Latest / System Speak: Complex Trauma and Dissociation / Guest: Rich Loewenstein

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Guest: Rich Loewenstein · System Speak: Complex Trauma and Dissociation

• 0:11
  Speaker 1: Welcome to the System Speak podcast, a podcast about dissociative identity disorder.
• 0:17
  Speaker 2: 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
• 0:46
  Speaker 1: to the podcast. Thank you. Doctor Richard Lowenstein is an adjunct professor of psychiatry at the University of Maryland School of Medicine in Baltimore, Maryland. He is the founder of, and from 1987 to 2020, was the medical director of the trauma disorders program at Shepherd Pratt in Baltimore, what was a national referral center for severely traumatized patients. He has been rated by US News And World Report as among America's top 1% of psychiatrists.
• 1:30
  After graduation from Yale University School of Medicine in New Haven, Connecticut in 1975, From 1975 to 1979, he was a psychiatric residency post doctoral fellow also at Yale University. From 1980 to 1982, he did a research fellowship at the National Institute of Mental Health in Bethesda, Maryland. He is the author of over 100 papers and book chapters on dissociation, dissociative disorders, trauma disorders, dementia, delirium, somatic symptom disorders, and consultation liaison psychiatry. He is the section editor, dissociative disorders, of the American Psychiatric Association, APA, DSM five text revision, DSM five t r, and he is the co editor of the fourth revision in preparation of the International Society for the Study of Trauma and Dissociation guidelines for treatment of dissociative identity disorder in adults. Since February, he has primarily been the lead author of the dissociative disorder chapter in Kaplan and Sadick's comprehensive textbook of psychiatry, CTP, with the eleventh edition chapter in press.
• 2:45
  Since 02/2001, he has authored or coauthored chapters on treatment of dissociative disorders in all editions of the APA's treatment of psychiatric disorders. He is a distinguished life fellow of the APA and has received the life time achievement award of the ISSTD. He is co investigator and senior advisor to the longitudinal treatment of patients with dissociative disorders TOP DD study. Welcome, doctor Lowenstein.
• 3:13
  Speaker 3: Well, hi. I'm Richard Lowenstein, and, so I've been working with trauma and dissociative disorders for over forty years at this point. Well, longer than that because I was working with dissociative disorders before I understood what they were. But, I'm happy to be here and happy to have you interview me and whatever you wanna ask.
• 3:38
  Speaker 2: Well, let's start at the beginning of that. How did you learn about trauma and dissociation?
• 3:47
  Speaker 3: Well, the I I as I sometimes say, I'm an adult child of psychoanalysts. And, when I was 10 or so, my mother was a psychoanalyst. We all liked Alfred Hitchcock movies. So we went to see Psycho. And, my mother actually worked at the Menninger Clinic in the forties where there was a group of psychoanalysts who were working with what we would now call possessive disorders, fugue, amnesia, quote unquote multiple personality.
• 4:17
  And she actually wrote a paper on what we would call dissociative amnesia, which I didn't know until much later. And it's a fascinating literature which has been completely ignored and forgotten. Was led by a psychologist named David Rappaport. But in any event, you know, I don't think either of us anticipated what that movie was gonna be like. But but the the, you know, spoiler alert, the plot twist is that the main, murderer is a dissociative identity disorder individual.
• 4:47
  And as we walked out, she said something to the effect of, well, that's a real condition, but it's very rare. So that was kind of the beginning. And then when I was in residency, a one of my residents someone ahead of me in residency, Francie Allen, had a word with Cornelia Wilbur. And so she was very excited, when the simple TV and movies came out, and I didn't see them and really didn't pay much attention to it. And I went to the NIMH in 1981 to actually work in sleep research.
• 5:19
  I was interested in brain disorders. Always had been psychodynamically oriented. So I was sort of a psychoanalytic psychodynamically oriented neuropsychiatrist, which is a contradiction in terms. And, Frank was had just started. I came a year after Frank.
