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Dissociative identity disorder (DID) has, for decades, been described in terms of a prototype model. Recent years has seen a realization that dissociation, including more intense dissociation seen in DID or DDNOS, is experienced in a myriad of different ways for different people and at different times.
However, I am not at all convinced that this realization is widely embraced. Clinicians not exposed to many cases of more extreme dissociation or those who try to grasp what dissociation is without prior experience, including those who are newly diagnosed, are often hard pressed to think outside the prototype. While the television series United States of Tara, for example, captures a good deal of what the experience can be of dissociation and switching, it also goes a long way towards reinforcing the well-defined prototype.
I have seen so many, including myself, get caught up in what the DID prototype says we are supposed to be like. That can be a real barrier to healing. It encourages us to deny those experiences that do not fit the prototype and accept those experiences that do fit. That is not to say that we do not have experiences that conform nicely to the prototype. In my life, I have seen, and experienced, florid DID which is much like the prototype of Part A knowing nothing about Part B, with self-destructive acting out. DID can really be out of control, but most of the time DID is not like that for most people. And, so, I think it is important to look at all of this from a broader perspective (i.e., that those of us with DID or DDNOS are much more than than the prototype).
For those of us who experience a wide range of dissociation, we know that the prototype is mostly feature driven and, as such, somewhat superficial. Massive identity shifts are often responses to stresses or triggers. Everyone has reactions to stress and everyone has triggers. With large dissociative walls, our reactions simply tend to be more extreme than others, but they are fundamentally based on the same principles. Complicating matters is that anxiety associated with changing states is usually self-perpetuating. Often there is an resulting panic when we realize that we have not been in control of what our body has been doing or have lost time.
In order to heal, our focus needs to become internal and personal. We have to realize that the task is to identify and come to terms with our myriad internal conflicts. When we do that, we are not focusing on the prototype, but rather our own unique experiences and feelings. That is how the barriers can come down, how communication can commence, and how collaborations can ensue. When that happens our experiences become richer. We become more aware. My increased awareness changed everything for me. In many ways it is not really easier, but much harder. I sometimes liked it better when I was not as aware, when I could just slip away and let some other part of me take over. Now I am somewhere in between, trying to find my way to a place of healing.
I see DID as a complex network, one that has features of the prototype (parts with rigid barriers), but also has fluidity that allows for barriers to come down and parts to interact in a seamless, dare I say completely normal, way. I have often represented this visually, with parts as circles and lines connecting them. I try to show the reality that the system is not static. That we are not locked into a prototype. That the barriers can come down, but that they can go back up too, and come to some appreciation that DID is really about how we interact with ourselves, no matter how "unconventional" it may seem on the outside.
While DID is unquestionably an enormous challenge, I think it helps to place it in some context. There are far more complex systems on different scales. DID for an individual can be seen as simpler, than say, the community in which you live. Or world governments. Or ecosystems. Or the network of neurons in our brains. Or online social networks. I am constantly trying to reality check my own complex inner world with the complexities I know exist in the world. When I am able to do that, my struggles become a bit easier to cope with.
I am not saying that DID is normal. Far from it. But I am saying that when we look at it in a wider context, we make it much easier for us to heal.
In my last post, I wrote about the language of dissociation, specifically focusing on the issue of names in dissociative identity disorder. That discussion leads me to the issue of language while maintaining healthy personal and public boundaries.
Many years ago, I decided that therapy and the hospital would be the places where I would trust and talk freely about all of myself using whatever language and techniques worked best for me. I decided, and a lot of this was a decision driven by instinct, that when I write publicly and interact with people in my life—including most family and friends—I would be extremely careful about the language I chose to use.
I try to write and communicate with others in such a way that broadly makes sense. I find one important way to destigmatize trauma recovery is to not use language that makes the issue esoteric or unique. I avoid altogether talking publicly, except here and with family, about dissociation. I find it makes me feel safer and less exposed. I have come to terms with the reality that dissociative identity disorder will probably never be understood or accepted without judgment by significant numbers. It will never be seen like cancer and probably never be seen like depression. It will be so strongly stereotyped because so few have direct contact with it. I have no problem with that.
