Latest / System Speak: Complex Trauma and Dissociation / Guest: John O'Neil, MD FRCPC

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Guest: John O'Neil, MD FRCPC · 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 we are currently learning and experiencing. As always, please care for yourself during and after listening to the podcast. Thank you.
• 0:59
  Speaker 3: Several months ago, in EMDR training with the ISSTD class, there was a quote that we discussed at length about the subjective phenomenological model of dissociation. And as we discussed the authors, I realized that I knew them from consultation group with Peter. And so I asked John O'Neill to come on the podcast and talk with us about the quote. Doctor. John O'Neil is a psychiatrist and psychoanalyst in Montreal, Quebec.
• 1:30
  He was assistant professor of psychiatry at McGill University and staff psychiatrist at St. Mary's Hospital until his retirement to private practice in June 2018. Doctor. O'Neil joined the ISS MPND in 1991 and has attended every conference since then, and now as it is called the ISSTD. His private practice has progressively narrowed to the diagnosis and treatment of dissociative disorders.
• 2:01
  Over the years, Doctor. O'Neil became a fellow of the ISSTD, co taught ISSTD's day long introductory workshop for eight years, hosted the town hall meetings for six years, became an ASCH approved consultant, has taught in the ISSTD's professional training program at all adult levels except the master class in Montreal and in Burlington, Vermont, and online. In 02/2009, the '46 chapter book Dissociation and the Dissociative Disorders, DSM-five and Beyond, was published, coedited by Paul Dell and O'Neil, for which O'Neill received ISSTD's Pierre Genet Writing Award. He is currently an assistant editor of the planned second edition of the book, now being coedited by past presidents Martin Dore and Steve Gould. You will hear him in the interview reference this book as the brick because it has a thousand pages, and it's a very large book.
• 3:06
  And it's from this book that the quote we discussed in class originated and why I wanted to talk to him about it. I had not realized until this day in class that my friend John O'Neil from consultation group was the same John O'Neil as the author of this book. So it was fun to put that piece together, and we are glad today to welcome John O'Neil to the podcast. Welcome, doctor O'Neil.
• 3:33
  Speaker 1: You're going to be raising whatever topic you wish to raise with me?
• 3:38
  Speaker 3: Yes. There's only I only have the one specific thing about the quote from you and Paul Dell, but just very simply Sure. About how you got into working with dissociation and how you define it and just very it's very, very easy.
• 3:56
  Speaker 1: Okay. So hi, everyone. Yeah. So I'm doctor O'Neil, John O'Neil, and I've been involved in the diagnosis and treatment of dissociative disorders, Fragus, about three decades now. And I'm also a psychoanalyst and a certified consultant with the American Society of Clinical Hypnosis.
• 4:26
  I have EMDR certification. And I co edited the fat book that some people call the brick because it's 1,000 pages long and with Paul Bell in 02/2009. Currently, it's in its second edition, but this time being co edited by Martin Dorhee and Steve Gold with bit of input from Paul and from me.
• 4:55
  Speaker 3: How did you first get involved with dissociation or first start learning about dissociation?
• 5:01
  Speaker 1: My wife, who's also a therapist, was working at Sejeff, it's a junior college in Montreal. And she was referred a patient by a colleague of hers who said, I think this one has multiple personality disorder. And my wife thought, yeah, right. As if that's never going to show up here. Anyway, she saw her and thought she had multiple personality disorder.
• 5:33
  So she referred her to me, and I saw her. And I thought she had multiple personality disorder. And this was a surprise to us. I in fact had seen my first case in 1978 when I was a first year resident at the Jewish General Hospital in Montreal. And I thought it was the only one I would see in my career because at the time, the idea was that they were one in a million and, well, six million people in the province of Quebec.
• 6:07
  And I'm seeing one of them. One of the chances. Anyway, so she made a certain impression on me in 'seventy eight, but not enough for me to really catch on to what to look for. And so then in the early 90s, there was this case that my wife had that I saw. And that sort of revived my interest in the possibility of a diagnosis.