• 5:40
  I'd known Frank in residency, and he had just started working with trying to study DID at the NIMH having working on a unit for refractory bipolar patients. And one patient didn't make any sense, and she was in a wheelchair sometimes. Sometimes she could walk. She clearly wasn't responding to any of the, what were then experimental medicines using any, convulsants for bipolar disorder. And he said, oh, this is fascinating.
• 6:10
  You have to you you should get interested in this. And I said, okay. Yeah. I should get interested in it. And I interviewed one of his, patients for the sleep lab, and she had every sleep disorder in a single human being that one could have, which seemed odd.
• 6:26
  And and when she left, he said, oh, wow. Did you see all the switching? And I'm, I didn't see anything. So moving along, I was a consultant to one of the units, medical units at the NIMH because we were trying to start a research consultation liaison service. That's Medicaid a medical psychiatric consultations for, to medical physicians around psychiatric issues in their patients.
• 6:53
  And they asked me to see someone. I'm not gonna even say what unit it was. And just for an outpatient referral, and it became clear to me that she was actually very suicidal. And, she seemed to have rapid cycling bipolar disorder and at that time, people were interested in temporal lobe, sort of sub threshold temporal lobe disorder. She seemed to have that.
• 7:16
  And you can't the NIMH is not a hospital. You you cannot stay there unless you're part of a research protocol, but you really fit the bipolar research protocol. And long story short, she did not have a good experience. She, was on placebo, developed all the side effects of lithium on placebo, which puzzled the investigators. And she had stabilized, and she was about to go home.
• 7:41
  And the nurse from the CL service was still there. And she said, well, you know, she's saying something about having multiple personalities. And I said, well, she doesn't have that. She's, you know, really rapid cycling. And so often we were then actually just starting to think about psychiatric disorders as state change disorders.
• 7:59
  But even back then, Frank and David Rubenau, who was now at UNC, also from our residency, really pioneered that idea, and I came along with them. And, you know, when you're manic, you're in a very different state than when you're depressed and you feel like a different person. And I said, I'll explain that to pursuing doing an exit interview and explaining, well, you know, Lithium isn't your friend, but we're working now with carbamazepine, and that could really help. And then I thought this is 1981. I thought, well, if I'm really a good psychiatrist, I should rule out what I say the person doesn't have.
• 8:34
  You know, you have to ask the questions. And but what do you have what's the mental status exam? How do you determine that somebody has MVD DID? And I had no idea. But I found myself saying, you don't have this disorder.
• 8:52
  But if there's anybody else in that body who would like to talk with me, I'd be happy to talk with them. And she began to not only switch, but shift states, which I think is a more accurate terminology really than switching. And, also, what I saw was the overlap between states, which is something that Frank really discovered also in his research that the state of DID is a state of multiple overlapping states. So this was nothing like whatever was in the literature. And after about about an hour, I think I sort of ended the interview and sort of picked up my jaw from the floor.
• 9:32
  And I realized three separate things. One, this was so called Freud's grand Sharco's grand hysterics, sidebar. There's now literature that all of them were profoundly traumatized in childhood, adolescence, adulthood, but in any event, supposedly had disappeared at the turn of the century, nineteenth, twentieth century, I still am the twentieth century. And, I really thought my one question saying you don't have this disorder, but hardly fits the iatrogenic paradigm, which was still very much in in vogue then. It would it seemed really improbable that this extraordinary phenomenology was evoked by this one question.
• 10:18
  And then I suddenly realized all the other ones I'd missed because I suddenly had the, in field biology, it's called searching image. And it literally was all people, men, women, and the VA, outpatients, inpatients, seen in the consult service, and and the medical units that it really didn't have any idea what to diagnose in them or, you know, what what were the diagnosis. But I had to call them something, so I called them something. And they all just fit. And it was suddenly like I saw it.
• 10:51
  And then Frank and I began to collaborate. And we actually had worked both both had worked in the VA as residents at, as part of the Yale University, psychiatry residency. And and we identified together a number of male, DIDs, which I actually think there are many, many more male DIDs than anyone expects. But in any event, lot that's a long story. But then I you know, this is supposedly one in a million.
