Latest / System Speak: Complex Trauma and Dissociation / Guest: Pam Stavropoulos, PhD

Transcript

Guest: Pam Stavropoulos, PhD · System Speak: Complex Trauma and Dissociation

• 0:08
  Speaker 1: Over:
• 0:11
  Speaker 2: Welcome to the System Speak Podcast, a podcast about Dissociative Identity Disorder. If you are new to the podcast, we recommend starting at the beginning episodes and listen in order to hear our story and what we have learned through this endeavor. Current episodes may be more applicable to long time listeners and are likely to contain more advanced topics, emotional or other triggering content, and or reference earlier episodes that provide more context to what
• 0:40
  Speaker 3: we are currently learning and experiencing. As always, please care
• 0:44
  Speaker 2: for yourself during and after listening to the podcast. Thank you. Very excited about what you have to offer and what you're going to share with us.
• 1:10
  Speaker 1: Likewise. I very much admire your work. I'm very excited to learn about the Plural Positivity Conference earlier in the year and your and your group's desire to narrow the gap between clinicians and lived experience, I think it's a very exciting time. And I know you've interviewed a number of ISSTD people on your podcast, like Richard Fetz and Peter Barak, so I think it's a really fertile time to be connecting.
• 1:41
  Speaker 2: It's amazing. That's very gracious. Thank you for being with us.
• 1:45
  Speaker 1: Not at all. To
• 1:47
  Speaker 2: start with, go ahead and just introduce yourself a little bit.
• 1:51
  Speaker 1: Sure. Well, my name's Pam Stavropoulos. I'm the head of research with Blue Knot Foundation in Sydney, Australia. Blue Knot Foundation is the peak sort of body for representing the interests of adult survivors of complex trauma in its many forms. We used to be called adult surviving child abuse, ASCA, and the first set of guidelines that we produced in 2012 of course now they're updated in 2019, which we'll talk about but the first set came out under the name of ASCA, whereas now we've had a name change, Blue Knot Foundation.
• 2:28
  So I'm head of research there, working years on the research side, and I'm also a clinician. I have a small private practice with complex trauma clients.
• 2:37
  Speaker 2: How did you get involved with complex trauma?
• 2:40
  Speaker 1: You know, that's a fascinating story, Emma. I connected with Blue Knot Foundation, which was then ASCA, I think it was around 2010, and I was hired to do a research project, a small research project. And to my surprise and shock, I realised there were not guidelines at that time for treating complex trauma as distinct from single incident PTSD. So I said to Cathy, you know, it'd be easier to do this if there were some guidelines in the area. And she said, well, why don't we, you know, apply for a variation on the grant and write some guidelines ourselves?
• 3:18
  So that's literally what happened. And, of course, much of the research comes from your country. There's been a hell of a lot on complex trauma over the years, but it hadn't really been put together in guideline format until relatively recently, and of course our first guidelines were 2012. That was also the same year that the expert consensus guidelines for treatment of complex PTSD came out, of course, so they were being released at the same time as our first set of guidelines. But the, yeah, the background to me being in this field and the guidelines in Australia was literally at the time, quite recently, they all the great research and clinical work in complex trauma had not been formalized into guidelines.
• 4:05
  So we've come a long way since then.
• 4:07
  Speaker 2: It's amazing. It is amazing. And I know that the community is super excited about it, and we've already had Kathy on and talked to her and shared a little bit about sort of her background and how she got involved. And so I'm super excited that you're going to share with us a little bit about the research and the guidelines themselves.
• 4:28
  Speaker 1: Where do you
• 4:28
  Speaker 2: even want to start with all that?
• 4:31
  Speaker 1: Well, look, maybe we can start with Cathy said, maybe it's time to update the guidelines, and I thought, oh, is it time already? Because we know well, time's interesting in itself. It goes very quickly sometimes. But it was six and a half, seven years since 2012, and a lot had changed. There's a lot that stays the same too.
• 4:50
  So maybe the first step is to just sketch out what seemed to have changed since 2012, why the landscape's different, and what some of the main themes of the current update are. Yeah. And then I can maybe fill in some of the detail around the research themes, and and we can to and fro about that. But I guess some of the main changes since 2012, and this one's very, very recent, is that there actually is a formal diagnosis now of complex PTSD, CPTSD. Now diagnosis, of course, is not the be all and end all.
• 5:22
  It's not the only lens by any means through which to view complex trauma, but it does represent a significant achievement of many people, including and notably, of course, Judith Herman, who've tried over many years to get this diagnosis up, and it now is. It will be in the it is the, you know, new iteration of the ICD 11, the International Classification of Diseases, announced its release in June of twenty eighteen, I think it was, and the diagnosis will come into being soon. Unlike the DSM, of course, there's no sort of freestanding complex trauma complex PTSD diagnosed in the DSM, but there is a dissociative subtype. And I remember Christine Courtois saying at the time that the diagnosis of PTSD is becoming more complex. So there is a widespread recognition of the need to take account of the more extensive impacts of complex trauma, the distinctive features of complex trauma, and the treatment implications.
• 6:26
  Yeah, I mean, as I said, obviously it isn't the be all and end all. Robin Shapiro said a long time ago, there's more to trauma than PTSD. There's also more to complex trauma than complex PTSD. So one of the problematics of it is that, to meet the criteria of CPTSD, people still need to meet criteria for standard PTSD, you know, the familiar features that we know of the hypervigilance and the intrusion and the numbing and so on. But, of course, many people with complex trauma actually don't meet the criteria of standard PTSD, so it's going to leave some people out.