• 6:37
  And then we went through the usual thing of thinking back over previous cases we had seen before that in retrospect, we thought probably had multiple personality disorder, which is what DID was called in those days. And joined the ISSTD, which at that time was called the ISS MPND International Society for the Study of Multiple Personality Disorder and Dissociation. And then we went on from there. So that's how it began. And so in the '90s, we learned from the, I guess you could say the masters of the time, the top gurus of the time.
• 7:34
  And I guess since then, oddly enough, well, I've I've been in it long enough now that I'm considered one of the one of the gurus, especially since coediting that book with Paul Dell.
• 7:49
  Speaker 3: The book with Paul Dell was quoted in a recent EMDR class that I took from the ISSTD EMDR class that they're giving. And when it was talking about dissociation and introducing dissociation specifically, how before we talk about the quote from the book, how do you usually explain dissociation? When you're doing a training or seeing a client, how do you explain dissociation?
• 8:21
  Speaker 1: I don't use the DSM definition because it's too short gun, if you like. It's it has too many too many bits of shot and puts them all together. I I make a fairly strict distinction between kinds of dissociation. And one kind is depersonalization, derealization. Another kind is association of specific mental faculties or functions from central consciousness.
• 9:03
  So that includes memory, motor functioning, sensation, things like that. Sometimes affect, you can think about, in other words, a particular body part that may be dissociated. And so you have anesthesia in that body part. So that would be like dissociation of sensation. You might also have dissociation of motor control so that an arm might be paralyzed or something like that.
• 9:36
  So you can have bodily symptoms. And you can also have psychic symptoms like dissociation of memory if you have amnesia or dissociation of affect if you have total blunting of affect or whatever. You can certainly have other kinds of dissociation like dissociation of impulse if you suddenly have no drive or initiative to eat or to relate or whatever. So you can have various kinds of dissociation of mental functions. And then finally, you can have dissociation of identity or what is really multiplicity consciousness where there's more than one conscious agent.
• 10:31
  And that really is restricted to DID and OSDD one or other specified dissociative disorder example one, which is basically some threshold DID. And those three meanings are really quite distinct from each other. Even though if you have multiplicity, as in DID or LSD1, then you or any one of your others or alters or other self states or whatever language you prefer to use may individually or as a group have symptoms from the other kinds of dissociation such as personalization, derealization, or dissociation of sensation or motor function or whatever. So I don't know if that's more confusing than clarifying, but to put it simply, depersonalization, derealization, to some extent, stand apart. And then dissociation of mental functions includes amnesia, and it includes what normally would be called conversion disorders.
• 11:59
  And then there's multiplicity itself, which is sort of something else again.
• 12:05
  Speaker 3: This was interesting to me in class, and the reason it got my attention is because it's the first time that I saw them in an educational setting distinctly grouped like that. Even though this work is a classic work, any time that I've had just in public education a presentation lecture about or textbook about dissociation, it only presented it in my experience, it was only presented as almost like a continuum, but you're explaining that these are different distinct things.
• 12:43
  Speaker 1: Each one has its own continuum. So you can have considerable dramatic multiplicity, for example, But it may be that depersonalization and derealization is not present dissociation of faculties and functions is that will almost always be there. But whenever you have it, you wonder what it's about because they're all presenting symptoms that aren't well, it's never something in its own right. So if have an anesthesia of a body part or if you have a flashback, a post traumatic flashback, then you, again, need to figure out what it's about before you really know where to put it. So some of these things are presenting symptoms that require further investigation to find out what they're really about.
• 14:01
  And others are, well, sort of if they're there, they're there, and that's all there is to it. If multiplicity is there, then it's simply there, and that's all there is to it. With regard to the other symptoms, they can come and go and, need to be further interpreted.
• 14:22
  Speaker 3: You also mentioned EMDR. What is EMDR like in treatment in dissociative disorders?
