use practical skills regularly to help keep us safe. Having and using a safety plan, imagining safe internal places, relaxation, grounding, journaling, listening to music, taking a PRN, and more, are all things we can do to push the odds in our favor. It does not assure that we will stay safe. It does not assure that we will not "break down." It just increases our chances of getting through safely.

Like all skills, we must practice them if we want to get better at them and increase their chances of working when we need them. Unfortunately, when we are feeling "well" or "together", those are the times when we usually do not practice. I have often thought that because so much of our life is consumed with difficulty, when we are in a good spell we want nothing more than to enjoy that time. There is nothing wrong with that.

This is why I have tried, and I know I am not always super good at it, to incorporate skills into my daily routine no matter how well or un-well I am. One of my greatest skills since I started working with my "Healing Guide" has been to keep a drawing journal. For the first year or more, I went through a Canson 120 page Field Drawing Book almost every month. I filled it with drawings, but also hand writing. The attention to feelings that I talked about in the last post could not have been done just in therapy. The drawing book turned out to be absolutely essential.

Another skill I have cultivated over time, was to build up my electronic journal. At first, it was just a single file that I edited when I was on a specific computer, and eventually I programmed a rather elaborate system—thank you programming skills—whereby I can write to the journal securely through a Web interface from anywhere or even from my iPhone-formatted page. This journal tends to be much more focused on words, but I also use it to attach art or photography I make.

I use the journal mainly to make sense of what is going on in almost real time. That is the key. If I find myself in a tough situation, I can immediately take out the iPhone (if only that is available) and make an entry about what is going on. Often, I can make an entry before I dissociate. In the past, there was no systematic way to keep track of things. Back then, this is just a couple years ago, if a trigger would generate a dissociative response, it would often just sit until I went to therapy. If that was several days later, my access to the experience was probably gone. That meant that my ability to learn from what happened was also gone.

One does not need a complicated system like I have to do what I do. You can easily keep a computer file on your home computer. If you want, you can even take it to and from work via a thumb drive. For the times when you are away from your computer, I used to keep what my therapist called a "feelings journal" in my pocket. These were pocket sized journals where you can jot down thoughts and feelings or pictures that you can come back to later.

I think the nitty gritty of cultivating awareness (and indeed healing from dissociation) is actually pretty straight forward. There is nothing complicated about journaling. It may take some time to stick and become standard practice. I know for me, I struggled for many years before I was able to keep a journal. I had notebooks all over the place, and I never was able to make it a regular healthy habit. I just did not want to spend the time. I did not really think I needed to. I was wrong.

For me, I see daily journaling for someone who is dissociative as absolutely critical. You are shortchanging yourself if you do not journal regularly. I once had a doctor tell me that my journaling was akin to how a cystic fibrosis patient has to hook themselves up to a machine to clean their lungs twice a day. She maybe went a bit too far in making her point, but looking at it objectively, she really did have a valid point.

One area I am really not that reliable in doing is DBT-like diary card check-ins. I have set up an iPhone App called LifeLog to do the recording for me. I have two cards, one is basically an acknowledgement of parts, listed by name. I go down the list in a mindful manner and acknowledge each. I do not do it to necessarily engage in discussion with each part; it is more like that I am taking a breath and saying "Yes, this is who I am and how I am made up."

The other card, is a more standard mood monitoring. I have adapted it for me by highlighting the areas I feel I need to pay attention to. On a 1-10 scale I rate the following: Acceptance, Happiness, Anger, Fear/Anxiety, Fatigue, Physical Pain, Dissociation Level, and Overall Safety.

Of course, like I said, doing these things does not guarantee anything. It does, however, give us a better chance. And even though many of these are "in the moment" techniques, it is important to appreciate that if done over time, the scale at which they work becomes greater and greater.

It is not a magical "awareness" that helps make us better. It is awareness generated from very specific skills, applied regularly like medicine, over time.