• 7:04
  So there are problematics around it, but I think it is important that it does exist. Judith Herman has talked about this. She talked about how the attempts to get that diagnosis up for DSM-four, and it actually passed the field trials. There was great hope for DSM-four, even, that CPTSD would, you know, become a diagnosis in its own right, but it did not happen. And Judith Herman, when she talks about this in the forward to a book that came out in 02/2009, she said the message that came back was that complex trauma or the proposed CPTSD diagnosis involves so many different criteria and impacts.
• 7:49
  You know, it could be schizoaffective, it could be depression, it could be anxiety. There's just so much going on. And Judith Herman's point was, but that's exactly the point. You know, we need a diagnosis that can, you know, represent the syndrome of impacts that complex trauma represents. So, yeah, look, think on the one hand, it's a major achievement.
• 8:09
  On the other hand, it's obviously not not enough by any means, but that's probably the first change and and since 2012. A second one for us in Australia, but also with international implications, of course, is our Royal Commission into Institutional Responses for Child Sex Abuse. Now, that's very interesting because when I presented the 2012 guidelines at the ISSTD conference in Long Beach in Los Angeles in 2012. Doctor Kathy Keseman, who now is the president of Blue Knot Foundation, unfortunately, was unable to be there, was unable to travel at that time. So I just went across and presented the guidelines.
• 8:50
  And I literally had up on a PowerPoint slide, you know, where is the impetus coming? Where is the next movement for complex trauma to be taken seriously? Because Judith Herman made the point long ago that trauma is extremely confronting in all sorts of ways, and to really stay in the public consciousness because it does slip in and out of awareness over time. A lot of this stuff isn't new. It's validated in ways now with the neuroscience and so on.
• 9:20
  But people have known about complex trauma for a long time in the field. And yes, it does, you know, it has slipped from public view. So this is Judith Herman's point that to be, you know, firmly lodged in public consciousness, it needs to be linked to a political movement, which is a fascinating point to make, isn't it, Emma? Because we often have these compartmentalisation. You know, this is politics.
• 9:42
  This is clinical work. This is you know. But, you know, Bessel van der Kolk said a similar thing in his bestselling book, The Body Keeps the Score. He says people will sometimes come up to him and say, why are you talking about politics when you're talking about trauma? And he says, because you have to.
• 9:59
  So that was very powerful when I read Trauma and Recovery, you know, the landmark text of the early 1990s by Judith Herman. You know, all this exciting material, even at the time, even before the neuroscience stuff was starting to break, to read what she said. Know, don't think that just because all this information is available that it's necessarily going to be taken up and advanced, and it needs to be linked to wider issues. So that's why when I was presenting the guidelines the first time, it's like, surely we couldn't lose all this amazing information. But if it does need to be linked to wider public consciousness, where is that going to come from?
• 10:38
  And, in fact, the Royal Commission in Australia was announced a very short time, about a month and a half after that. So that's our movement. That's the vehicle through which public awareness has massively increased since 2012, which is fantastic. Now, of course, whether the recommendations of the Royal Commission, which went on for five years, which was comprehensive, which took enormous amounts of testimony and, you know, inquiry into so many mainstream institutions of society. Not conspicuously, of course, the institution of the family, as we're all very aware, which is the main sort of context in which trauma frequently occurs complex trauma.
• 11:23
  But, nevertheless, it alerted the public, the Royal Commission, to the fact that, you know, complex trauma is perpetrated in the heart of mainstream societal institutions that we've been encouraged to trust in. You know, the church, the local clubs, all sorts of areas throughout society sporting clubs, educational institutions. It is really no institution in which, you know, which is immune from the possibility and actuality of complex trauma being perpetrated. So whatever people do with that information, it's out there now, and that's a major shift. A third major shift, and again, I'll sort of fill in the detail later if we have time is the changed treatment landscape.
• 12:09
  It's now a very dynamic field of course. There's so many different approaches in therapy broadly, not just trauma therapy. And that's very challenging, it's very exciting. How do we make sense of the diversity of approaches that are out there? Are they suitable for complex trauma treatment?
• 12:28
  If so, how do we integrate them? And it's challenging, of course, in terms of even how to represent them, because when we talk about traditional treatments or alternative treatments or mainstream treatments, that's very contingent on where we're coming from, and an approach which may be traditional in one area may be, you know, not at all in another. So, yeah, a third theme has really been to try and make sense of of the congestion of approaches that are out there, you know, the explosion of of inaccess to the Internet that people are going online to, you know, find out all sorts of things, what challenges that pose to the complex trawler field. And the other main piece, I guess, is the dissociation piece. It's not really a piece.
• 13:11
  It's it's prevalent. It's it's huge in its own right, There's much more in the updated version of the guidelines on dissociation and the major need, the great importance of every clinician knowing about dissociation, not just the most severe forms of it, which is often what people think about and think, oh, we don't need to worry about other forms, but it does take many forms, and obviously we're going to talk about this, and clinicians really need to be aware of that. So that was another impetus for the guidelines. I guess one other change that's not opposed to it, but that was announced just in time before we went to press to be able to include was the Jenny Haines legal case. And Jenny Haines, of course, experiences DID and took her father to court.