• 14:30
  Speaker 1: I use it, very select I selectively when there's a specific trauma that comes up in the course of therapy, which is sort of subjectively, continues to be subjectively a bit overwhelming to the person concerned. And it is one of the ways that one of those traumas can be worked on or worked through. It's not the only way, but depending on the patient, some patients respond better to EMDR, some respond better to hypnosis. So it's really a clinical judgment call that I make together with the patient as to how best to tackle when given fairly acute and focused symptom.
• 15:32
  Speaker 3: What it what about hypnosis? You mentioned hypnosis as well. What is that like when treating dissociative disorders?
• 15:39
  Speaker 1: Dissociative disorders are auto hypnotic. So anyone who has a dissociative disorder is engaged in self hypnosis to some degree. So in treating anyone with a dissociative disorder, there's two ways to go about it. One way is simply to employ or facilitate the patient's own self hypnotic abilities or whatever. It's almost like directing traffic, you know, suggesting, oh, why don't you go this way?
• 16:16
  Oh, okay. Oh, I'll go that way. And in patients who are perhaps less spontaneously autohypnotic to use what we call hetero hypnosis, which is where you induce a hypnotic state to facilitate further work. So from my point of view, working hypnotically and doing therapy with someone that has DID, for example, or OSDD one, well, it just comes with the territory. It's automatic.
• 16:58
  Speaker 3: How have you seen treatment of dissociative disorders change or evolve from the beginning to now?
• 17:07
  Speaker 1: In the early 90s, the stress was really on what we would now call stage two. And, that meant confronting and working through traumas and doing a lot of that work. And that led, I think, to quite a few casualties, therapeutic casualties, which is what led to the development really of a staged approach, where with stage one you work very hard on containing and maximizing normal functioning, maximizing emotional stability, maximizing sleep regularity, and good diet, and good self care, and all the sorts of things that someone really ought to pay attention to before you go diving into working through the specific life events that led to the condition in the first place. So the major development that I've seen since I got involved has been the staged approach and the much more careful and gradual approach to treatment than we saw in the early 90s is the major difference.
• 18:41
  Speaker 3: What would you want someone who's just being diagnosed with a dissociative disorder to know? What would you want them to know?
• 18:49
  Speaker 1: It would depend on which dissociative disorder they were diagnosed with. There are cases of, you say you never heard about the three being separated out that way. But way back in DSM II, was not part of the equation. And so it stood alone. And the other two kinds were called dysuria, dissociative type and conversion type.
• 19:24
  And then in DSM-three, those two were separated out. So conversion went over to the somatoform disorders and just, well, MPD was with the dissociative disorders. And thrown in there was depersonalization disorder and amnesian puke. But amnesian puke could have gone over to the somatoforms, except that it's more in the head than in the body. So the divisions that you said were novel to you have very clear representatives history of how to classify dissociation.
• 20:09
  And so when faced with a client today, it depends on whether they have pure depersonalization, derealization disorder, or if they have relatively pure dissociative amnesia with or without a few or relatively pure somatoform dissociation, because that's the other word that's given to it. Or most commonly some form of multiplicity that has some blend of those other symptoms mixed in. So it depends a lot on the diagnosis, keeping in mind at the same time, of course, that any of the symptomatic displays of what we call dissociative symptoms, such as depersonalization, derealization, or sensory motor conversion, or pseudo neurological symptoms can all be surface presentations of underlying multiplicity. But they aren't all necessarily that. So diagnosis is important and it's often a work in progress.
• 21:33
  It can sometimes take weeks or months to really pin down exactly what the underlying condition is. And certainly I've had patients whose multiplicity didn't show up for a couple of years. And then it was not dramatic, but it still did show up and made a major difference treatment once we could address it. Pure depersonalization derealization disorder remains a bit of a statistical outlier or the odd member of the group. It's less well understood.
• 22:17
  The cause is less well understood. The treatment is less well understood. Despite the fact that it's perhaps seems to be less severely symptomatic, fairly narrow, it can be quite severe and may need to be treated in a way that's quite different from some of the other dissociative disorders. So it depends very much on the patient and how they present. And, what you figure out is what you and the patient together figure out what it is that needs to be dealt with.
