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Presentation: History of Diagnoses · System Speak: Complex Trauma and Dissociation

• 0:08
  Speaker 1: Over: 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 longtime 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.
• 1:05
  This is my presentation that I will be doing for the twenty twenty one ISSTD virtual conference. This is not a recording of the conference. I am recording this as part of my rehearsal and preparation for the conference. It will not be exactly the same when I present and this is not a recording of that presentation which has not happened yet I am recording it prior to the presentation. I open by reviewing some of Herman and Howell's history about dissociative disorders from moral invalids to shell shock to the rap groups of the 70s that led to the first rape crisis centers where women began to acknowledge that trauma was trauma even when it happened at home, not just when it happened at war.
• 1:57
  I reference back to hysteria from my previous presentation where it's used to describe both physical and behavioral symptoms all the way back to 2000 BC. It wasn't until 1952 that hysteria was acknowledged as a derogatory term. And when it was dropped by DSM-one and renamed Briquette syndrome, the number of self report symptoms were reduced from 59 to 25, which cut the lived experience descriptors by more than half. Then in 1968 both the DSM-two and ICD-eight came out and had the same thing under different names. So there was still confusion that recently in the recent regional conference for Toronto Christine Forner talked about how even then the journals would not accept Cornelia Wilbur's presentation of a multiple personality case and that this is why she had to have it written as a novel, as Sybil, to fight against stigma and get it accepted as part of what is already being described but was now being more clinically and clearly understood.
• 3:22
  And then it wasn't until 1975 when an article called out the common and accepted practice of clinicians who are presenting case presentations and case studies and consulting with each other of sharing too much information and confidentiality and the ethics of the lived experience within the context of treatment began to be addressed. It wasn't until 1972 that journals began to publish articles about multiple personality and then in 1977, the ICD-nine was the first to include multiple personality disorder, but it was included as a neurotic disorder. Three years later in 1980, the DSM III ended the psychodynamic assumption of etiology as the process of distinguishing dissociation, conversion, and somatization. It shifted to measurable and quantifiable symptoms and symptom durations, separating diagnosis from theory for the first time. This was in part due to the rise of insurance and managed care, which ultimately is what led to the need for treatment guidelines not to describe to patients what they were experienced or advocate for care for patients, but in response to requirements from managed care and trying to justify payment for treatment.
• 4:59
  In the meantime, what has been lost is the psychodynamic emphasis, which is too often neglected secondary and post secondary training and not always taught for new clinicians. This leaves the person vulnerable to or even harmed by the clinician's lack of awareness and understanding of what is happening relationally in the clinical setting. I reviewed the multiplicity model, which is the model of DID and OSDD as multiple personalities, more than one personality, which was the standard model for decades and centuries. That PTSD may have an apparently normal part with separate emotional parts because of the trauma and complex PTSD or disorder of extreme stress or borderline personality disorder may have an ANP with several EPs but OSDD and DID is an experience of multiplicity and any one of those personalities may have an A and P and one or more EPs. Then in 1991 Peter Barrish published his famous article about attachment.
• 6:23
  This is one of the most mis quoted and mis taught concepts in the history of our treatment. He did not say that disorganized attachment caused DID. Disorganized attachment was not even a term yet when his article was published. Disorganized attachment doesn't even show up in the literature until a year later. What he said was that disordered attachment was a cause of dissociation.
• 6:53
  He was following the thoughts of Bowlby. When parents fail to respond to the distress signals of infants, infants will detach or dissociate from their emotional and physical pain. This forms the basis for dissociative detachment in response to continued abuse. He was also emphasizing the need to understand the psychodynamic process that when these people grow up and come to therapy with a responsive therapist, their attachment behaviors are reactivated from infancy. And if a clinician does not understand the psychodynamic process, some of these therapists will view this as overly dependent behavior or manufactured crises and actually back away from them right as they are needing to connect with them.
• 7:48
  And this is where survivors can be so easily harmed. It is actually the hardwired attachment system being reactivated, which is a good and healthy thing. He has also talked on the podcast about how we have to have a healthy dependence before we can have a healthy independence. Using this, I tried to explain the difference between an A and P and an EP. A and P stands for apparently normal personality and EP stands for emotional personality.