I know this is not the first time I have talked about these skills. I discussed the iPhone Apps I use in Survivor's iPhone Essentials, Part I (July 2010). I have discussed journaling in many posts, but specifically focused on it in Journaling (May 2010).

Two of the key reasons for the huge leap forward in healing I have made over these past couple years are motivation and hope, which were made possible by enormous gains in self-awareness.

Some of you may know that this site began as a record of a "consciousness" experience I had after several months of working with my current therapist, my "Healing Guide." That experience is chronicled in A Healing Journey (Original). At the time, I believed that experience was the "end game." That I was fully healed. Looking back two years later, I am still trying to make sense of the experience and place it into the proper context (although I have addressed it at various times, see the Enlightenment category).

I know that the "full conscious" experience is forever part of me. I also know that experience was not a singular event. At various times since, I have had similar experiences, where I felt like the barrier between my body and mind and the "life force" which exists all around me became one. Usually I do not have these experiences in the extremely pure manner I had originally. But I have wondered if I actually do have them in as pure a form, just that they are not new to me anymore and experienced differently. One thing is certain: these experiences, on whatever scale, help me keep faith that I am healing and that I am on the right path. They are my touchstones.

I see such experiences now as acutely clarified sense of awareness.

My consciousness experiences did not come out of nowhere. They came at the same time I focused on what the feelings were in my body and mind. For decades, I had struggled with trying to make sense of my inner and outer worlds through intellectual understanding, mostly in therapy. When I began to work with "My Healing Guide," she encouraged me to focus on feelings. She is, after all, trained as an art therapist. So, for many months we worked on expressing feelings through art. I learned, quite quickly, that I was able to access my feelings without processing them through thought. This was not so completely new to me. I had done it with my music since I was a kid, and to some extent with my photography. But it was absolutely new in the context of therapy, and that was when my world changed. That was when everything sort of started to come together for me.

I have come to appreciate that healing—and indeed much of life—requires us to find balance between thought and feeling. But, perhaps most importantly, before any balance can even be attempted, healing needs to be focused around positives. It cannot only be dwelling on the past, on what happened, on symptoms. Sure, we all need to grieve. We all need to tell our stories. That is part of healing. But there is more to healing.

I believe deeper healing is achieved when we challenge ourselves to live more in the present and future—which means setting ourselves up for a better future—and doing that while cultivating internal awareness using mindful approaches. For me, the awareness became my grounding force, my proverbial rock, a net which I could rely on to hold me safe when dealing with even the hardest issues from the past (or even present). I find I am in a much better position if I can work on healing from a place of strength or from a positive point of view. This was the key for me because it was the first time that a sense of safety came from within and was not derived from anyone external. I learned that I am my own healer and that I can indeed heal.

It is not easy work, especially since the responsibility is all on me. Balance is not painlessly achieved. It is most always a moving target. For me, I find that when I make the effort to be self-aware, I increase my chances of finding much-needed balance. I also find that self-awareness is a choice. Sometimes I need to be reminded to make that choice; this is where "My Healing Guide" really makes a difference. I have to be willing to look inside. I have to be willing to give myself a chance.

Most of all, I have to be willing to approach struggles in a manner that is quite the opposite of the internal mechanisms of my longstanding dissociative coping. To do that requires internal collaboration and patience. I find that I have to continually prove to parts of me that the self-aware approach will lead us all to a better place, even though it makes the road rockier for some of us. Much of the proof is in the data I have through my journaling. So, my job has changed over the years, from first having no direction, to then trying to force parts unwillingly to go against the grain, to now being more of a coach and mentor.

I keep saying "We can do this!" And, for the most part, we can.

I have not posted (or read much of other's blogs) in two weeks because much has been happening in my life. So I have taken time to step back a bit and focus on being with my family. This appears to be an annual tradition for me, as I noticed the very same thing happened last year. On another front, the Expressive Arts Carnival will be back with an activity on November 1st. Finally, please bear with me while I solve the problem of site notifications sending out blank e-mails.