• 14:00
  And her dissociative self states, her alters we can talk about the language actually testified, you know, in court. That was part of the grounds on which her father was convicted of, you know, the massive abuse that generated her DID and received an extremely lengthy prison sentence. To have a legal validation now, again, we're not saying that, you know, medicolegal axes are the only ones we take notice of, not at all, but it's been difficult enough to get, you know, sexual assault cases into the courts at all for all the reasons that we know about. So to have that recognition of the DID diagnosis validated in that way by a judge within the judicial system, and this is very groundbreaking stuff. So in many ways, we are in quite different terrain, I think.
• 14:47
  Speaker 2: It's different than any ever before.
• 14:49
  Speaker 1: Yes. Absolutely. Absolutely it is. Yeah. So they have ballooned in size.
• 14:57
  Maybe not everybody will be happy about that. We now have 44 guidelines to take account of new themes and more nuance. I won't obviously go through all the guidelines, but there's half a dozen I want to quickly reference. The first one, a new one, guideline six, is about the importance of every clinician knowing the core dissociative symptoms, namely depersonalisation, that sense of feeling disconnected from, you know, oneself or distance between thinking and feeling. There's different definitions of that.
• 15:29
  Derealisation, you know, when the external environment we're estranged from. Amnesia, identity confusion and identity alteration. Now, of course, if all those five symptoms are presentand we'll also talk about the problematics of the word symptoms, I'm surebut if all those five are present, we're in the land of DID. But of course, those symptoms can occur in varied combinations. There's many different dissociative disorders which clinicians need to know about and mostly don't, because dissociation still isn't on the curricula of most psychology and psychotherapy causes.
• 16:06
  And there's also what we call subclinical forms of dissociation, don't meet the criteria for disorder, but which nevertheless may impair people's quality of life. So if clinicians aren't able to detect or at least have on their radar the possibility of dissociation, there's a great chance that, you know, it won't be detected, and that's going to really interfere with appropriate treatment. The other thing, of course, is dissociation, which is basically and, again, there's lots of definitions and different views, and we can talk about that too but, you know, at a very basic level, it's a disconnection from the present moment. And, of course, if that occurs, that's going to be severely inhibiting of therapeutic benefit. If a person's persistently dissociating or even, you know, intermittently dissociating at different points and the clinician isn't aware of that, and, of course, the client themselves may not be aware of that, that's going to really impede the therapy.
• 17:05
  So it's very important that we're all aware of that possibility. Daniel Siegel, of course, has famously talked about mind sight, you know, the ability to focus and be present and so on. And I think it's Cathy Steele who, I think I'm correct in saying, coined the phrase mind flight, which is, of course, what dissociation is. So you're talking about different things here. Christine Fawn has written about this as well.
• 17:33
  So it's really important that we all know about dissociation, what to look for. And, of course, it's harder to detect. We all know about hyperarousal, which is generally more visible. You know, there's often a change in the person's demeanour and skin colour, voice tone, delighted pupils looking agitated. We can all sense something's happened for a person when there's that response.
• 17:57
  But dissociation, of courseand, again, it's complicated when I say it's the shutdown response. There's other forms, and it's possible to be dissociated while being behaviourally active. But in contrast to the general hyperarousal, hypoarousal is less visible, and a person may just look as if they've hesitated or had a moment or not concentrating, and they may be. We're not saying everybody who has a mild attention lapse, you know, is dissociative. But it could also be indicative of an of a response that that's regularly triggered that that the client is experiencing their daily life to their detriment and that therapists aren't even looking out for.
• 18:37
  So it's just so important. So that's guideline six. Then there's guideline 19, which is attune to and integrate diverse interventions and treatment approaches within a phased model of treatment. Again, I can fill in the detail around that, because that's a fascinating change. Or maybe I'll say something briefly on that.
• 19:02
  With the first guidelines in 2012, there weren't many challenges to the phased treatment model, really. It was almost like two ships. I mean, trauma people are doing phased treatment, many other people in the sort of single incident trauma are doing exposure therapies, and there's not much connection between the approaches. But more recently, there's been a challenge to the phase treatment model, we needed to take account of in the guidelines. And the short answer is, I think, the challenge is very problematic, but it did need to be taken account of.
• 19:37
  Definitely I'll say something a little bit more about that in a moment. Phased treatment, think we're still endorsing it in a nutshell, but that doesn't mean that we don't necessarily integrate, you know, where we responsibly can, diverse approaches within a phased model, which may be able to safely accelerate treatment. But anyway, we can come back to that. So that's guideline 19. Guideline 20 is ensure all treatment modalities are dissociation informed as well as trauma informed.
• 20:09
  So, as you can tell, the importance of dissociation many people would now say they were trauma informed in their modalities, and, of course, there's no one complex trauma treatment. But it's still possible for even otherwise good therapies to not be aware of or take account of the dissociative response. And, in fact, EMDR is a very good example of a very well evidenced and very rightly respected and widely utilised modality. As Francine Shapiro said, in what, of course, unfortunately would be her last contribution to the field she established, as she said in the recent iteration of her book in EMDR that came out in 2018, that if clinicians aren't well versed in understand dissociative disorders, utilising standard EMDR protocols can be very problematic. She specifically cautioned against that.
• 21:05
  And, of course, there are varieties of EMDR now that do take account of complex trauma. The field is moving all the time. People like Annabel Gonzalez, Sandra Paulson, there's many people now Laurel Parnell attachment focused EMDR therapy, which is specifically more around rebuilding disrupted attachment and resource installation and so on. That's an important point, I think. Even within particular approaches that are otherwise very good, not everybody within the field is dissociation informed.