• 8:21
  But what does that mean? I think that it's a lot more than just daily living parts and big feelings. A A and P is when the experience of that stealth state or that part or that alter or that self, however you want to say it, is missing access to the emotional personality. The A and P is aware that the EP is missing, which is why they're distressed. But the EP is detached from and unaware of the A and P, which is why it feels like you can't function.
• 8:57
  So when we are detached from the psychological and the affective, what we experience is depersonalization and derealization. When we are in a self state or ego state or alter or part or whatever language you want to use, when we are experiencing an emotional personality, that EP is detached from but sensing evidence of the ANP. The ANP is detached from but unaware of the EP's distress while continuing to function. So that means the experience is detached from the physical, which is when we get somatoform. So when we talk about therapy breaking down the walls, it's not just breaking down the walls between people.
• 9:51
  It's breaking through those barriers through both attachment and associating. We do that through top down and bottom up interventions. The top down connect us externally as we talk and process in therapy. We also experience the psychological and affective I exist and I feel and I am with another, which means I am. But as we associate bottom up internally, we experience our physical bodies.
• 10:25
  This is me. I am functioning. I can. That's how we break through barriers of dissociation. So going back to our timeline, in ICD-ten in 1992 they abolished the NOS and did new super grouping, John O'Neill calls it, where dissociative and conversion disorders are put together but dissociation has moved to first place in the name.
• 10:57
  In the DSM IV DSM IV TR in 1994 and February, multiple personality disorder was renamed dissociative identity disorder. This was a move to better describe what the process of the experience was. So the focus shifted from the existence of separate personality states to the process of dissociation as identity being dissociated from the psychological and affective and physical. So in some ways it was very helpful, but it also set the stage for the confusion between models of multiplicity, like multiple personalities, and models of divisibility, which is a division of consciousness or personality into parts, such as the theory of structural dissociation. So in 02/2009, the Structuralist, that theory of structural dissociation was published in 02/2009.
• 12:14
  They described there being only one personality instead of there being multiple personalities. They changed the P in A and P and E P from personality to part of the personality. They described how we are naturally divided into parts, that no one is born integrated, and that it's healthy attachment that integrates the parts into one personality developmentally. But trauma disrupts that process and the degree of disruption depends on the timing of trauma in development. So this took the multiplicity model and shifted into a divisibility model so that PTSD may have an ANP and EP because of that split between the experience and their response to the experience and it moves OSDD down into secondary dissociation with borderline and complex PTSD where there's just one ANP with lots of EPs.
• 13:24
  And then it makes DID with tertiary dissociation as one personality with lots of ANPs and EPs but not multiple personalities each with lots of ANPs or EPs. That is the distinction. And this is significant that we understand that distinction so that we actually know what we're talking about. In the DSM-five in 2013, dissociation was still included, but differential diagnosis paragraphs were omitted. This is significant because it results in a high prevalence of misdiagnosis due to a lack of study, poor clinical discernment, and inadequate education.
• 14:13
  The results are an assumption of one personality regardless, which dismiss millennia of more than one personality understanding. And that has been passed down from clinician to clinician and becomes ultimately fresh historical trauma for the dissociative patient through misdiagnoses and improper treatment. This leaves dissociative disorders included but isolated so that they are reenacting the abuse dynamic even in diagnosis. There is also no other diagnosis that has to go into treatment already knowing what the diagnosis is because it's not referenced in other differential diagnosis paragraphs, and it is by default a not knowing diagnosis, meaning the lack of awareness and the amnesia, makes it difficult to directly say this is what's going on. So this was the second time that diagnosis was separated from theory and for the first time put them together by category rather than reported lived experience.
• 15:28
  This impacts trauma based disorders because what is happening depends on which perspective from whom internally. Are you interacting with the ANP? Are you interacting with the EP? Diagnosis actually depends on who is there for the assessment. It also forces an external medical perspective on clients who have already endured trauma in a field that traditionally has dismissed or exploited survivors.
