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Psychological First Aid · 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 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.
• 1:02
  Hello. This is Doctor. E. I am currently on a speaking tour doing some trauma trainings after recent disasters, natural disasters, and with some refugee camps. It is a difficult time of year for us anyway, and so I prefer rather than being in crisis just to spend the time away and earn some extra money for our family.
• 1:37
  So right now, I have just left California, and I'm now in Puerto Rico. I have spent all of last week training the government and county leaders after the fires that they've had there. A new one broke out while we were there, and so that was concerning, but it was contained more easily than the terrible one a year ago. However, fire for us is a bit of a trigger, and so we had to work together differently and with new practice while away from the therapist to be able to handle that. In Puerto Rico, they had a severe hurricane.
• 2:26
  It was Maria, Hurricane Maria, two years ago, but the country was so devastated that it has taken almost two years for them to get to a safe place to enter the recovery phase after the disaster. It was almost ten months before they had power again, and even all of the vegetation was wiped out. So it's been very difficult after hurricane Maria for them. And here I have met with principals and teachers, as well as government leaders talking about the impact of trauma on children and how to use expressive therapies to help process as they come out of shock. I will spend much of November touring North Africa and The Middle East and Greece speaking in refugee camps there and doing trainings for nongovernment organizations and nonprofits there in the refugee camps.
• 3:28
  So it's a bit of a busy season for us, and we have been gone since the October and will not return home until right before the new year. That has changed our schedule some and has been difficult for some of the other folks inside to be away from the family and our friends, But also because we had two children with multiple hospitalizations this year, our family is in a bit of a crisis. And so I've got to do what I've got to do to be able to provide for them. And so I have left them to earn extra money. I'm still working my day jobs in the morning from two a.
• 4:16
  M. To seven a. M. Before I do the trainings from eight a. M.
• 4:20
  To 6PM. And then I go to bed by 7PM and sleep because I'm so tired at the end of the day. But as part of a family, we do what we have to do to take care of our children, and it's just been a big year for medical expenses, and our family is struggling. All of that to say, my apologies for the disruption in the schedule of the podcast. It's simply because I've been out of town and out of the country, and I'm doing the best that I can to provide for the family.
• 4:55
  While I spoke very in-depth about the history of DID as well as the polyvagal theory at the conference earlier this year and shared those talks on the podcast. Some of the training that I'm doing is far more simple, and I thought I could share it in case it's still helpful for any of you. If it's not or you're not interested or already material that that you know, then feel free to skip it. But I thought it was worth sharing in case any of it's helpful. Obviously, this is condensed material, and I'm skipping through not just the presentation, but the format of it and the expressive art therapy projects that we do together, but I thought some of it might be helpful.
• 5:49
  The trauma trainings that I'm contracted to do are in accordance with the World Health Organization principles for disaster response and Resilience, a model that they call Look, Listen, and Link, as well as Psychological First Aid. So this is not about in-depth therapy, but there may be some things that are helpful in following the model or understanding information about it and why it helps with trauma, and I can share it here as well. If nothing else, then you can understand a little bit of what I'm doing for the next month before I report back to those organizations. When we talk about first aid in a medical way, we're talking about the initial response to a medical emergency. It might be a small thing like getting a band aid or cleaning a wound or maybe bracing a broken arm or leg until help can come.
• 6:56
  It's not the actual medical care that's given, but it's the initial thing to sort of contain the wound and to do what you can to help and support the person's body until help can come, like an ambulance or getting them to the doctor or a treatment facility. In the same way, psychological first aid is very much the same thing except mentally and emotionally. It's not therapy. It's a psychosocial support that helps people cope until they can get more help. In this way psychosocial support cares for the psychological emotional and social needs of a group of people or a specific individual and because of that it is unique to the social context in which the person lives.
• 7:51
  So for example, people who were in the fires in California are going to have different psychosocial support than the people who were in the hurricanes in Puerto Rico or in refugee camps in The Middle East. During a war or following a natural disaster, the needs of a person are especially acute, and because of the loss of resources due to the disaster or displacement from the disaster or the war zone, there are fewer resources available. Because of this, a holistic approach that reflects the context of the person and where they're at and how they're living and what is surrounding them and what is available will build more resilience than not helping them at all until all of those things are back in place. Obviously, with a war, people are displaced for a long time. And following natural disasters, it also takes a long time.