• 21:41
  So that's a key point to sort of point out. Whatever approach we're using, we need to make sure that it's dissociation informed as well as generally trauma informed. Another guideline is the importance of updating our understanding for memory. Now, we've produced a quite separate publication I won't say quite separate, it's very relevant, but we haven't reproduced a lot of the material we've done on memory in these guidelines, but we've got the links for people to go to that publication. But basically, it's very, very important, of course, that every clinician understands the distinction between explicit memory, which is largely conscious, largely verbalisable, goes under lots of names, doesn't it?
• 22:24
  Narrative or autobiographical, semantic, declarative. It can be very confusing, but basically explicit is verbalisable and conscious. And then there's implicit memory, which is largely non conscious and not verbalised. It's a distinction between the VAMs and SAMs. I think it's John Arden or someone said the verbally accessible and the situationally accessible.
• 22:51
  So, implicit memory, and there are many forms of that, and it's a complex topic. Basically, this is well, there's different types of procedural memory in the body, you know, riding a bicycle, remembering how to ride a bicycle without necessarily having to consciously focus on that. But in terms of traumatic memory, traumatic memory is a particular form of implicit memory, and it has particular features. Clinicians need to know there's a lot of misinformation now still around memory, but memory is not unitary. It does take different forms.
• 23:22
  It is perfectly possible to forget deep trauma, and in fact, do. That is itself a survival mechanism. You know, the whole discussion around recovered memory, which is a you know, people forget and recall often with situational triggers years later, traumatic events. That that's been shown and established with with the Holocaust, veterans, not just with survivors of child sexual abuse, which is where the debates tended to be. You know, this is how the mind works often under extreme stress.
• 23:56
  So that basic distinction between implicit and explicit memory is very important. And just the last couple I was going to particularly mention before we get onto the research side misconceptions about DID. Yeah, that's very common, despite the very strong evidence base, despite the fact that there are now neuropsychological studies that have compared the resting and activated brain states of people with DID and DID simulators and have shown them to be different. You can distinguish between the different brain patterns if that's the evidence people want to look at. Mean, DID is a legitimate diagnosis, and yet it's still dogged by controversy, quote unquote, by a lot of myth making, you know, that it's all theatrogenic, it's made up, it's therapist implanted, it's culturally specific to The United States, it's the same as BPD, you know that there's a map there.
• 24:49
  So what myself was very fortunate to be involved in, and Bethany Brand and some of your key people in the trauma field, produced an article that we've provided a link for in the guidelines it's called separating fact from fiction. And we go through about half a dozen of these key myths as clearly as we can myth one and then show the evidence of why it is a myth, myth two, myth three. So that's the key one, I guess. Not every clinician is going to read these guidelines and will treat DID, but they do need to know that it's a legitimate diagnosis and how to respond to the misinformation that's still generated. I suppose just one other one I'll mention before getting on to the research is the distinction between getting better and feeling better.
• 25:35
  That comes from Richard Cloughton, of course, has done an enormous amount to contribute to the field and has been very pioneering. If someone's been dissociative and start to recover the capacity to feel, if the dissociative barriers start to dissolve, it's quite likely that the feelings are going to be very challenging, very unpleasant, maybe very scary. And this is precisely the time when a client, you know, when they're starting to break down or dissolve the dissociation, panics, feels terrible, wants to stop therapy, thinks that it's all gone wrong. And if a therapist doesn't understand that distinction and is able to work with it and reassure the client this is not a regressive step, and it's certainly something that can be managed clinically. People can panic when feeling starts to be recovered, rather than realising that, yeah, getting better doesn't necessarily mean feeling better in the first instance.
• 26:35
  Anyway, so we could maybe talk about that. So there are half a dozen guidelines I'd just immediately point to that are perhaps a bit different than the previous ones, and I'm certainly happy to go through that. Maybe I'll just give you the chapter heading. The first part of guidelines are the guidelines themselves, you know, one, two, three. I should also say we've produced two other sets of guidelines on competencies, like what do therapists need, what are the skills that therapists need to work in this area.
• 27:05
  And they're important. That's a short separate set, freely available on our website. We can talk about that. But what's interesting is that a lot of otherwise diverse therapies don't make a number of assumptions often about a coherent, continuous subjectivity that isn't applicable, certainly, with many forms of dissociation. This has very real treatment implications.
• 27:27
  For example, it's standard in many counselling approaches to encourage a client to use I statements quite quickly, you know, owning one's experience. But for a client, and even for many of us, and we'll talk about in a minute the model of the mind, may not be that we experience ourselves at all or in that moment as an integrated, coherent being. So we have to work differently in many ways than standard commonsensical, quote unquote, notions of what good therapy is like. That's a separate set of guidelines and another set on we've got so many guidelines in I won't go on about that. But we have two other sets that are in some ways quite basic and shorter that people may want to look at as well.
• 28:13
  But in the updated guidelines that we're talking about today so the first section is the guidelines themselves, and the second section is the research base, which is the same format as 2012. So we've got five chapters. The first is understanding complex trauma and the implications for treatment. So that looks at the CPTSD diagnosis, also the limits of that, the extensive impacts on self conception, relationships with others, views about the world, ability to self regulate, complex trauma, what it looks like. I remember Christine Courtois saying it's not only that the self is unregulated, it's often unrecognised, which again gets back to the problematics of I statements.