One of the reasons why I started this blog was that I came out publicly when a child sex abuse scandal in our town came to light. I spoke out in the newspaper and as a parent in the community about the issue and came forward as a survivor myself. I did that in a subtle way to lend some credibility to my argument, saying that we all needed to make sure that we appreciate and attend to the plight of the victims. I am now appreciative of the fact that my coming forward changed my path to healing positively. I was careful about what I said, but it helped me to come out of the darkness and changed the dynamic internally. So it taught me a lesson that I could be effective without telling all the details.
I am mostly comfortable with being able to talk in a public language that sounds mostly "generic," but I do it while knowing inside that the reality is often quite a bit more complicated. Nowadays, I often talk with friends and family about "not being connected" or "feeling depressed." I know it sounds like the stuff of life that everyone has to deal with. Of course, on some level it is. And here, while I do often use a more "technical" language, I still am extremely careful about the words I use and what I share.
But, like everything in life, some people's experiences can be more in the extremes. I find that there are safe and not safe—or appropriate and not appropriate—places to talk about some of my more extreme experiences. I do not find it helpful to try to educate everyone in my life about what it is like to have struggle with massive shifts of self or self-harm because people are so affected by stereotypes. And here I am careful, for example, not to delve into details about traumatic memories. For me, that stance is not invalidating. Rather it is a personal stance aimed at helping me feel safe and having boundaries around what I disclose. Perhaps it can be seen as my playing it safe. But, even though it is totally different kettle of fish, I would also not talk to a public audience about the intricate mathematical details of the Lennard-Jones potential in molecular modeling (which is what I do for work).
So, I have these boundaries in place and one may wonder if I am only creating an irreconcilable conflict by having such acceptance in therapy and being so careful about how I present myself outside of therapy. I could imagine these questions of me: If I am able to keep my "outside life" appear relatively normal, then am I only creating imaginary issues in therapy? If I just cut out all that uncomfortable stuff from therapy will my life just be so much easier? Is therapy creating my problems?
Those are all valid questions, and all are questions I have asked myself, over and over, in different ways for two decades. To be honest, this has often been a source of internal conflict and I have addressed some of these conflicts here and in my comments on others' blogs, even very recently. In September, I wrote The Uncertainty Principle. In that post, I wrote about the pitfalls associated with definitive answers to complicated issues. I wrote about how many psychiatric "authorities" can see the same person and draw very different conclusions. I wrote that we must challenge ourselves to ask tough questions, struggle with doubt, and find a way to live with friction.
In some ways, how I work in therapy and how I conduct myself publicly is a measure of this necessary friction. But, as I have said before, it is how we use friction that is important. We can let it become an insurmountable barrier and lead us down a path of a false set of beliefs that, on the surface, feels more comfortable. But I have never found denial to be a long-term solution.
Like I said in the last post, I believe when I talk in a specific language about parts of myself openly in therapy, in the hospital, and in my private journal, and am careful about what I say publicly, I find that is actually an approach helps me to heal.
One of the more difficult issues surrounding dissociative disorders is the so-called dissociative disorder language. Unfortunately, it is this language that is one of the reasons why dissociative disorders, including dissociative identity disorder, continue to be controversial. Perhaps the most difficult aspect of the language is naming of dissociated parts of self.
I know there are many times when my therapist asks the dreaded question "Are you feeling grounded as Paul?" In the hospital, I am sometimes asked the much more ingratiating question "Who am I talking to?" Either can go down in one of two ways. One frequent response is to be taken aback and roll my eyes. I often feel like I am "Paul" but maybe a very different shade of myself, and so the questions feel incredibly awkward. But then there are clearly times when I (or rather some aspect of me) readily answers to a different name. I suppose there is a middle way and that is that I am taken aback, but then realize that I am only acting as a barrier to some other part of me.
I believe, and this is based on my personal experiences, that the complexity of dissociation and how it manifests drives this type of necessary communication. My level of dissociation varies enormously over time. On one side, I can often be relatively whole with access to many aspects of me, experienced mostly as "shades of myself." But, on another, I can also often be extremely fragmented with little awareness of anything beyond what some narrow segment of me knows. As a result, there is no "perfect" (or probably even easy) way in therapy to interact with me, and while sometimes these questions feel uncomfortable, there needs to be space to ask them. If we are not direct, there is a huge potential to avoid addressing very real internal needs, which can then lead to problems such as safety issues or intolerable internal conflicts.
In therapy, the place where I make the most deliberate and focused effort to heal, there really is no other language to describe the very real partitioning in my head. We use names for parts because they have names, and to not use names would make communication difficult if not impossible.