In an editorial to the most recent Journal of Trauma and Dissociation (Vol. 11, pp. 261-5), Dr. David Spiegel writes about how dissociation will likely be addressed in the forthcoming DSM5. For those of you not familiar, the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM, is psychiatry's approach to standardizing mental disorders. I understand how many look askew at any psychiatric labels, myself sometimes included. But there is the reality that correct diagnoses are an important component to healing. Having a manual and common language helps to increase recognition, accurate assessment, and align treatments.

There has been some concern that the dissociative disorders, especially dissociative identity disorder, would be subsumed under other diagnoses and thereby essentially be "declassified." Even now, despite their presence in the current DSM, they are not well integrated into the psychiatric community. There are large biases against dissociation, that strangely do not seem to be as apparent in illnesses such as depression or schizophrenia. Probably this is due to the sometimes ephemeral nature of impairment. To the observer, it often appears that dissociatives can just pull themselves together, lending some credence to the belief that no real disorder exists. Yet, to the dissociative, we know there is much more to what we deal with than just being able to pull ourselves together. We know about what it means to lose our identity, to have huge gaps in memory, to have wild swings of consciousness. And, as I have said before, I believe one of the main reasons for the bias is that many clinicians and lay people are uncomfortable with the notion that an adult human being can have a fragmented sense of identity or lose control of their minds and bodies.

In his editorial, Spiegel, a member of the DSM5 Task Force, asserts that the dissociative disorders will be included in the revision which will come out in 2013. He gave a summary of what the task force is proposing. They are proposing that there be a stress and trauma spectrum section which will include PTSD and the dissociative disorders. In so doing, the DSM5 will emphasis the common etiology of these "disorders." This would be a controversial move, since the current version focuses more on description of symptoms. Even though there would still not be a diagnostic requirement of a trauma for a dissociative disorder to exist, placing dissociation squarely into a section with an emphasis on trauma etiology would be a blow to the false memory advocates. It would be a validation and positive step for those of us who appreciate that dissociative disorders do have a strong basis in trauma.

In fact, it appears that this trauma etiology will be pursued even further based on studies by Ruth Lanius and colleagues that there is a substantial subgroup, of nearly one third, of those with post-traumatic stress disorder showing mainly symptoms of dissociation which are far different from the "classic" PTSD symptoms. These clinical findings are supported by the functional MRI studies which show that the dissociative subgroup has increased prefrontal cortical activity and reduced limbic activity in response to traumatic stimuli, which is opposite of the typical PTSD response.

One of the proposed changes to the criteria for dissociative identity disorder I think is a step back. It states that the disruption of identity "may be observed by others, or reported by the patient." Detractors of dissociative identity disorder will say that there is no clinical input. On the other hand, there are clearly disorders where there is primarily patient reporting. Depression comes to mind. The onus would then be on the clinician to determine whether the self-reporting of the patient is consistent with the rest of the criteria for the disorder to warrant the diagnosis.

Complex PTSD, as proposed by Judith Herman in 1992, is not addressed in the current DSM and appears not to be addressed in the DSM5. I think this is for good reason. To do so, would confound matters. The commonly understood symptoms of complex PTSD are basically PTSD symptoms plus overlap with many other areas (such as anxiety, personality, and dissociative disorders). I think we all, patients and clinicians alike, need to appreciate that the DSM will always have limitations. The manifestations of all of these disorders in practice are almost always more complex than any manual can ever hope to capture. But the goal of the manual should be to make a best effort and provide a guidepost.

To learn more about the recent studies showing the dissociative subgroup of PTSD, see the home page of Dr. Ruth Lanius at the University of Western Ontario. She does not have her most recent journal articles listed. If interested, check out: Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype (in American Journal of Psychiatry). To read the Spiegel editorial, see Dissociation in the DSM5 (in Journal of Trauma and Dissociation).

I am taking a one month break from the Expressive Arts Carnival. The next activity will be posted on November 1. If you are interested in finding out more, check out the home page or drop me an email.