• 28:57
  So looking at shame, which has been described as a core affect of complex trauma, Critiquing some common sense understandings of resilience that's become a bit of a buzzword resilience, and it's very important, of course, to be celebrating strengths. But it can mean that clinicians are insufficiently attuned to the difficulties of the subjective experience of a client. It's perfectly possible, as we know in our field, to tick all the boxes of looking as if we're functioning overall. But the whole point about dissociation is the separation of different parts, know, the disconnections and the lack of co consciousness. So someone may be functioning very well in their work, you know, have relationships, you know, be earning money, and yet their subjective experience is deeply impaired.
• 29:49
  It's very hard for people, of course, for all of us, to present vulnerability. So if a therapist is just happily endorsing all the positives, that being a resilient person, people can miss clinicians can miss where a client's really still struggling. So, yeah, a lot of stuff in chapter one on complex trauma. Second chapter is squarely on dissociation. It's called what is dissociation and why do we need to know about it?
• 30:14
  And obviously, we could have whole seminars on that. I'm thinking one way of looking at it is Rich Shafetz's comment in his great 2015 book Intensive Psychotherapy for Persistent Dissociative Disorders, and I know you interviewed him very recently, when he says think about not about dissociative disorders in the first instance. Dissociation is not mainly about that. It's about how the mind copes with the unbearable. So that is good rule of thumb for us in the field, and it's a very empathic one to rather than immediately go into the notion of disorder.
• 30:48
  Dissociation as a response is highly protective in the first instance. And with complex trauma, of course, the difficulty is that if the mind becomes organised around dissociation as an almost default response, which is frequently, as we know, the product of severe childhood trauma experiences, it becomes problematic, like all defence mechanisms. So dissociation has a number of forms. Many of us would say the problem, you know, we're going say the problem, quote unquote, is when the dissociative response is persistently activated for defensive purposes in childhood. So it's really very interesting that we know through attachment theory, through many approaches now, the vital importance of a child connecting to a caregiver, for survival.
• 31:39
  John Bowlby talked about this. He talked about defensive exclusion. He didn't use the term dissociation. That's fascinating too. Elizabeth Howe and Sheldon Ichkovitz have recently released a book actually, they've released one since then, but I think it was 2016 on what is called the Dissociative Mind in Psychoanalysis'.
• 32:03
  A number of contributors to the book talk about You know, a previous generation of clinicians and researchers in the field were really talking about dissociation in different terms. Winnicott would be another example. The point being, whatever we're talking about is the need for the child to dissociate what threatens the attachment bond. So it's profoundly protective in the first instance. It's an amazing, extraordinary capacity that we all have.
• 32:31
  Obviously, not everybody is going to, depending on our circumstances and a lot of things, develop a dissociative disorder. But there's a sense in which we all dissociate what threatens the attachment bond to our caregivers. So the broad rule of thumb in this area would be the more we have to dissociate to survive and to maintain that bond, it'll protect us in the first instance, but if the underlying reason for it over time is not resolved, it will impair our ability to function and connect with others. It's a very challenging, intriguing, fascinating, important dynamic dissociation that we do need to understand. Guess here I just want to mention, too, Frank Putnam's great book that came out in 2016 called The Way We Are.
• 33:20
  And in it, he puts forward what he calls a state theory of personality, which is really interesting because he points out that, you know, it's still not common among theories of personality, and we know there's many, many theories of personality which he basically distinguishes between developmental and dimensional approaches, are quite different. But on the whole, he's saying, they still presume, predicated on a basically stable, enduring conception of personality, you know, fixed, persistent, globally defining traits that pervade the person's interactions with the world. Whereas, by contrast, he advances the state model of personality, which I think is very interesting and hopefully will start to really be taken up. As he said, that allows a far wider range of disparate behaviours, the state theory of personality. It accounts for the fact because we're all in different states at different times.
• 34:21
  We all respond differently in different contexts. So the idea of a continuous coherent self for anybody is problematic. He says we're all multiple to some degree. Now, that's not, of course, to at all minimise or diminish the situation for a person with lived experience who has very distinct self states that aren't co conscious. So, certainly, if we're talking about DID, it could sound a bit frivolous if I'm just saying, Oh, you're multiple.
• 34:47
  But the point Frank Putnam's making is that, of course, and as we know, as attachment theories, neuroscience, as even common sense when we think about real we are very different according to context. We all do assume different roles in different contexts. There's our work self, there's our home self. So what determines how functional we are overall is how readily we can segue between different self states. And, of course, if somebody experiences childhood trauma, it's going to be more difficult.
• 35:15
  There hasn't been that good enough childhood experience to assist movement between the different states. Coherence is a To the extent that we're coherent, it is a product of our experiences over time. It develops over time. We're not born being coherent, so probably getting into a lot of you know, deep theories about the mind here. But I think that's a really helpful way to see things.
• 35:40
  And how often do we say, you know, oh, that person seemed to act out of character? I mean, all sorts of ways. We're challenged when people respond to things in ways that seem surprising on the basis that we know them. You know, it's not like themselves. Whereas the state theory of personality can account for that.
• 35:57
  It recognises that we're often very different towards depending on the context that we're in. And I think this is something we can all identify with and start to perhaps consider dissociation on a continuum. Not everybody accepts that model, but I think what Frank is saying is really, really important. It has treatment implications too. Mean, ego state therapy is very interesting in itself, and there's many diverse approaches that utilise ego states.