• 15:59
  In 2020, Simone Rendier's research confirmed that dissociative identity disorder is a traumagenic disorder. It's also distinct and distinguishable from other disorders in the fMRI. And we discovered through her studies that the neurobiological impact of relational trauma is actually more damaging than even physical or sexual abuse, which we already agree are bad. In 2021, Simone Reindeer's latest research also identified possible biomarkers for DID. No other diagnosis has been as researched and as defended and still so quickly dismissed.
• 16:54
  In 2021, Kathy Steele presented and was asked about what changes she has made since structural dissociation theory was released. It's been decades now and she reported that she has moved away from ANP and EP language back to ego state language. In addition to this, Vanderhardt also wrote in 2021 a published article that he described where he shifted to talking about changes in levels of dissociation to degrees of dissociation. He acknowledged a broader understanding of disassociation and emphasized multiplicity and division of actions as unique to DID. Because of this, he is now saying that ego states is not enough.
• 17:51
  Dissociative parts of the personality may comprise any number of psychobiological states, which implies that labeling them as only ego states or self states is giving them too low degree of reality. Putting this in context of what is intergenerational trauma or historical trauma, we talked last spring in our presentation about how dyadic trauma is about what happened in the past. Intergenerational trauma is about what's happening again. Collective trauma is about what happened to us together. Historical trauma is about what is still happening to us because of what has already happened to us.
• 18:39
  So in the context of lived experience, a person coming for treatment for dyadic trauma has already experienced the original trauma, and the traumatic experience of therapeutic treatment is still evolving when treatment goes wrong. Intergenerational trauma happens when treatment models that are inadequate are passed down and diagnostic manual changes that dismiss lived experience. Collective trauma is about what has happened to us together. There's a history of exploitation, misdiagnosis. Survivors have a shared history of exploitation.
• 19:26
  We have a shared history of misdiagnosis that is far too common before we are properly diagnosed. We often have a shared history of traumatic therapeutic experiences, and we have a shared history of oppression, not having a voice in choosing treatment, not being included in development of treatment guidelines, not being heard in treatment model application. Historical trauma is about what is still happening to us because of what has already happened to us. When Simone Rendiers presented, she reminded the clinical community that in the average time from seeking treatment to receiving a correct diagnosis of DID, the average person receives four incorrect diagnoses, spends seven to twelve years in mental health services, experiences years of inefficient pharmacological treatment, and endures several experiences of hospital admission. These years of isolation from appropriate and effective treatment are a collective historical trauma experienced by survivors reminiscent of the dyadic trauma dynamic.
• 20:44
  Sikh Frincessoon said, I am a soldier convinced that I am acting on behalf of soldiers. I have seen and endured the sufferings of the troops and I can no longer be a party to prolong these sufferings. We can change the end of his quote to reference plurals rather than only veterans. These plurals refused to be forgotten. Moreover, they refused to be stigmatized.
• 21:11
  They insisted upon the rightness and the dignity of their distress. In a 2020 interview with Cloughed, which aired in 2021, we discussed how therapy in the past was a single point focused experience in multiplicity. Now, the therapy is only part of a diffused focus experience because the survivor also has access to published works, online resources, virtual support groups, social media, blogs and podcasts, conferences, both professional and lived experience, and organizations of resources by survivors themselves. When we talk about historical trauma, it consists of three factors: the widespread nature, the traumatic events resulting in a collective suffering, and the malicious intent of those inflicting the trauma. There are three ways that clinical microaggressions impact treatment.
• 22:20
  There is the impact of ableism that blocks self awareness of that malicious intent as a part of historical trauma. There's a lack of cultural humility in uncovering it. And there's the impact as additional trauma for those with lived experiences when things go wrong in therapy because of the other two. There is an implicit bias. Associations outside our conscious awareness lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender or diagnosis.
• 22:58
  The therapist must avoid assuming that he or she knows the correct answer in advance. The therapist's role is not to lead the client to a particular conclusion, but to walk the client step by step through the process. In 2021, Salter and Hall published an article that included addressing issues of shame and dignity. It said, quote, shame is the emotional correlate of attachment failure, child abuse, and neglect. However, it is also a socially located and politically structured experience that is exacerbated by public policy, professional practice, and government decision making.