• 8:52
  In California, it's been a year since the Camp Fire, and people are still cleaning up the sites of where the fire burned their homes. Only a few people have been able to rebuild or move back into their homes. The roads are open now, some of them, but many resources are gone as well as the basic things that are part of a cultural context, like restaurants and parks and places of business. And Puerto Rico, the hurricane was two years ago, but then they were without power for ten more months after that, and most of the vegetation was gone. And so it took a long time to get things cleaned up and rebuilt enough to function, and there's still a lot going on for recovery.
• 9:40
  But with psychosocial support, you can restore feelings of safety and reduce the stress of what you're enduring and regulate emotions as things process rather than continuing to remain in shock for one to three years. It goes back to what we've shared about before with adaptive coping skills or maladaptive coping skills. I know it's really unfortunate language, but any way someone is coping is usually the very best that they can do. But we can help them explore more efficient coping skills that are more effective in meeting their own needs. This helps them to feel more empowered to care for themselves and those around them instead of only being in crisis or feeling helpless and hopeless.
• 10:30
  It also helps us in understanding each other and how we can reach out in ways that are helpful rather than just watching it happen or getting involved in ways that are not actually helpful. When we teach the World Health Organization guidelines of look, listen, and link, look refers to checking for safety and checking for urgent basic needs and checking for vulnerable population or others with serious distress reactions. Listening refers to approaching people who may need help, asking about their needs, and listening to them and helping them feel calm. Linking refers to helping people address basic needs and access services, helping people cope with problems, giving information, and referring them to resources that are available rather than focusing on what's not available. And then doing the work to help connect people with loved ones and social support.
• 11:33
  I will speak about all of these further in a moment. What's important is that you don't force people to talk or intrude your way into people's lives if they don't want help. It's also important not to give false reassurances about how everything will be okay or at least you survived or I know how you feel because you don't know how they feel. And such platitudes are violating and intrusive and insufficient in actually helping. And sometimes everything isn't okay.
• 12:09
  And it's actually okay to say that. It's actually okay to say that this was difficult and this was hard. It's okay to say I'm uncomfortable or that was scary or this experience was really bad. Those are actually important pieces of healing and important connections in the brain and emotions for beginning the process of healing and providing hope. So validating people's feelings is far more important than dismissing them.
• 12:40
  So it's important not to tell people what they should be feeling, thinking, or doing. It's also important not to tell people how they should have behaved in the past. The past is done, and there's nothing they can do about it now. And especially in a crisis, people are doing the best they can with very little time to make decisions and very little resources to help them get through it. So there's no point in making them feel worse about things that happened in the past during a crisis.
• 13:11
  The other thing that's really important both in psychological first aid and in counseling, is that you don't make promises that cannot be kept. When you're building an alliance with someone or trying to establish rapport and you make promises that cannot actually be kept, then the survivor sees through that or will experience the disappointment of that, and it will only cause more pain, frustration, and a loss of trust. It's a kind of betrayal instead of actually helping. When we speak about psychosocial support, one of the important pieces is looking at the needs of a community. There are people who had direct exposure to what happened.
• 13:55
  There are people who were close to what happened. There were people who heard or saw what happened and were witnesses to what happened. There were people who had friends and family who were in the event disaster or the war zone. And then there's the general public who were not in the area and may or may not even know about it. That's a geographical level.
• 14:22
  Along with that, there's another circle of people who may sympathize with those people because they've been through similar experiences. But when we talk about vulnerable populations, we're talking about marginalized people. They may be people in the GLBTQ community. They may be people who are elderly or SNFs, which means skilled nursing facilities, so elderly that are in nursing homes already. They are people who don't have family or friends, the homeless population who aren't even on the grid and no one will be looking for them, people who speak other languages or have disabilities like autism or schizophrenia or deaf or blind.
• 15:10
  There are other populations we also forget about who are vulnerable populations in a disaster or a war zone, those who had other events that were stressful already, those who are grieving and still recovering and not yet themselves in a new way, those who have been in crisis already or are otherwise emotional sensitive, and those who already have trauma, like foster children and survivors. Survivors. All of these populations need to be assessed, and we need to be aware of them as part of the recovery process. All people, whether they are a vulnerable population or not, will be affected in some way by the event, the natural disaster, or the refugee camp. And amongst all of them, there are all kinds of stress responses to these traumas, and all of them are okay.
• 16:07
  Many people may feel overwhelmed or confused. They may be afraid or numb or even dissociate. Some people may have small reactions, and some people may have more severe reactions. But all the stress responses are natural and appropriate for all the reasons we've shared in other podcasts when we talked about trauma and the brain. With these different kinds of responses, there are different domains that these responses are expressed: cognitively, emotionally, socially, and physiologically.