• 36:28
  You could say we all have ego states. Also here, very important, is Richard Clough's point that, you know, when he's talking about DID and structural dissociation, which is the sort of personality divisions that are much more severe than sort of less chronic forms of dissociation that the rest, you know, many of us may slip in and out of without it being severe and disabling. But Rich Cloughton said that all alters are ego states, but most ego states are not alters. So, again, we're not saying that this more sort of normal multiplicity model is putting everything in the same basket and it's all equally not at all. There's certainly more severe chronic forms.
• 37:08
  But we can potentially utilise certain treatment approaches, like ego state therapy, when it's informed by understanding dissociation and so on, to assist clients. Although treatment of dissociative disorders may be regarded as very specialised, and it certainly can be, we're also keen to encourage people to think about how models that we may be familiar with, without thinking that they could be helpful, with suitable supplements and adaptation, can actually really assist work with trauma and dissociation. So that's the second chapter. The third chapter is phased treatment, or basically called revisiting phased treatment. So very briefly on that, I think I mentioned before that in 2012, the expert consensus guidelines on treatment of complex PTSD.
• 37:56
  So, of course, the term being used well before the diagnosis came out just recently. And those 2012 guidelines, as I said, came out at the same time as our first guidelines, so we hadn't been able to read them at the time. But a number of eminent people in our field, very diverse people, you know, Bessel van der Kloeg, Mirri Lou Koitra, Christine Courtois, Julian Ford, I mean, Bessel van der Kloeg, a range of sort of key people in the field said I think it was 85% said they would use a phased treatment approach for complex trauma. That was very much the view, and that represents, of course, a continuation of treatment of trauma from the nineteenth century. You know, it's basically a three phased model.
• 38:37
  It's referred to by different terms sometimes, first phase is stabilisation and safety, which is about assisting the person to feel okay in their bodies, to be able to regulate affect, because it's one of the major things, of course, complex trauma disrupts. The second stage is processing, and of course, the emphasis in the phase treatment model is that you don't go to processing until the person can stabilise and manage their affect. And it's not literally like a one, two, three. Of course, it doesn't roll out completely chronologically. But the whole rationale of phase treatment is that you don't go to processing prior to being pretty sure that the person is able to regulate the feeling that processing is going to throw up.
• 39:15
  And the third phase is the integration. And as I say, the terms are different. I think Judith Heumann talks about remembrance and mourning. James Chew talks about early, middle and late phases. But basically, that phase model has been around for a very long time, the tripartite model.
• 39:31
  And in 2012, it was endorsed very clearly. But since 2012, and this is why we needed to take account of it in the updated guidelines, a number of therapists and researchers and clinicians, mainly from the exposure school, have challenged phase treatment model. Now, what's interesting about this, of course, in terms of research and we'll get on to evidence based treatment in a minute, hopefully is that it's been difficult for a lot of reasons to have outcome studies around trauma, and certainly complex trauma. One of the reasons being the exclusion criteria have been very restrictive. The most severely impacted people who were wanting to get more refined approaches to assist have been excluded from outcome studies.
• 40:14
  So that meant that we in the field could say, quite rightly, Well, you know, our cohort is not being looked at in outcome studies. That's starting to shift now. And Bethany Brand, who, of course, who, you know, the treatment of patients with dissociative disorders study, it's a fabulous international study around dissociative disorders, and that's in the process of being prepared for an RCT. So, again, things are moving on. But, basically, a group of therapists have challenged the phase model, and these are the people who endorse the so called evidence based approach, which sounds great and who would disagree with that at one level, but in fact usually relates to short term exposure based, you know, what are called first line trauma focus.
• 40:59
  There's a few terms that can be a bit confusing. When I first heard the term trauma focused, I thought, Oh, that's great. They're focusing on trauma. But, in fact, it's a more particular approach. And what these first line evidence based treatments have in common generally is taking issue with the phased approach and thinking we don't need a first phase stabilisation.
• 41:20
  We can go straight to processing. And the rationale for that there is some rationale. We're not saying phased treatment is beyond criticism, and we'll get to that in a minute too. But the approach The rationale for that is that if we spend too much time or even at all doing stabilisation, we're withholding, you know, very helpful evidence based treatments that can assist people more effectively and efficiently and quickly and so on. So that sounds very good on the face of it, but it fails to recognise what many of us would say the more distinctive features of complex trauma is that people with complex trauma start in a very different position than people who, you know, may have anxiety or even single incident trauma.
• 41:59
  And certainly, if a clinician isn't savvy about round dissociation, they can miss signs of it, and it's possible for the client to be triggered by and within the treatment itself. So when we hear about prolonged exposure in particular, it's another one that, oh, you know, this is all great prolonged exposure is recommended. There's a lot of approaches that will say that. There's a lot of research there, but we're wanting to draw people's attention. Well, there's many of us in the field too who say, well, we're not so sure about that, and there are studies around that too.
• 42:28
  So we've put that in the guidelines. Judith Herman said, I think it was in 02/2009, very explicitly, what one does not do in the early phases of therapy for complex trauma is any form of exposure therapy. And the emphasis is on any. And Peter Levine, who's a very different clinician and researcher in some ways, he, T2, in his fantastic book Trauma and Memory, has been quite critical of exposure therapies and certainly prolonged therapies for trauma in general, much less complex trauma. And he makes use of that wonderful, you know, the image of the Greek myth of Perseus and fighting the Medusa, when the goddess Athena advises Perseus not to look directly into the eyes of Medusa because he'll be turned to stone.