• 23:45
  It is not without clinical precedent to address these issues. In Corteo and Ford in 02/2009, they said, direction. Clients recognize that they have the opportunity to become active agents for change in their own behalf. Without this experiential foundation, the person is likely to experience instability in not knowing about personal preferences and values depending instead on changes in the immediate environment and body states. In addition, the National Institute for Healthcare Excellence published in November 20 this quote, This systematic study of psychological trauma therefore depends on the support of a political movement powerful enough to legitimate an alliance between investigators and patients and to counteract the ordinary social processes of silencing and denial.
• 25:06
  End quote by Judith Herman. So when we talk about the politics of lived experience and a history of plurality, they have taken from the politics of disability and LGBTQ plus politics and lived experience. I shared last spring how it was the blind community who demanded that we are still citizens. It was the deaf community who said if we are citizens then we have rights. It was the mobility community who said, If we are citizens with rights, we want access.
• 25:44
  And it was the neurodiversity community who said, If we are citizens with rights and access, then we get to decide for ourselves what access looks like. And then with the LGBTQ plus community, the impact of politics, community response, and grassroots supports brings up the question, when can I keep my rights and access? From this and disability trauma research, we get nothing for us without us. It is a Latin slogan used to communicate the idea that no policy should be decided by any representative without the full and direct participation of members of the group affected by that policy. This involves national, ethnic, disability based mental health, and other marginalized groups.
• 26:37
  The Nothing for Us Without Us slogan originated in Central European politics in 1505 and became a motto representing democratic norms and transfer of power to the people. It was used by East European activists at an international disabilities rights conference in the 1960s and then again in the 1970s by disability advocates in South Africa. It was then adopted in English in the 1980s for the disability activism in America and taken up specifically by the GLBT community during the HIVAIDS crisis. Charlton then published a book about its meaning and use in disability advocacy in 1998, as did David Werner. Plurality in this context becomes radical acceptance.
• 27:28
  Radical acceptance and behavioral activation are primary mechanisms for changing trauma related patterns. Acceptance involves taking things as they are and not becoming so wrapped up in trying to fix problems or people that obvious solutions are overlooked. To accept is not to be passively resigned or hopeless, but to be actively involved in understanding things as they are rather than as one wishes or demands they should be. Plurality then is an anthropological designation, not a clinical one. It is an overall umbrella term for all those experiencing multiplicity.
• 28:16
  It was intended to be inclusive, people waiting on an accurate diagnosis, people without access to treatment, people with dissociation but not DID, people without privilege to pay for treatment, other cultures and faith traditions that include dissociation but are not trauma based. It includes a broad spectrum of internet platforms, dissociative disorder support groups moved to Facebook after Yahoo, dissociation hash tags on Twitter, DID chat for weekly live meetings, similar hash tags and meetups on Instagram but develop face claims, discussions on Reddit and Discord, private servers such as Chris Itterman's United Front peer support and group coaching, and the Plural Association international nonprofit with Dissociative Disorder Warmline, YouTube channels presenting as people with DID, and now podcasts. Through all of this, we developed community organization. It was developed through shared experiences online and at conferences. The timing coincided with a shift from abreaction based therapy to the phase based approach.
• 29:31
  Basically, it externally adopted the structural dissociation emphasis on communication, cooperation, and collaboration. Plurals took what they had been asked to do internally to develop safety and stability and implemented it externally to create a community in a way that had never before existed. In this community organization, there's a general meaning making process that happens when social groups interact with each other and emotion specifically, which creates new and binding understandings of social responsibility. This collectively as a culture, even with its own use of language, impacts how trauma survivors hold multiple identities simultaneously that influence their conceptualizations of trauma, therapy, and the recovery process. In the last decade, linguistic movements toward first person language in effort to emphasize the whole person rather than traits that might identify them, such as a disability diagnosis.
• 30:42
  It became a matter of respect from the clinician and dignity for the patient to shift from DID client, for example, to person with dissociative identity disorder. But more recently, an added push against even that stigma to provide a more nonpathologizing approach in dropping the disorder and simply using the phrase person with dissociated identities. Along with this has come the use of DI instead of DID, as well as the more casual term multiple. The community's response to this maintained that it was still a diagnostic based orientation, and it felt confining to the therapeutic setting, which is a minor part of plural lives outside treatment. It also indicates privilege that few have access to or can access or are able to access treatment.