• 23:02
  Speaker 3: Why do you think that these pieces are not taught? Like, why is so much left out? I feel like if I had not found ISSTD and received such incredible training through the classes and webinars and conferences and trainings that there's so much I never would have known because it was not taught at all. And when I work in hospitals, the doctors and physicians and emergency room people, like, they have no idea. They really they it's not just that they're stereotyped against it or because of stigma.
• 23:43
  Like, there's really a gap in knowledge. Why why does that happen?
• 23:49
  Speaker 1: Well, it happens because most people wish that it didn't exist, especially multiplicity. And even within the DSM-five, and it's been true ever since the DSM-three, and even in the DSM-five, if you don't specifically go to the section on dissociative disorders, you don't read about it anywhere in the rest of the DSM five. So if you're reading the section dissociative disorders in the DSM-five, then when it comes to differential diagnosis, you'll be referred to schizophrenia, you'll be referred to ADHD, to bipolar disorder, to anxiety disorders, PTSD, to personality disorders, to substance use disorders, as you read through the different things that ought to go through your mind when seeing a patient that you think may have a dissociative disorder. But when you go to any of those other sections, dissociative disorders are never mentioned. So that's an internal contradiction within the DSM-five for which there is no good excuse.
• 25:18
  If you go to schizophrenia, it will not mention as a possibility a dissociative disorder. If you go to bi affective disorders or bipolar, it won't mention DID as a possibility. Most egregiously, I guess, if you go to borderline personality disorder, even though one of the criteria says transient stress induced paranoid or dissociative symptoms, it won't list a dissociative disorder in the differential diagnosis of borderline personality disorder. So these are basically anyone who doesn't specifically look at the dissociative disorders will read the rest of the DSM and conclude that dissociative disorders don't exist. You're never prompted to think about them.
• 26:15
  And so if you have a gross deficit like that in a document as important as the DSM, it's not surprising that you'll find it as well in other approaches to mental functioning. There's another example. If you look over the criteria for general personality disorder in DSM-five, you find that a general personality disorder assumes and requires that there be only one pattern of functioning, one pattern of personality expression and so on. And that immediately means that anyone that has any form of multiplicity can't have a personality disorder and isn't being talked about in that entire section. Despite the fact that most people that have internal others, other self states, alters, others, whatever you want to call them, the personality differences within a given person may be really quite dramatic, at times even exaggerated.
• 27:43
  So that's another example. Virtually all personality theorists assume that there's only one personality that one can have. And so if you were to ask the majority of psychiatrists and the majority of academic psychologists, What do you think of dissociative disorders? The accurate answer would be we don't think of them at all.
• 28:17
  Speaker 3: What would you tell either new clinicians or clinicians who are new to treating trauma or dissociative disorders? Where can they start to learn?
• 28:27
  Speaker 1: Well, they can start to learn by, you can point them to the dissociative disorders section of DSM-five. That's kind of the baseline, rudimentary, entry level sort of thing because it's short, it's sweet. But more important, it's official. Something really simple, the population of Greater Montreal is about 3,000,000. And so if you live in an urban setting that's around 3,000,000, the official prevalence of DID is supposed to be one point five percent.
• 29:05
  And 1.5 means that there's forty five thousand cases of DID in Greater Montreal. That, by the way, is a huge number. It's more than the number of schizophrenics. It's way more than the number of illnesses that are readily identifiable, like rheumatoid arthritis or things like that. Most illnesses are numbered by prevalence in number of cases per 100,000.
• 29:46
  But when you have one point five cases per 100, then you're dealing with a huge prevalence, which despite that fact, well, they generally aren't identified. I think there's a good reason for that, which is that the range of symptom expression of people, let's say, with DID is enormously wide. And I think it's kind of obvious given the numbers that the huge majority of people with DID fly under the radar, don't become symptomatic enough to be brought to the attention of clinicians and live their lives and then die without ever being identified. So any one with DID who's identified as having it at any point in their lives are at least in the medium range, if not the severe or extreme range symptom expression for DID. So that's why certainly in the earlier days, they typically showed up with diagnoses of atypical schizophrenia or atypical bipolar disorder or borderline personality disorder or atypical anxiety disorder or complex PTSD or whatever, but rarely ended up actually getting the correct diagnosis of DID or MPD in the old days.