• 43:16
  You know, Medusa, the sort of Gorgon with all the tentacles coming out of her head. And she advises him to use a shield. So when Perseus fights the Gorgon Medusa, he's reflecting the face in the shield rather than looking directly at her. I think that's a lovely way of conveying the concern that many of us have about exposure therapies, which is about going straight in, you know, looking at the eye of the storm. And there's also questions about what we're even exposing people to.
• 43:42
  Mean, trauma is about interpersonal violation and betrayal often. It's not about spiders and simple phobias. It's another point Peter Levine has made that exposure therapy goes back to the '50s, isn't it, with Joseph Walper? Very specific simple phobias. So extrapolating from that to, you know, more current variants and prolonged exposure, as if that's the same thing as complex forms of trauma is a whole other animal.
• 44:12
  Yeah, so it is a case that complex trauma people are now being included in more studies, but many people are the exposure therapists are saying, oh, well, that just shows that it's just as good exposure therapy and first line treatments and evidence based. You know, childhood trauma history doesn't preclude you from benefiting from exposure. Well, many of us would have doubts about that, so we're looking at that in Chapter three. Now, having said that, that's not to say, as I said, that phased treatment is beyond refining or we don't need to revisit it in any way. Basically, we are still endorsing it.
• 44:44
  Absolutely. There has to be some kind of phased approach. And, you know, if you look at some of the critics of phased treatment, when you look at what they're actually saying, they're implicitly adhering to a notion of phases anyway. They might not call it that, but it's hard to see how the range of impacts of complex trauma in particular cannot be addressed in some kind of attempted sequence way, because somebody who can't self regulate is in a different position than somebody who can. Another important distinction is unpleasant and unbearable.
• 45:15
  What people are exposed to, obviously, if someone's severely anxious, that's very unpleasant. But it's not quite in the ballpark of overwhelm and trauma .you know, complex trauma related dissociation, where the dissociations occurred in the first place because it was overwhelming. So we do risk in endorsing evidence based treatments with people who do, oh, it's all great for all sorts of forms of is putting in the same basket what are actually qualitatively different things, arguably. So that leads to the next thing. Well, how do we where do we go from here then?
• 45:47
  And that is this whole notion of new treatments. Is it possible to integrate some of the insights and interventions and approaches of very different and sometimes short term. That's what's interesting into the different phases of phase treatment. So that leads into the next chapter called New and Emerging Treatments New, quote unquote. The ones specifically look at are energy psychology, EMDR, brain spotting, which is a fascinating, more recent therapy, clinical hypnosis, and MDMA assisted psychotherapy, which of course is really taking off and will be, I understand, quite readily available for psychotherapy purposes in your country.
• 46:34
  So there's a lot of diverse approaches that are challenging the way we think about what effective treatment looks like. So we're sort of looking at how do all these interesting approaches, many of which do have an evidence base, so we're making a distinction between evidence based in the sort of standard, short term, exposure based, trauma focused and so on, and approaches for which there is an evidence base but not necessarily one that's recognised by formal trials or that is in a position to offer formal trials within that stricture. And there are problems within formal research methods too, which we'll get to in a minute. But that's basically what chapter four is about, looking at all these different approaches and how might we utilise, draw on to assist people with complex trauma, and do they take a candid association and can we assist more effective stabilising safety processing? So it's possible, say, that it's an intervention of energy psychology, say.
• 47:35
  I'm just saying that. I'm just pulling that out of the air. There's a million things out there, but energy psychology is quite well evidenced in its own terms. I don't practice it myself, but I know people who do. It's possible that an intervention from that field potentially could assist somebody in phase one, you know, whereas many of us who haven't taken account of some of these so called newer therapies, which, of course, they're not new, but depending on where we're coming from, so we're really missing out and perhaps unwittingly shortchanging our clients by not recognising just what is out there to address challenges, especially around physiological relaxation, which is very challenging, of course, for dysregulation and complex trauma clients.
• 48:19
  We all know now that phrase, bottom up rather than top down, or bottom up as well as top down. A lot of our therapies are still top down. This is a point Schwarz and Corrigan have made, that many therapies for trauma are still protocolised, which would be the sort of evidence based stuff, and affect phobic. So there's still kind of privileging cognition often and not working with the body. Now, to some extent, that's changed.
• 48:48
  We're all aware of the importance of somatic stuff now, of physiological soothing, but what that really means is quite major in a challenge, to some extent, to talk in therapy. We need to be able to find ways to integrate interventions that can assist people physiologically, because many would say and, of course, polyvagal theory very important and that's now being developed into clinical application. There's now clinical polyvagally informed therapies. Stephen Porges is an enormously important person, and interestingly, a key exponent of energy psychology has said that it's often been regarded as a strange, weird treatment, but it's possibly the case that Stephen Porges' polyvagal theory is providing the evidence base that didn't exist before. One of Stephen's major contributions is this notion of neuroception, which is detection of threats prior to awareness.
• 49:50
  He'd say neuroception precedes perception story follows state. What we tell ourselves about our experience, the meaning we make of our experience, actually follows our physiological response. That's hugely significant. In fact, he uses the phrase 'cues of safety are the treatment'. When we're able to recognise that and to integrate approaches and interventions that can assist people to soothe and stabilise physiologically, there will be major psychological benefits.