• 31:40
  It feels limiting to the specific timeframe of being in therapy in contrast to the lifetime of lived experience. And it excludes those who are not yet diagnosed, those who consider themselves multiple but not disordered, and those who consider themselves multiple without any history of trauma. For this reason, the broader and more person centered term of plural was formally adopted in 2018 with extensive collaboration among support groups online, a variety of proposals submitted from Plurals themselves, and an actual voting across the different support groups and a variety of platforms with more than 23,000 votes cast. Once we had decided on an overall umbrella term, we decided to gather at the first Plural Positivity World Conference, or PPWC. For this, I was asked to take a general public survey designed by them through voting for their own use as a community with survey questions submitted by the community and the community voting to approve the questions.
• 32:53
  It was not research approved by any internal review board. Consent included publication and presentation of the results. This is not uncommon in that culture with online public opinion polls and annual surveys as an optional part of registration with the Healing Together Conference. The results of this survey were shared as a poster session in the twenty twenty Annual ISSTD Conference and publicly posted on the System Speak podcast web site. One result interesting to note, even after voting to adopt plural as the term of choice, only 27% identified as plural, 35% of respondents instead identified as DID, and 22% still identified as multiple, indicating less than a third actually prefer the term plural for themselves despite the advantages agreed upon in voting to adopt the term.
• 33:56
  The survey also linked diagnosis to identity. Thirty four percent of respondents identified as traumagenic. I am this way because of trauma. Two percent identified as endogenic. I was this way before I was born, but not because of trauma.
• 34:15
  One percent as exogenic. I was this way since I was born or grew up this way, but not because of trauma. Thirty eight percent as traumagenic adaptive, I am this way because of trauma and still use dissociation adaptively to deal with life, but not necessarily intentionally and not as part of my intentional cultural expression. Thirteen percent identified as traumagenic cultural. I am this way because of trauma, feel mostly in control of my symptoms, and have intentionally adapted to it as a cultural lifestyle.
• 34:54
  This shows us that in the overall plural community, seventy two percent are traditional DID patients. Only fourteen percent are the new plural presentation who identify as plural but not DID. Other issues in these results were that they voted on politically correct terms to be more inclusive and reduce stigma. Examples are that animal alters or alien alters are now known as nonhuman alters. They also identified introjects alters, which is different than psychodynamic introjects, as fictives.
• 35:36
  We'll talk about that in a moment. They also set goals as a community, increasing the safety of online support groups, calling out misrepresentation in media, calling out lack of institutional courage, such as with therapist violations that become public, development of DID Awareness Day, and a call to be more inclusive in support groups of those not yet diagnosed or not disordered. Like with everyone else, the political upheaval in 2020 played an early part in the plural community development. Subgroups of the plural community includes, among others, a high number of individuals with disability, individuals who are autistic, and individuals of the LGBTQ plus community, and it was from these historical rights movements that the plural community formed its politics. They adapted language from the political climate and protests from 2020 as well.
• 36:37
  This began the shift from plurality as an overall umbrella term to culture specifically. When Simone Rendiers reports that people go through so much from the time of seeking treatment to receiving a correct diagnosis, or there's a huge population of other people who have cultural or faith traditions that include multiplicity that are not traumagenic, that is a lot of people outside of diagnostic categories that still need support. The question becomes, Who am I while I wait for correct treatment? Plurality provides a whole life encompassing identity with which one can identify and with which ego states can agree regardless of the wait. From there, there became an expansion and evolution of plurality.
• 37:37
  They quickly invited and embraced Tulpas. This comes from a Tibetan philosophy that includes auras and astral projections where your thought projections become real. Those projections do not have to look like who is projecting them. What is projected then becomes other and those others then become people and it is experienced as multiplicity. It is distinguished because these are not alters, but people, and that developed into the plural political perspective that all alters are people.