I have always struggled with names of parts. I realize that some believe the very notion of having names for parts causes more problems or even creates them in the first place. I can understand that argument. For those of us with dissociative disorders, I think we need to come to our own personal understanding and response to such a message. For me, accepting that argument leads to denial and barriers. But, and this is a very big but, having names for parts should not ever be an excuse to take away our personal responsibility. I have seen this over and over again. We must own our actions, even if a part of us, even with a name, did them. I believe it is crucial to keep that perspective.
Names for dissociated parts of myself is one aspect of the language that my "system" (if I can use that word) ended up using to make sense of that system. While I know there were names associated with parts way back when, they were not so clearly defined as they are now. A number of the "hurt" parts were always thought of as shades of Paul or "young pieces of Paul." So there were many variants of the name Paul. And also there were "characteristics" as names, like "Dirty One", "Sexual One", "Evil One", etc. My experience of my dissociation as a kid and young adult was always in those contexts, with massive gaps in my awareness.
Back in 1991 when I found myself in the mental health system and my level of dissociation became more apparent, there was a more clear defining of names as a way to talk about experiences so that those who were helping me and I could find common ground. It is so much harder to say "the part of you who is very spiritual and wants to go to church and holds a lot of physical pain" than to just say a simple name.
The names of parts are much more specific now, and while this is one of the sources of controversy concerning dissociative identity disorder, this increased specificity has helped me in so many ways. I have long accepted that I have extremely compartmentalized parts of myself, and if I did not address them head on, I would be at an extreme disadvantage.
Being able to define parts more clearly allows me to know more specifically what parts represent, what their issues are and what their needs are. It has helped me put the pieces of my self and my life back together. It has helped me to be more whole and more functional in my life. It helps me to be more aware and safe. But most importantly, it has helped me to heal.
There has been a debate for at least two decades concerning the diagnostic validity of the dissociative disorders, in particular dissociative identity disorder. Anyone who struggles with pathological dissociation has seen this, probably firsthand. On its face it is not hard to appreciate why there is such controversy. Some just dismiss the disorder outright because far out experiences like having such widely varying personality states (often with their own names even) seems implausible. For others, they believe it is either therapist misleading or patient collusion to exaggerate symptoms much like an actor is required to perform for a scene, and there is some historical evidence of this. Many talk about the validity of the experiences, sometimes referred to as the "Swiss cheese" of consciousness, but believe they should be subsumed under other diagnoses.
I talked about this subject a year ago in Is Dissociative Identity Disorder Real? I want to come back to it today.
While I talk about dissociative identity disorder fairly regularly here, I do not generally like to treat it so separately from other forms of dissociation. That is not to say that I do not think dissociative identity disorder is not a valid diagnosis. I absolutely do. For one, I think much of what we have to contend with is similar (though on a different scale) to what many others have to contend with. I think many appreciate that dissociation-like experiences are widespread in the world, if we include things like avoiding difficult situations or being disconnected from our families or not being aware of what we are doing. Of course, most people's experiences do not rise to the level of being diagnosable dissociative disorders. There are billions of people who seek more awareness and deeper connections in their lives, which at its core, is what healing from dissociation is all about. And, while dissociative identity disorder is usually singled out, those who are recovering from childhood sexual abuse and have been diagnosed DD-NOS, PTSD, Complex PTSD, Borderline, or nothing at all also have a challenge to find more wholeness in their lives and heal dissociative tendencies. So, I always try to use language that applies broadly. This is the main reason why I often avoid much of the parlance of the disorder, because the label is much less important than the experience.
Since dissociative identity disorder is an elaboration of what all people experience, this leads to a bit of a "Catch 22." It is a problem because this is the argument many detractors use. But it is also an advantage. Personally, I want to struggle with something that, on a fundamental level, is normal to the human condition. That gives me hope for healing. If dissociative disorders are on a continuum, then I do see healing as finding a way to move down the ladder of that continuum. For me, that makes it all much more manageable. Yes, there are many times when I feel utterly not normal. When I am at my most fragmented. When I have bitter wars inside. When "I" do unsafe things that I would not possibly agree to in any rationale or grounded state.