• 31:41
  Well, there's one issue that we haven't brought up, is the reason you decided to invite me to talk at all, which had to do with the phenomenological definition of dissociation.
• 31:57
  Speaker 3: Oh, that's that's right. So in the EMDR class, in the training manual, it's on page 39. I don't know if you have a copy of the manual, but it's on page 39. It says subjective phenomenological model of dissociation by Paul Dell and John O'Neill have suggested that dissociation has two distinct sets of phenomena whose relationship remains uncertain and which commonly co occur, faculty dissociation and multiplicity.
• 32:28
  Speaker 1: Oh, okay. Yeah. And, there, I guess, the personalization and realization are folded into faculty, although they really do stand apart. The subjective phenomenological model of DD is it's more Paul Dell's approach. And it has to do with what symptoms are most typically, by the way, phenomenological means what is it that the patient experiences?
• 33:08
  That's what phenomenological means. And what is it that the patient experiences that they can describe to you and that you can put a name to? So that would be the phenomenology of association. So what are those symptoms? And they include things like depersonalization, derealization, intrusions such as hearing a voice or getting an image or feeling something in the body or finding your one of your body parts doing something that you didn't do on purpose with a hand or a gesture or something or saying something that you didn't intend to say, but the words just come out and there it is.
• 34:01
  So very much the intrusions, the amnesia, of course, and so on. So the phenomenology is anything that you can attribute to any symptom that a patient may have, which indicates to you that there is some dissociation going on in the patient. And so the range of symptoms is really very, very high. And in the case of DID or OSDD-one, the most glaring of these would be these sort of subjective intrusions into your own consciousness. So that's the phenomenological model that that Paul prefers.
• 35:04
  We had lots of debates about it, though, because if you see dissociation as that which keeps things apart, then every time you have an intrusion that's not being kept apart very well. If it were being kept apart really well, then it wouldn't be intruding on you. So those are, again, two different ways of using the word dissociation. Even though someone with rather strict severe DID, for example, whose host personality experiences absolutely nothing except lost time episodes. And there may be evidence from other people and from everything else about what they were like and what they did and all that sort of thing during the amnestic episode.
• 35:55
  And they may have no consciousness of that at all. So in that case, the only symptom is amnesia. On the other hand, if they also experience intrusions and co presence and sort of unintended acts and symptoms in the body, then this from one point of view, you can say, oh, that's all dissociation. You can also say, yeah, but it also means that the dissociation is starting to weaken because you're getting all these leakages in a sense and intrusions from the others. So they aren't as dissociated as they used to be.
• 36:39
  They're now a little closer, a little less dissociated. So
• 36:45
  Speaker 3: Sorry to interrupt you. Is that why it can feel worse before it feels better?
• 36:51
  Speaker 1: Oh, yeah. Absolutely. Yes. Exactly. Because, you know, if you have complete, like, airtight dissociation, then all you know is yourself and amnesia.
• 37:11
  But if you start to have leakage of dissociative barriers, so you then experience all these intrusions or co presences and all that sort of thing. It may be from a subjective point of view highly uncomfortable, although from a strictly degree of pathology point of view, if you want to put it that way, that's because you're becoming slightly less dissociative. And some of the divisions between you and your others are starting to weaken. And you're starting to have more co consciousness, more co presence, more symptom sharing, and so on and so on. Yeah, so exactly what you just said is quite true indeed.
• 38:04
  Does that make sense?
• 38:06
  Speaker 3: It does. Thank you.
• 38:08
  Speaker 1: Is there anything else you'd like me to comment on or that you want my opinion on?
• 38:14
  Speaker 3: There's just like you said, it's just so big, and there are so many pieces. And this specific quote was what I was curious about, but you explained that. It lists on the paper, it lists them two separately, the faculty dissociation and multiplicity, but you are separating out a third one as well to put depersonalization and derealization in a third group. Is that right?