• 11:19
  Right? Which, of course, you dissociate dissociation. So if it's one in a million, how can I think of twenty people that I misdiagnosed all at once? It's more than one in a million. So I went to UCLA then afterwards, and I was partly on the consult service, and I was teaching and so on.
• 11:36
  And I there there were a couple of people who were interested in dissociation at UCLA. And, I said, well, you know, I'll supervise residents who have MPD cases. And I began to see that this was not one in a million. And I began to see more and more DID individuals and realized how, you know, DID is like, as we'd say, single personality disorder. There's no one way to be DID.
• 12:04
  There's no one way to be a single SPD. And, it was just a remarkable, remarkably different people across many, many other variables. So that's really how it began.
• 12:21
  Speaker 2: There's so much history in that story. And the pairing up of you two, what happened next as you all collaborated?
• 12:33
  Speaker 3: Well, so I went to I went to Los Angeles, and Frank and I stayed in touch. And we and then we're really, really close friends. We're we're, you know, we're we are, we're not just colleagues and collaborators, but we're extremely good friends and think together. Frank's a genius, and I've kinda feel like, well, I I'm a good translator of Frank's a genius. But in any event, we did a couple of studies.
• 13:02
  One was, because I began to see the the UCLA psychiatry department is this huge department. And it it again, it's hard to be brief in describing something, but it has a huge medical hospital where I was based seeing people in medical consultation. You know, this medical resurgence called a psychiatrist to see somebody. And then it it had a huge psychiatric hospital also on the campus. And, the there was a nurse on one of the psych units who picked up a PID person who, was came in after having some kind of fight somewhere, and he had no memory of the first eighteen years of his life.
• 13:45
  And so then I began to see people she was picking up, and I began to see other folks in the VA system who were sent to me for consultation. And so Frank and I collaborated on the paper on men males with DID in the late eighties. And also, I was working with on the epilepsy units as a cons consultant. And, there was early literature that dissociation is explained, quote unquote, by temporal lobe issues. And so we wanted to study the, you know, give the essence and stuff to people with seizure disorders and found really they they did not have much in the way of dissociation, particularly temporal lobe people.
• 14:30
  Although, I saw a couple of people clinically who when they were having some clinical seizures appeared quite they sort of would fill out a a a DES in a way that looked dissociative, but actually, they were having sort of subclinical seizure for them. But any event, so we kind of discounted that idea that this is really explained by sub threshold epilepsy. And then I moved to let's see. We were together in Washington. Then I moved back here to Baltimore in '87.
• 15:03
  The a colleague of mine, Steve Sharfstein, who yeah. I mean, I'm sorry to go on with because I have to fill in the the details so you understand the story. The National Institute of Mental Health has a, sort of a extramural branch and an intramural branch. And the extramural branch is directed at people outside of the government, and giving grants and so on. And in the, clinical center is a research center, which is devoted to seeing patients, inpatient, outpatient for research.
• 15:36
  And Steve was in the, he was head of the extramural branch, and he was part of the Carter Mental Health Systems Act. He's a a social psychiatrist in many ways in developing programs, in inner cities and so on. And the Reagan administration came in then in 1980, and they got rid of every grant that had the word social in it. And so Steve fled over to the other side of the intramural branch and set up a started to set up a research consultation liaison service. And then I and and so then I came back to and I also saw many dissociative men where whom I were called to see in consultation about whatever their medical issues were, not just in the psych hospital.
• 16:24
  And, then I came back to be he then came to run run Shepherd Pratt, and he wanted me to come back and, you know, run outpatient department or something. And I I'm not a good bureaucrat. I don't I don't I don't do meetings very well. And, because most meetings have no purpose, and and I'm kind of purposeful. I'm sorry.
• 16:47
  Interrupt anytime you want, by the way.
• 16:50
  Speaker 2: No. That was just funny.