• 16:43
  Some of these responses are comfortable, and some of them are uncomfortable. I like that much better than adaptive and maladaptive. Some uncomfortable responses in the cognitive domain are confusion, disorientation, worry, intrusive thoughts, images, flashbacks, and self blame. But comfortable responses happen too, and some of those may be determination, resolve, sharper perception, courage, optimism, and faith. In the emotional domain, uncomfortable responses may include shock, sorrow, grief, sadness, fear, anger, numbness, irritability, guilt, shame.
• 17:30
  But at the same time, comfortable responses may be feeling involved, challenged, or mobilized, having an opportunity to participate in the healing and recovery of others. Uncomfortable responses in the social domain could extreme withdrawal or interpersonal conflict or other kinds of isolation. Comfortable responses would be social connectedness and altruistic helping behaviors. In the physiological domain, uncomfortable responses may be fatigue, headaches, muscle tension, stomachache, increased heart rate, exaggerated startle response, or difficulty sleeping. While comfortable responses may be alertness, readiness to respond, or increased energy.
• 18:22
  It's really important to note that trauma responses are not always bad, and not all of them are difficult. Some of them are very empowering, and it can be a great strength to note the good that comes out of trauma responses, as well as those responses that are more difficult. And all of these things are true, I think, for an internal system as much as an external system in crisis, like a community. So whether it's a community like the fires or the hurricanes or the refugee camps, or whether it's your internal community because you're a survivor with trauma and parts having dealt with them. I think all of these things apply, and that's part of why I wanted to share it on the podcast.
• 19:09
  In neuroscience, when we talk about the window of tolerance, as we have mentioned in previous podcasts, it has to do with the three levels of stress. At the lowest level of stress, we aren't really bothered. Like the alarm clock in the morning we react by waking up or maybe by hitting snooze and going back to sleep. At high levels of stress, we may be confused or impatient or irritable, and our efficacy lowers as we're not as productive because we're anxious or even frozen. We may see things like fight or flight or freeze or fawn or any of the other stress or trauma responses.
• 19:53
  But at a medium level, we're actually at our best. We're productive and useful, and we think clearly, and we can be creative and innovative in that middle of the window of tolerance. But when it's too much for what we can handle, then our body reacts neurologically and moves into fight, flight, or freeze. It's when we dissociate more or switch more or try to run away when people are helping. Recognizing this is important because the actual definition of trauma at its most simple form is the loss of a resource.
• 20:40
  Traumatic experiences usually accompany a serious threat or harm to an individual's life or physical well-being, or it's perceived that the life is in danger, or it is witnessed that someone else's life is in danger. And so when there is a violation of basic psychological needs, such as safety, trust, independence, power, or intimacy, as well as physical bodies, we experience trauma. This is an important piece because sometimes, especially in the world of DID, we focus on trauma being some form of abuse, such as sexual or physical abuse. And while those are absolutely examples of trauma, violations of safety, trust, independence, or power can also be kinds of abuse, even besides emotional or verbal abuse that are sometimes talked about as well. When we have positive psychosocial support, we may have a sense of control and connection that helps us give meaning and power in difficult experiences.
• 21:58
  But when we are on our own, or our system of support is overridden by the severity of the trauma, then we may feel helpless or defenseless or even hopeless. So there are three pieces of trauma, a life changing event, the perception that it is life threatening to ourselves or to those around us, and the loss of resources that we are unable to cope or feel helpless or powerless while having to face the situation. That's what defines trauma, a life changing event, our perception that it is life threatening, or a loss of resources so that we are unable to cope and feel helpless or powerless to deal with it, and those resources may be internal resources. Again, it doesn't just have to be external, like the Camp Fire or the Hurricane Maria. But when we have psychosocial support, we have more favorable reactions to trauma, like appreciation of family and friends who are safe and good and helpful, having the courage to meet challenges and address difficulties, utilizing humor, taking positive action steps in our own healing, adapting to our expectations that may change as our environment change, shifting priorities to focus on quality of life and quality of time with friends and family, and an increased commitment to ourselves, our family, and friends.
• 23:40
  So when we talk about these favorable responses to trauma, we're talking about ways of coping, and coping is a capacity to respond and recover from something that is stressful, such as a disaster or other trauma. Some people cope by relying on their belief systems. And by that, I don't mean a faith system necessarily, although that could be included, but simply on whether you believe the world around you is safe or not, whether you believe the people around you are helping you or not, whether you believe in yourself and your own capacity to overcome difficult things. Other people have a coping style through their affect, meaning their emotions or feelings. A person who utilizes his or her emotions as a coping mechanism is relying upon the ability to express or ventilate through feelings.