• 38:16
  That evolved into all alters should have personhood. This began a split between the overall plurality community and traumagenic DID community over concerns from traumagenic plurals about cultural appropriation from non trauma plurals. The expansion of non trauma plurality grew to include otherkin. This is a subculture of people who identify as not entirely human and have origins such as reincarnation or soul dysphoria, ancestry issues, parallel universes, dissociation as an astral projection or shape shifting. Themes may be religious, mythical, or fictional.
• 39:05
  Some examples include fiction kin, other kin who identify as fictional characters, concept kin, abstract concepts, weather kin, other kin who identify as weather systems. They may be mythical like centaurs or aliens or demons or dragons or fairies or spirits, or they may be natural such as horses or foxes or wolves. It explains other characteristics. Common plural experience to have hundreds or thousands of altars. This seems to overlap with maladaptive daydreaming.
• 39:40
  These altars come with extensive backstories unrelated to the host, rich and vivid and highly detailed inner worlds. Many of these develop further on apps and video games or in computer sims. Altars have relationships with each other, culture and religious ceremonies of marrying each other. Altars have pets and babies and jobs, friends, and families in those inner worlds, and then all of those also become alters. This has led to the development of the widespread use of fictives, alters from movies, video games, anime, and role playing games.
• 40:20
  These kinds of plurals view themselves as political activists and peer support specialists. They are often anti cis med, which means system of medicine, referencing the treatment establishment. It's a play on words from cisgender. Cismed became a derogatory slur used against the treatment establishment, used against organizations, institutions, and publications supporting canceled clinicians, used against traumagenic DID systems, which has reinforced the political polarity between traumagenic DID systems and plurals without any trauma history. This plural culture views most treatment as oppressive at best and violating at worst.
• 41:08
  Cismed, used in reference to the clinical fragility of the treatment establishment, views the clinical fragility as a lack of cultural humility. It views a lack of cultural humility as unethical. It perceives the treatment establishment to be white and male and straight. They perceive that no treatment improvements or research development has happened in the last twenty years. They reject structural dissociation theory because it denies multiplicity, because it is incongruent with lived experience, and because it classifies structural dissociation theory as ableist.
• 41:46
  It perceives treatment goals as forced rather than collaborative and perceives complicit silence and lack of institutional courage when well known public faces of the establishment lose their license or have charges brought for boundary violations. Advocacy work includes embracing new plurals, psychoeducation, social media blasts, community leaders communicating across platforms, calling out institutions and organizations, notifying community of therapist violations, graphics to explain treatment models, resource lists by country and by state based on lived experience, and DID Awareness Day in groups, social media, and with organization collaborations. One example is they have educated the community on the F words. We know flight, fight, or freeze. Pete Walker talked about fawning.
• 42:43
  And Chris Itterman has added follow, fortify, fabricate, and facilitate. They also provide psychoeducation about functional multiplicity. They have three goals for this. One, to support those without access to treatment and those in long term treatment. They also want to improve quality of life while waiting for treatment, while waiting for a DID specific therapist, and during the long course of treatment.
• 43:11
  It's also political to empower those who don't want treatment, to empower those who are done with treatment, and reclaim power from oppression that clients ought to be in charge of their own treatment. They also offer peer support through coaching and classes, such as on topics like shame, internal communication, relationships, the inner world. They have live weekly peer support groups, book groups, topical presentations, the PPWC, state licenses as peer support coaches, and they also work more intentionally across fields, such as with dietitians, occupational therapists, and anthropologists. There's also an increase in collaboration, such as presenting about plurality at the trans conferences and autism conferences. The International Plural Warm Line is also available for issues that traditional hotlines can't understand.
• 44:12
  This is an example of an infographic from the Plural Community. This is by the Plural Association. It says, Plurality simply means people who are many. It is a community umbrella term that people may use freely to self identify with. It includes all sorts of people and experiences, including but in no way limited to how psychology explains multiplicity.
• 44:39
  We hope this chart helps you identify how you want to label your plurality. So when we talk about plurality as a culture, as opposed to traumagenic DID as a diagnosis, it's not entirely without clinical precedent. When clients are allowed to guide staff to what was important to them, safety and a sense of security and connection, these being ones the client regains or reclaims, but rather than being reestablished, these need to be developed for the first time. This applies even to goals for treatment, whether to choose integration or not. The role of the therapist in this enterprise is to guide the client through the process of thinking something through to a conclusion while leaving the outcome or actual conclusion in the hands of the client.