• 38:41
  Speaker 1: It's not really that I'm separating it out. I'm declining to put it together. Just remember, it started separate. It started separate in ICD-nine, DSM-two, and then it was put together by DSM III. So it's only been considered dissociative since 1980.
• 39:03
  And ICD-ten declined to put them together. ICD-eleven is finally putting them together. Depersonalization, derealization remains kind of the oddball in all of this, which basically means that it's really difficult to figure out exactly what it's about and what causes it and how to treat it and how to rise to this and everything else. For example, for faculty or functional dissociation or multiplicity, the origins in trauma and neglect are much clearer than for depersonalization, derealization. And depersonalization, derealization seems to be more like related to disordered attachment.
• 40:09
  Now, I know you've had Peter Baruch on, and he's talked about detachment as, or rather disordered attachment as a key to all dissociative disorders. And I think he's right in that regard. But you almost always get trauma as well in those other things. Whereas in personalization and realization disorder, you often can't get a real history of trauma or overt neglect. But you may get basically bad, screwy, inappropriate mother child attachment patterns, but not necessarily more than that.
• 41:02
  That doesn't mean that that's what it is, but that's that's what that's what tends to show up.
• 41:10
  Speaker 3: That goes back to Simone's research in the spring with the MRI scans about relational trauma being more damaging neurologically.
• 41:20
  Speaker 1: Yes. And that's been true for quite a while. And it's interesting that on the one hand, it's always easier to notice, to put your finger on, to point to a trauma because it's a specific event than it is to point to something that's missing. It's always easier to identify bad things that happened that shouldn't have happened than it is to notice or identify good things that didn't happen that should have happened. And at the same time though, all of the research that points to basically attachment and neglect on the one hand versus overt trauma on the other.
• 42:20
  It's the attachment and neglect that are better predictors of multiplicity and other kinds of pathology than the trauma itself. So like I say, the trauma is easier to notice and to deal with and to confront and to identify and everything else. But it's not as important either from a cause point of view or from a treatment point. Not as easy. It's harder to notice and harder to treat.
• 42:54
  Let's put it that way.
• 42:55
  Speaker 3: Thank you so much.
• 42:57
  Speaker 1: You're welcome. That'll do for today.
• 43:00
  Speaker 3: No. You were brave and good. Thank you. I'm sorry to have bothered you. I just I didn't even know.
• 43:08
  I don't know. I hadn't connected the dots even that I knew the name and the book, but I didn't realize it was you. And we were in class and he was talking about you. And I was like, wait. Wait.
• 43:19
  I know this guy. So I just wanted to hear from Yeah.
• 43:26
  Speaker 1: Sure.
• 43:27
  Speaker 3: It was interesting because I I don't know, you know, what was blocking that there, but I had literally you to the book. So when I heard you in class, I thought, oh, I know who that is. I need to ask him. I can just ask him. Well,
• 43:44
  Speaker 1: think you've seen Paul as well. Right?
• 43:46
  Speaker 3: Yes. Yes. In our group.
• 43:48
  Speaker 1: In our group. Yeah. But well, there he is. And yeah, just to underscore that he and I don't disagree about anything really substantive. In fact, from a substantive point of view, we agree on pretty well everything.
• 44:06
  It's just with regard to what slant or what interpretation or what use you want to put the word dissociation to. And he puts it to one use and I put it to another. So that's the main difference.
• 44:22
  Speaker 3: I love that though, the capacity to have different perspectives on the same pieces and put them to use different ways. That's very different than what's happening in America right now with politics.
• 44:35
  Speaker 1: Isn't it though? Yes. Okay, Emily. So that was fun.
• 44:39
  Speaker 3: Thank you so much. I appreciate it.
• 44:42
  Speaker 1: And and good luck with the podcast.
• 44:45
  Speaker 3: Thank you.
• 44:47
  Speaker 1: Take care.
• 44:56
  Speaker 2: 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.