If we focus on the messages that detractors use, there are usually two outcomes: becoming defensive and succumbing to denial. For me, I find that I start with the former and end up in the latter. But this is dangerous ground. Becoming defensive tends to push one towards a rigid stance that does not appreciate "both sides" or seek a middle ground. And denial can be hugely destabilizing. While some denial is part of the natural healing process, it is not part of the overall solution. I know that firsthand. For several years I was "well enough" to flee therapy, appear well, disavow parts of me and pretend it all did not exist. But I also know that during that time I was not paying attention to what was happening in secret. There was an upside: I ended up quite functional in certain very public areas of my life. But, that came at a severe cost, as I was quite dysfunctional in other areas. For me, that "position" did not stick. It was not in line with what I needed to do for healing. For some people, and I am one of them, multiplicity is very real and part of the fabric of who we are.
I now know I need to have acceptance for the "multiple" way my mind works, though I struggle with this a great deal. This acceptance has helped me change; to be more whole and heal. The goal of good therapy for dissociative disorders is to become more whole. Period. To move from what is more like "Swiss cheese" to what is more like "American cheese." The route is through increase in awareness, which is proportionally difficult to how elaborate the dissociative walls are.
Another issue that is often brought up in any discussion concerning perspectives on multiplicity is Sybil. Sybil defined late 20th century multiplicity. But dissociation is experienced on a continuum. It was a mistake for many therapists in the 80s and 90s to think that everyone was in the Sybil mold. There is vast understanding of a continuum of experience now. Good treatment now does not involve abreaction, regression and purging of memories. That was a lesson learned a long time ago. But rather it is to promote a more whole way of living that holds one's self accountable for actions and teaches grounding and other techniques to quell what are very real, and sometimes extreme, internal conflicts and disparate views of self. And as far as memories go, good treatment does not make them a focus but does not shy away from them when they become an issue. Good treatment works towards containment so that survivors can deal with issues of the past while also learning to navigate through life in the present.
While therapists have a responsibility in the treatment of dissociative disorders, survivors clearly do also. I firmly believe this. Anyone who uses their multiplicity as a means of scapegoating behavior, or puts their whole life in the identity of a multiple, or only identifies as a victim, is putting up an enormous barrier to their own healing and doing themselves a disservice. Survivors (and therapists) need to know there are no guidelines for being multiple. It is recognized that multiple systems are very different for different people. People with any dissociative disorder should not be pushed, by themselves or others, into a belief system that says you have to have X parts, or have this level of trauma, or that you have to have these types of parts, and they have to behave in this sort of way, etc. In other words, we must be driven by our internal truth and not by external pressures.
I believe that if we are guided by truth, we will achieve more clarity. I have found that I have fewer internal conflicts, I am more whole, I am more functional in the world, I am able to feel more, etc., when I accept what I know to be a reality of how things are inside. That is another way of saying I accept my truth. When I do not accept what is real for me then nothings fits together. The bottom line is that everyone has to come to terms with what their reality and their truth is. That acceptance should be respected by others. And that acceptance is the basis for change, growth, and healing.
I will expound upon the subject of truth that I brought up at the end of this post in a subsequent post. Truth is the theme for both the Blog Carnival Against Child Abuse and the Expressive Arts Carnival this month, both hosted here. I welcome writers and artists to submit to both as I think truth is a crucial topic that can benefit from several different perspectives.
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 or fragment. 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 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 believe 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 believe 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).
"Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way: Science is the belief in the ignorance of experts."
The famous physicist Richard Feynman said those words. And while it can be argued very easily that science and psychology are quite different beasts, I do think we can apply the quote in both domains.
In the decades I have been involved with healing from "disordered" dissociative coping, I have met a good many in the psychiatric community, including well-meaning experts who look through the same narrow lenses that we dissociative survivors often do. So, I have had the biased "borderline expert" firmly declare, after a mere 45 minute interview, that I was borderline. I have had a prominent member of the false memory syndrome foundation, after another 45 minute or so interview, proclaim that my multiplicity was not real; so I responded, during an inpatient stay at the general hospital, by being very singular which he heralded as a success. I had an expert in "violent human behavior" worry that I could be homicidal, which would be bizarre if you knew me. I have also had the novice resident—admittedly no expert, but she thought she was which was the problem—on a dissociative speciality unit explain to me that every little memory fragment must be completely validated in order for me to make any progress; talk about setting yourself up!