• 45:33
  It is important to listen to these plural voices. In our language, we can use plurals to encompass a positive identity, to dissociate from stigma of multiple to include those still in denial of or perceiving themselves to be without trauma. It also provides the possibility of identity exploration. This makes a person with dissociative identities, for example, a reference to the person, not the disorder, and it leaves disorder intact for those who are distressed by it and or whose functioning is impacted and so have a diagnosis. It still provides plural as an overarching inclusive term in general and specifically when the survivor chooses and or identifies with it as part of pride instead of stigma.
• 46:27
  There were two studies prior to the Plural Positivity World Conference survey. One was in 2015: the varieties of TULPA experiences. This study showed that tulpas are perceived to be entities distinct from one's own thoughts. Over a third of hosts reported that tulpas felt as real as any physical person. TULPAs seeming to be independent in their emotions, cognitions, and opinions.
• 47:00
  TULPAs experience through a mix of auditory, visual, and somatic visualizations and hallucinations. It includes possession, a technique that allows a tulpa to temporarily command the body, and it includes switching, in which the host dissociates to have an out of body experience while the tulpa controls the body. There is an absence of amnesia, depersonalization, and other traumagenic symptoms. The second one was the ISLER study in 2017, TULPAs in Mental Health, a study of non traumagenic plural experiences. In this study, more than 25 of the Tulpa community was noted to also be diagnosed with an autism spectrum disorder.
• 47:49
  Fifty six percent of the Tulpa community reported a mental health diagnosis. Of these, seventy nine percent reported their diagnoses came prior to their experiences in Tulpamancy. Sixty six percent of the total respondents diagnosed with a psychopathology report that their disorder either somewhat or significantly furthered their decision to make TULPA. So far, there have been two studies since the survey. The first one was by Baker in 2020, who found that pleural cells was linked with mad pride movements to reclaim pathologizing psychiatric diagnosis such as DID.
• 48:32
  This has been linked to queer theoretical and activist perspectives by considering how depathologizing plurality follows similar endeavors in relation to homosexuality, kink, and transgender. Plurality of self is related to the wider queer endeavor of challenging stablefixed identities and critiquing neoliberal, capitalistic, individualistic ways of comprehending the self. The second one was Martin Thompson and Lancaster, also in 2020, which measured relationship satisfaction between hosts and their tulpas. Non traumagenic plurals say they began the practice because they are lonely or struggle with social anxiety. They reported that their conditions improved after the creation of their TULPA.
• 49:22
  The host's perception of relationship quality level increased when the host and the TULPA both scored low for each domain of the PID five BF. However, when the host scored higher in disinhibition than the TULPA, this was correlated with a higher relationship quality. We also listen to plural voices when we use our resources to support them: Healing Together Conference with an Infinite Mind. ISSTD had a DID Awareness Day plural panel this year. We can refer to the Plural Association Warm Line.
• 49:59
  Beauty after bruises also supports treatment. In updating treatment guidelines, survivor review for shame based language and cultural humility is critical. Functional multiplicity should be considered as a stage three, making stage three stage four, and functional multiplicity documented explicitly as a valid treatment goal. In the area of research, the plural community is calling out the use of middle class white women and asking for diversity in participants. They're asking for compensation and credit.
• 50:35
  2020 Blue Knot Foundation guidelines is a great example of this. And in the development of framework, we need to prevent and reduce ruptures in the therapeutic alliance, co lead solutions, and understand that lived experience best identifies barriers to treatment. Treatment teams can be more inclusive, not just to peer recovery coaches or peer support, but also other resources, such as registered dietitians. Annie Goldsmith is a member of ISSTD, has taken the classes in the professional training program, and occupational therapist Kathy Collier has given excellent advice, especially to survivors and medical appointments. Peer recovery coaches can be integrated into general medical settings.
• 51:26
  They may support reduced acute care utilization and increased treatment engagement. They may be an impactful and potentially cost effective addition to the care team. That being said, plurals self identifying as non traumagenic plurals are a unique group. They report they are functioning well. They are not distressed by their multiplicity and therefore are not disordered.