• 24:45
  These people may be people who are very good at crying or very good at being angry or have explosive outbursts when their feelings are not regulated. The social coping style is a person who copes with difficulties through social channels and seeks support and control through the structure of his or her relationships. So some people rely on their friends more or need their friends more than others. Imagination is also a coping style. It's a way to use creativity as a means of coping with stress or trauma.
• 25:25
  Sometimes we see children acting out trauma with toys, or sometimes this plays a part in the role of trauma and dissociation. Cognition is another coping style where people cope by problem solving and trying to deal with the problems directly. And then finally, physiological activity is another way of coping. It allows necessary buffer time and permits informal processing of traumatic experiences. And so this could come through physical activities or physical playtime or things like sand tray therapy or play therapy, or other sensory motor activities.
• 26:11
  It could also be as simple as going for a walk or a run, or going out dancing. Most people don't just have one coping style. Most people utilize one or two or three and may have a combination they primarily or most often rely on. But people use these coping styles to be resilient, which is the ability to cope with a crisis and adversity, and to be able to hold on to something positive despite difficulty. It's also what helps them be flexible during a time of crisis and gain back resources and strengths internally even while external resources are still being rebuilt.
• 26:53
  Understanding all of those layers, both within the community and within the person, is a part of look from look, listen, and link. Listening requires a lot of communication skills. The first thing that's really important is staying calm. Because of the nature of a disaster or a trauma or other sort of incident or event. Our bodies automatically increase physical and emotional arousal levels, and that anxiety is contagious.
• 27:26
  We talked about that when we've talked about the polyvagal theory. But if you are anxious, other people around you will also be anxious, and so it's very important to stay as calm as you can. It's important to remember to maintain a calm presence without being emotionally distant, to remain stable and balanced in order to help others master or regulate their own experiences as well. When we talk about not being emotionally distant, that includes being warm. Sometimes they call it unconditional positive regard, which means valuing the person and offering them warm acceptance instead of judging them for what they've done or how they're responding.
• 28:15
  Compassion and kindness are expressed in attentiveness and open posture, a calming tone of voice, and accepting of anything that someone shares with you. Providing acknowledgement and recognition is a way to validate what someone else has experienced and their own individual and unique experience of trauma, and their own stress reactions that may be different than yours. It is understandable and to be expected that even people experiencing the same trauma may have completely different stress responses. Empathy is also really important. I would recommend looking up on YouTube the sympathy versus empathy video by Brene Brown.
• 29:06
  It explains the difference between sympathy and empathy with a little cartoon that may be helpful. But at the very least, when people are sharing what's happened to them, be prepared to listen, focus and attend to all of what they're sharing at both the cognitive and emotional levels. Empathy itself is the capacity and willingness to be able to feel with another person, to stay present with another person. If someone is sharing what happened to them, be prepared to listen and to be present with them. Focus and attend to all aspects of what they're sharing in all levels of communication, including both the cognitive and emotional levels.
• 29:53
  That means being vulnerable yourself and entering their world of pain and loss and hopelessness, even rage or shock or despair. But they should not be left alone with unmanageable or uncontrollable feelings. That can be a really hard thing in therapy even at the end of a session or between sessions. So it's an important conversation to have with your therapist, what to do in those scenarios, whether you can stay and sit in the waiting room for a little while before you drive home, Or what are the appropriate ways to contact the therapist between sessions, whether that's on phone calls or text or emails or not at all? It's important to know upfront how best to do this, and it's another time when journaling may help.
• 30:49
  It's important to be authentic and genuine. That's part of warmth and empathy. It doesn't mean being blunt or indiscreet. You can be authentic and still be sensitive to the other people's needs and the tones of the way and the tones of what you say or how you respond. Empowering the other person includes acknowledging and supporting a client includes acknowledging and supporting their strength, competence, courage, and power, their resilience that can help them start restoring a sense of control.
• 31:29
  And in communities, whether that's internal or external, it helps determine the kind of assistance they receive and the pace of any kind of self disclosure, and it allows for agency, which is the ability to choose. This is really important in your internal system as much as it is for these communities following a disaster response. Always focus on the strengths and positive coping mechanisms, and note what they're already doing to protect, to help, and to attempt to utilize resources. When we talk about supportive listening, we're asking other people. We're talking about listening to someone else who's going through a hard time.
• 32:15
  Our function then is only to be present with them. In English, we say a shoulder to cry on or an attentive ear. We're not there to give advice or find solutions or make them do things our way. Supportive listening means giving another person space and allowing them to fully and safely express themselves and their feelings. I'm pushing too much may push them away.