If you are dissociative, and find yourself in the mental health system, you probably have encountered a similar range of opinions and advice. How are we supposed to find our healing path when we are caught in a mass of confusion? Where can we turn? How can we possibly sort all this uncertainty out?
I always considered myself to be a healthy skeptic. I actually really like that about myself. Sure, it oftentimes makes things more complicated than they need to be and the path becomes a rather windy one. But, as I think I have said here before, I am a scientist and used to questioning everything.
To illustrate, I will share with you another Feynman quote from the 1964 Galileo Symposium in Italy:
We absolutely must leave room for doubt or there is no progress and no learning. There is no learning without having to pose a question. And a question requires doubt. People search for certainty. But there is no certainty. People are terrified—how can you live and not know? It is not odd at all. You only think you know, as a matter of fact.
I believe the best therapists are the ones who are not too proud or too arrogant to admit they do not know all the answers and help us navigate the choppy sea of uncertainty. They tend to be extremely careful about how they impart advice. These are the people I have aligned myself with. So, with all my experience with partisans over the years, I have always come back to the humble open-minded therapist. In this realm, I get great advice. I get advice such as "I don't know if that memory fragment is real" or "Try to validate the emotions over the memories" or, my all time favorite, "You are the expert, Paul."
If we are our own expert, then this means we must carry a huge load in the healing process. We must ask the tough questions. We must struggle with doubt. We must untangle the puzzle that is us. All this friction, this uncertainty, I think is absolutely necessary.
For me, I keep coming back to what makes the most sense to me, another source of positive friction: a level of acceptance for the way my internal makeup has been and a desire for a brighter future. For more wholeness. For more peace. For more healing. That feels right.
In Trauma and Sexuality, I wrote about sexual healing being a taboo subject in both the literature and in therapy. Not many want to talk about it. Yet it is one of the main areas where childhood sex abuse victims were damaged. It is my contention that since the problem is not addressed directly in the literature and hard to bring up in therapy, that we all tend to discuss the issues tied to sex in an unconsciously masked kind of way. We can talk about being hurt sexually and what was done to us (and think we are talking about sex directly). About being suicidal. Depressed. Triggered. Switchy. And on and on.
But, while all of these are important to talk about, none talk about our relationship to sex in the present. Many of these are symptoms of what is a core issue in the present. So I like to face it all head on. What is our relationship right now to sex? How is sex in the present dysfunctional? How is sex in the present hurting us? Helping us? Recreating? Overcoming? And how do all these questions about the present relate to the past?
I understand, I think, the essential barriers to talking about sex, even in the "safe" confines of the therapy office. For those of us sexually abused as children, we focused on hiding the fact that we were being hurt in that specific way. It should not be hard to appreciate that this is fertile ground for creating shame and guilt; stains on our soul which stay with us through adulthood and whose purpose seems to be only to deny us from seeking healing of any kind (or even thinking we are worthy enough to heal).
Not to mention those of us who were sexually abused were generally taught (we generally call them "the rules") to behave a certain way in dealing with sex, through a number of manipulative means. As with any kind of learning, neuronal circuits are formed. Sex abuse ties in with reward, pleasure and fear circuits in the brain moderated by powerful neurotransmitters like dopamine. Literally, there is an imprint on our brains. These imprints are terribly difficult to heal from. But we can heal from them if we deal with them directly instead of dancing around the perimeter. It is very easy to dance around the perimeter, however.
My belief is that the first step in sexual healing is acknowledging the original sexual injury, and that it is an injury in the present. The second step is being able to break down some of the guilt and shame barriers to talking about the subject. But there is more.
Obviously, each of us were affected in different ways sexually. Some become hyposexual and just run away from sex. Some become hypersexual. Neither of these extremes is necessarily bad as long as you are comfortable in them. But most of us are not comfortable with who we are sexually and this is why it is an area we must heal. It is unavoidable.
To further complicate matters, many of us use sex to recreate and perpetuate our abuse, whether it be through fantasy or in real-life, though I do believe there is a marked difference between the two. In the literature, re-enactment is a more commonly discussed sexual outcome. In these situations, we are continuing the cycle of abuse by placing ourselves in psychological or physical situations harmful to us. It can often be a way to resolve an intolerable conflict around control of our bodies, or to maintain an outcome we expect, to cement core beliefs of worthlessness, and on and on.