• 16:53
  Speaker 3: Yeah. I mean, most meetings are so people can say they went to the meeting. But in any event, and he once said he said, no. You never would have been able to do that. You know, tolerate fools gladly, and that's probably true.
• 17:07
  And so, he wanted me to come back and do that, but I went to Shepherd Pratt. That was right around the time that inpatient dissociative disorders units were starting. And, and Shepherd Pratt at that time was like a 350 bed hospital. It had a hundred, child and adolescent separate hospital, 250 inpatient beds. And, they I also after seeing that initial patient, I really wanted to develop a mental status exam for dissociation so people could because the the strategy for diagnosis back in those days was to do hypnosis and find a I prefer cell state terms.
• 17:50
  And, a, that is not most people aren't trained in hypnosis. Most people who are trained in hypnosis are not sophisticated enough to figure out what is actually dissociated from something that is, or an ego state, so called, which is I think of as a aspect of the mind that kind of, I mean, one of the things I'm big on is we use metaphors to talk about the mind. We don't really own that. And whatever metaphors we use influence kinda what we see about the mind. But the mind, we don't know what it is.
• 18:25
  It's a, you know, it's a there's a big struggle about, well, what's the brain? But we don't even understand the brain very well at this point, but not really not at all. But the, you know, what is the mind then from the brain? So if I I'm gonna I'm gonna say encapsulate, that's not a re that's not something that happens in the brain. There's a little door or a little capsule, but it's a a metaphor.
• 18:49
  But ego states don't have a sense of their selves. They can't initiate an action. They don't have a body image, for example. But in any event so I thought it would be really important to help residents and other people learn how to ask questions in a clinical interview. So I developed this interview and published it in 1991, which is still the most popular thing I ever wrote.
• 19:13
  And I think in a lot of ways, the best thing I ever wrote. Although, at this point, it needs a lot of updating partly because depersonalization, derealization disorder hadn't really been classified then. So I I would actually one of my many projects I don't get to is to redo that article with Daphne Simeon, who's the the personalization, derealization disorder person, and develop a mental status for depersonalization, derealization disorder. But anyway, so I taught the resident I I was on the resident training unit when I first got there at Shepherd. So I taught the residents how to diagnose NPD.
• 19:50
  I'll use that term because I was with the term. And Trevor Pratt at that time had two hospitals. It was a acute hospital where actually the length of stay was ninety days, which may seem incomprehensible today. And another side of long term therapy place was that there there was a whole, movement, if you will, starting in the forties to do psychodynamic psychoanalytic therapy with, quote, unquote, psychotics. And that was a response to the barbarity, barbarism, I guess, is the right word, of psychiatry of the times, which diagnosis meant, you know, intrathecal in that's into the spaces in the brain, core serum, or, infusions of gold, through something called metrazole shock, which happened with around the time of this ECT.
• 20:42
  Nobody ever wanted metrosol twice, but it it was the most horrible subjective feeling. And it was really a movement against that dehumanization, try to humanize, quote unquote, people with psychosis. But they weren't very concerned with diagnosis. So if you read that literature, their successes are primarily with people who are dissociative, not schizophrenic. But in any event, So Shepherd Pratt had one of those hospitals.
• 21:12
  Harry Stack Sullivan had been there in the fifties and had a specialized unit for schizophrenia. And so there was a tradition of kind of psychodynamic therapy to quote unquote, you know, schizophrenics, borderlines, and other concept that I don't think much of. And, but in any event, so the residents start on the short term units, and then on the second year, they go to the long term units. And after I taught them to diagnose MPD, I mean, they turned the place upside down. Probably eighty percent of the patients over there were were MPD, DID.
• 21:45
  And that just I mean, it was and it it it created a lot of issues, both inside and outside because Paul McHugh, who is chair at Hopkins, is one of the founding advisers to the False Memory Syndrome Foundation. And what I was doing was utter anathema to him, and I use that word advisedly because he's a very religious Catholic. But any event, Shepherd did not have a tradition of doing specialty inpatient programs. And so for a long time, I tried to for several years, I tried to work as a consultant and trained residents to be a consultant to work on the other units with people who were dissociative. And it did not work.