• 51:56
  Therefore, the treatment guidelines do not apply to them. Plurals identifying as plural who also report they are functioning well and not distressed by their multiplicity and are not disordered and so the guidelines do not apply also do not need to give input into the guidelines that treat a disorder that does not apply to them. They do, however, need to be acknowledged and recognized in literature as a part of cultural humility, and they need safe access to alternative treatments for other things, such as depression or anxiety. Because they are two distinct groups, it is important to be able to differentiate between traumagenic OSDD or DID and the non traumagenic plural community. Although everyone or every many are unique, some common differences between the two groups are this: traditional traumagenic DID patients usually have a more covert system, whereas the pleural system is often very overt.
• 53:16
  Traumagenic DID interferes with their function primarily because of the trauma pieces specifically, whereas plurals may not be bothered by their multiplicity. In the same way, people with DID are often very distressed by their DID, whereas plurals may not be distressed by their plurality. With DID, there is a phobia of parts or alters or others, whereas with plurality, they are often very proud of their different selves and the other people in their system. Traditionally, people with DID referred to parts or alters or insiders or others. Plurals more often present as referring to them as people or persons or subsystems.
• 54:09
  People with DID traditionally have limited internal relationships at the beginning of therapy, although that's developed through the course of treatment, and plurals often have extensive internal communities with all kinds of different relationships. Traditionally, people with Traumagenic DID have limited awareness of their internal world. And again, that's something that is developed over the course of therapy. Whereas with plurality, the inner world may be a very rich, extensive, and detailed place. With traditional DID, outsider's sense of switching is in a dissociative context, whereas with plurals, there is a self report of switching and a continuous conversation kind of experience.
• 55:05
  With traditional DID, they may be hesitant to disclose names or roles, whereas plurals are able to do detailed mapping and know the jobs and declare their own names in mid conversation and often share their names even preferring to be called by the correct name. Traditional DID has a limited number of alters, although that obviously varies with different experiences, but plurality can have hundreds or even thousands of alters. With traditional DID, there may be some nonhuman alters. That's always possible. But with plurality, fictives play a major role in the system and the plural experience.
• 55:52
  Regardless, because of the increased acceptance of lived experience and because of feedback from the community, last spring I introduced a four phase treatment model for multiplicity. Just as originally stage one was not long enough for safety and stabilization, there is a missing phase at the end, at the other side of processing as well. We need to emphasize shame work in phase one and somatic work in phase two, move phase three to phase four, insert a new phase three of functional multiplicity in between there. And a new phase three becomes about practice and rehearsal about holding both, like object relations. Phase four, strengthening the emerging self.
• 56:45
  This is who I am. This is what I know. This is what I think. This is how I feel. This is what I do in response.
• 56:53
  It looks like this. Stage one being your presence, the therapist's presence, safety and stabilization. It includes healthy dependence, psychoeducation, pattern recognition, skill building. And then phase two, about their present, the client presence, holding presence with selves and others myself. It includes somatic integration, bilateral work, expressive work, peer support, external community.
• 57:22
  And then phase three about our presence internally, the functional multiplicity, practicing presence, healthy independence, comforting myself, exposure to the past, support utilization. And then phase four, my presence here and now with access to there and then, being able to navigate both memory time and now time, flexible boundaries, attuned responsiveness internally and externally, an emerging self of who we are not yet, but who we are becoming. Those plurals refused to be forgotten. Moreover, they refused to be stigmatized. They insisted upon the rightness, the dignity of their distress.
• 58:13
  Thank you.
• 58:51
  Speaker 2: Thank you so much for listening to us and for all of your support for the podcast, our books, and them being donated to survivors and the community. It means so much to us as we try to create something that's never been done before, not like this. Connection brings healing. One of the ways we practice this is in community together. The link for the community is in the show notes.
• 59:19
  We look forward to seeing you there while we practice caring for ourselves, caring for our family, and participating with those who also for community. And remember, I'm just a human, not a therapist for the community, and not there for dating, and not there to be shiny happy. Less shiny, actually. I'm there to heal too. That's what peer support is all about.
• 59:46
  Being human together. So yeah, sometimes we'll see you there.