• 32:42
  They need you to be present and available, not overpowering or suffocating. A good understanding of what they're saying is important, but that's not all. It's also necessary to give support and reassurances, not in a fake platitude kind of way, but in a way of demonstrating your presence with them. You can also help empower them by reminding them of strengths and offering them acceptance and empathy. When practicing supportive listening, it's important to make yourself available and to ignore things that are not relevant and focus on what they are saying instead of being preoccupied with other things.
• 33:31
  It's important to make sure that the space of the conversation is private, safe, and comfortable. It's important to have faith in them that they know themselves better than anyone else and that they know what they need and that they're capable of meeting those needs. There are several ways you can do this. Repetition is one. Not in a mocking way like little robots like children can do, but in a way that confirms that you've been listening and that helps them understand that you are present with them and hearing what they're saying and understand what they're sharing.
• 34:14
  While deepening that understanding, it also offers insight. It gives you a way to participate in the conversation without making yourself the center of it. It shows that you're being attentive to them and caring about what they're saying. Another way to do supportive listening is through clarification, which is simply means listening closely to what they're saying and then simplifying what they shared and offering it back to them so that they have opportunity to agree or clarify with what you shared about what you understand what they were saying. This helps both of you get deeper understanding.
• 34:56
  Verbal support is another way to show that you have faith in them and that you are present with them and that you are supporting them until answers are found. You can also suggest alternatives or suggest ideas, but without advising or giving directions. This can often happen through questions that help the person just listen to what's going on and think about other answers and solutions to what the problem is. Remember that you're not only listening to the information and details that they're sharing, but also to the related emotions and what they're not saying. Remember to respond in a coherent way with an appropriate tone of voice, body language, as well as the words you're using.
• 35:41
  Listen openly and without judgment, belittling, or any kind of shaming of the other person's feelings, thoughts, or behaviors. Remember that you're wanting to just be present with them, and part of communication and presence is nonverbal communication. That may include things like eye contact, touch, space, voice, even gestures or facial expressions. All of these things send messages whether you realize it or not or whether you're aware of it or not, and all of these things are also in fact impacted significantly by different cultural values. People may also be sensitive to a variety of these because of past trauma or personal experiences.
• 36:31
  So it's important to be aware of and sensitive to these different areas of nonverbal communication. Finally, link has to do with helping people address basic needs and access services, cope with problems, get information, or connect people with loved ones or other social support. And again, this is entirely applicable to communities in disaster areas as well as to internal systems with DID. When people feel vulnerable, isolated, or powerless after an event or trauma, life is disrupted, and the more distressed they are about it, the more daily life is disrupted, especially if they're unable to access usual supports or find themselves living in stressful conditions. So linking to services or to the therapist or to things like the podcast or online support groups or workbooks like coping skills for trauma and dissociation.
• 37:38
  Any resources you have, as well as support people like friends or safe family or others inside who are safe and good and kind and able to help, all of that will add to the resilience and the empowerment of the person who's in distress. In disaster sites, refugee camps, and also when an internal system is in crisis, there are many challenges for self care and stabilization that we may otherwise experience. You may get assignments given with little notice or urgent needs without warning. You may have limited information available. You may need to make difficult choices in a hurry.
• 38:25
  You may be needing to balance the needs internally with the needs externally, whether that's with your system internally and the demands of you in the world around you or your basic self care for your own system, balanced with family or work demands outside you or your personal issues with the world going on. There's potential for repeated exposure to traumatic elements or other triggers, intense emotions, or repeated activation of stress with limited time for recovery. An example of that one would be our Africa trip this summer that was significant for our daughter, but also had its own challenges and new traumas. Following that, we had tornado experiences back home and then came here where a fire broke out while we were here to help with post fire recovery and then moving on to the hurricane site and then to the refugee camps. It's a lot of trauma altogether, and we've really got to be careful about self care and processing and staying in touch with our support system.
• 39:39
  So I know that disaster information and refugee camp information for psychological first aid or trauma responses, I understand, may not interest everyone and may not apply to everyone, and this was very, very watered down, a five day training in an hour. But there are some general principles that I thought might be useful. And as I have gone through these weeks of this tour of trainings, I really had many thoughts and recognition of how some of these things apply internally within a DID system as well. So if I provide that basic information, then maybe we can flesh it out a little more as we go or when we have opportunity to do so. But I wanted to share the information in case it is helpful and because it is what I had to offer today.
• 40:42
  Thank you. 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.