• 50:28
  This is very challenging to think about story following scope rather than proceeding. It's quite challenging to talk therapies. That also leads to, I guess, the final chapter, which is evidence based and the challenge of and for complex trauma. I've already mentioned the distinction we're making between evidence based and an evidence based. But the model of evidence based has been criticised.
• 50:55
  It is conceded, even by its most fervent adherents, that it does not work for many, many people. It's one thing to have an evidence based treatment, but translating that clinically is a whole other ballgame. There's many people who are missing out in terms of effective treatment if we were to hold, you know, the only standard to use as evidence based treatment. I think that's an obvious point for many of us, but perhaps not obvious for others who are working from different perspectives. Stephen Porges has talked about a top down bias in medical research, which is a fascinating point.
• 51:26
  It's not just, you know, we therapists who are saying this, the bias towards measurement of motor fibres at the expense of sensory fibres. Obviously, his work is around the vagus nerve, which he says approximates 80% of sensory fibres. Yet a lot of the emphasis in the laboratory in terms of formal studies and medical research does, in fact, contain a bias towards the emphasis on motor fibres rather than at the expense of sensory fibres. This raises a whole interesting issue, Emma, of what we're even talking about with evidence for psychological therapies. The more we take account of the body and the importance of somatic approaches, the more we take seriously bottom up as well as top down approaches, the whole issue of what effective psychological research even is is raised.
• 52:25
  This is a point that Bruce Eckers made, that David Graham's made, talk about phenomenological rigour that clinicians and clients have access to in terms of real world fluctuating changes and states within the therapy room, rather than something abstractly measured in a top down way that's biased in the ways that Stephen Gorgias describes. It's very interesting. It's very dynamic, the field. We're basically just wanting to distil. A lot of it is sort of summary, it is research.
• 53:02
  There's a lot of references. We're hoping it will encourage people to become aware of dissociation and some of the variety of approaches that are out there and how they might be responsibly utilised within treatment of complex trauma. And I guess that's the next phase that we're looking at, is how to do that. How can we draw on approaches that are perhaps very alien to us but which perhaps do accord with the principles of polyvagal theory, the neurophysiological foundations of affect, and how we integrate those into a phased model yeah, to potentially safely accelerate treatment, but not in the sort of short term traditional way, if that makes sense. That's amazing.
• 53:51
  Speaker 2: Thank you so much for sharing with us.
• 53:54
  Speaker 1: It's very exciting, isn't it? It's a very exciting time, I think, for our field. Yeah.
• 53:59
  Speaker 2: It's a huge thing.
• 54:00
  Speaker 1: Absolutely. Yeah.
• 54:02
  Speaker 2: Can you tell people where the link is so that they can find it?
• 54:05
  Speaker 1: Sorry. The link to the guidelines? Yes, ma'am. Oh, okay. It'll be www.blueknot.org.au.
• 54:17
  That's the general link Blueknock Foundation, but pretty quickly you'll find a link to the guidelines, which are downloadable free of charge or also available in hard copy for a small charge. We do want this information to be readily available and accessible. I'm sure you'd agree, Marina, it's just so important that we're aware of this complexity, but also that there's ways of making sense of it and ways of working with it more effectively than we've known how to do before.
• 54:48
  Speaker 2: Thank you so
• 54:49
  Speaker 1: Not at all. Very most welcome. And thank you for your work. I always listen to your podcast and very much enjoy them, and they're fantastic. Yeah.
• 54:59
  Thank you, Emma.
• 55:00
  Speaker 2: Thank you for your time. I very much appreciate it.
• 55:03
  Speaker 1: Not at all. Hope to talk to you again.
• 55:06
  Speaker 2: Oh, thank you. You you were amazing. You provided such a great overview of all of it and gave such information and the research behind it and helping people connect the dots between what you're presenting and the theories and where it's all come from and the need for it. And it's it's interesting because I feel like in a way, in that neuroception kind of way, the community has felt a need for it. And now it's sort of been almost in that attachment repair kind of way.
• 55:40
  It's almost validated that need. When the research comes into place and says, no, this is this and this is this and why we are pulling it all together.
• 55:48
  Speaker 1: There's a great way to put it, Emma. It is it's it's bringing together like, there's so many insights and, you know, so much now available, and we need to make those links and draw on on, you know, what we can use to really help and assist. Absolutely. Yeah.
• 56:02
  Speaker 2: Yeah. And there's there's layers and layers of how powerful is in the different ways that it's powerful. It's such rich content. It's such important history and the research being all pulled together in that way. And then it's just powerful in how it's applied.
• 56:20
  There's just so many layers to it.
• 56:21
  Speaker 1: Absolutely. Yep. Yep. Thank you. Yeah.
• 56:25
  Speaker 2: Thank you so much for your time. I appreciate it. Thank you for joining us with System Speak, a podcast about dissociative identity disorder. You can listen to the podcast on Spotify, Google Play, and iTunes, or follow along on our website, www.systemspeak.org. Thanks for listening.
• 57:24
  Speaker 4: Thank you for listening. Your support of the podcast, the workbooks, and the community means so much to us as we try to create something together that's never been done before. Not like this. Connection brings healing, and you can join us on the community at www.systemsspeak.com. We'll see you there.