I think of all of this in terms of neuronal imprints and in terms of being a way to manage overwhelming feelings. I believe it is probably likely that the degree of re-enactment is correlated with degree of dissociation. With dissociative identities, parts were created for specific purposes and roles which are harder to move out of. Further, it is easier to realize how re-enactment solves certain problems—like being able to tolerate overwhelming feelings of "parts" of us—while isolating other parts of us who are traumatized by present-day behavior.
These are explanations and not excuses. Since, in most cases, the original abuse is not happening anymore, we are responsible for our behavior. In this case, I think it is most aptly labeled as self-abuse behavior.
When one is able to label one's own re-enacting as self-abuse, then the third, perhaps the most important, step in beginning to achieve sexual healing is reached. We can achieve this only when we realize that the "positive" effects of recreating our own abuse are dwarfed by the negative effects. And this takes a good deal of self-awareness and brutal internal honesty.
If we keep these three steps in mind—acknowledging original injury, overcoming guilt and shame, and labeling re-enactment as self-abuse—then we are making a great effort to heal. The prognosis, I think, is good.
While sexual healing may seem daunting, the good news is that once you have achieved all three steps, there is no going back. Yes, there are "setbacks", but once you gain awareness, you cannot lose it, you can only temporarily misplace it.
A huge disclaimer here goes without saying: I am not an expert. This post is based on my personal experiences and interactions with other survivors over the past 20 years. It is not meant to be a comprehensive, or even necessarily scalable view on the sexual effects of abuse. I think there is a good chance it may be quite scalable. But I do not pretend to assert that as fact.
How society views child abuse has changed dramatically over the years. In the 70s and before, there was nearly complete denial, a virtual "Don't Ask, Don't Tell" policy. In the 80s, reports of abuse shot up in frequency, the pendulum swung in the other direction and survivors were often validated. In the 90s, there was an appreciation that memories are malleable and some cases called into question the whole abuse "movement." Survivors, as well as the mental health community, were put on the defensive. Consequently, it was unpopular to be a survivor in the 90s.
In the past decade, we have reached a sort of middle ground. While a final destination has not been achieved, there is momentum. In which direction are we moving? Are we moving in a direction that tends to help or hurt children? What about survivors? I think these are questions whose answers are outstanding.
The pessimistic view is that while children are technically protected by a slew of laws and safeguards, things may not really be that different now. Only time will tell, of course.
Yes, children are taught about safety in school. There is mandatory reporting. On the whole, those are good. But I do believe that one of the consequences of mandatory reporting is that child protection agencies are overworked and understaffed. As a result, judgment calls need to be made, and who falls through the cracks? Like many well meaning responses, we may not be giving the effort enough of a priority.
Another contributor, which effects survivors negatively, is that I believe collective societal denial is still as strong as ever. In my own hometown in 2007, as an example, there was a public case of child sexual abuse at a gymnastics school. Many young women came forward telling of abuse from a decade or more ago; their stories were consistent. There was also a visual confirmation of physical abuse in the present day. When the case hit the press, the reaction from many (but certainly not all) of the gym parents was: "Not true. They are lying. He's such a nice guy. It's all misinterpreted and taken out of context." What was most distressing was that the ones who were closest to the situation were most in denial!
For me, this was a tipping point in my healing journey. I suddenly broke my silence and spoke up publicly. I came out of the shadows. And learned that to heal you cannot be in the shadows. I learned that to heal, you have to validate your own experiences, else you will be continually seduced by denial.
I was not an activist. I simply wrote a letter in our local paper, stood up for the victims and said that I understood the pain that comes from child abuse. And I was not as shy to bring up the scandal when I talked in public. For this, I got a whole spectrum of responses from hate mail to support.
I learned that there are basically two sets of people when it comes to child abuse. One with their eyes open and one with their eyes closed. For me, this helped me appreciate why we are at a crossroads now in our society.
We can only hope that more and more people are having their eyes opened. That the momentum is in the direction of increasing protection of children. And further, for those who are not protected, that the barriers to healing are not as high.
We can do our part, too. I am not narcissistic enough to think that my speaking up here will change the world. But I do believe that the more of us there are speaking the truth in whatever way we are most comfortable, the more we can help push things in the right direction.
When we keep our eyes open, when we seek healing, when we validate our experiences and the effects of our experiences, then we are unquestionably making a positive difference.
This post was partly written in response to the discussions in a recent post titled Pediatric Symptom Checklist.