• 22:30
  It is simply there it was sort of the split. The the main dissociative split in the world is not good, bad. It's belief, disbelief. And it's, you know, projected out into the culture at large and to, you know, the the ether at large. And so they were the believers and the non believers.
• 22:49
  And the believers wanted to protect our patients from the mean non believers who said things like, I know a borderline when I see one. You go upside their head. That's a quote from a nurse. And so it it it that did not address appropriately what needed to be done. So after a lot of negotiating, we convinced the business people that we would bring in new business, not just recycle their patients.
• 23:15
  So I started an inpatient unit at an outpatient program. Judy Armstrong, who was the most brilliant one of the most brilliant beings I've ever known, started trying to figure out how to do site testing, which nobody had figured out how to do that, which I've referenced in the most recent paper and other papers. And again, I you know, I'm a psychiatrist, so I come along for the ride. The psychologist started the testing stuff, but it it was that was really amazing. And, we started our unit in 03/19/1992, within the DDU.
• 23:51
  And we're we're gonna do it very slowly because we had no idea how it was gonna go. And within a month, we were filled with a waiting list. And that was when what I call the nuclear winter of managed care happened. And Shepherd was really in their sights because Shepherd was a long term hospital. One of the main, sort of starting managed care companies was in Maryland.
• 24:14
  And, they literally would come to the hospital and read through charts and it it it was a nightmare. But we were the only thing for a while that was full and made money. So, you know, that made us popular in one sense, but there was still an incredible controversy of who we were doing. So, anyway, why don't I just stop here? I mean, there's so much history, but, I could go on and on.
• 24:37
  But let me stop and, see what else you wanna ask me.
• 24:42
  Speaker 2: Well, I think you're getting into, one of the questions I did have while I had time with you, and I know there's some politics that we have to be careful about and sensitive to. But I think that there is confusion for some clinicians, some people with lived experience where they don't understand the history of that and the impact of managed care and why Shepherd Pat was, like, the place. And people like, oh, I still wanna turn there for help. But now when they go, it is not the same experience. And people are surprised and shocked.
• 25:19
  And, like, if you know the back story, it's very easy to see why this has happened, and it's so sad. But what is appropriate that you can share to explain that shift recently?
• 25:31
  Speaker 3: Well, I can I can explain it, because I I probably will not be as diplomatic as I should be? So the, our program, I mean, it went through lots of iterations and the the and it's just every imaginable thing. We were actually pretty good overall at dealing with managed care. And, you know, I think we we were pretty good given how toxic that situation was at at helping patients stay longer, if not as long as they needed, really, which often, if someone was in, really decompensated two to three months inpatient was not a unusual idea because it often took a month for people to just figure out that we might actually wanna hear what they have to say and weren't about to punish them in some way. But, when Steve retired and a new regime came in, it had a it was not managed care.
• 26:30
  We were still financially successful. But it was, I think, a very different philosophy of how hospitals should be run, and they had no real interest in psychotherapy, but also in kind of programs with people who had their own, I would say, constituency. So they first got rid of the eating disorders program, which was even though philosophically, the eating disorder folks and our folks disagreed completely, the the head of that unit, program is a internationally respected researcher. He's a real straight shooter. We disagree, but, you know, he would he would we disagree collegially, and they he got they got rid of them.
• 27:19
  And it sort of either people left or people like me were suggested that I leave. And in fact, the environment was so toxic that I, on the one hand, felt terrible because I wanted to help the patients, protect the patients, protect the staff. Because part of doing this is, you know, is creating a situation where really talented people come to work, dedicated people. They're incredibly dedicated people in that program. And, you know, let them work.
• 27:53
  Leave them alone, really. And, you know, if they have problems, I know they'll come talk to me. But, you know, the the program wasn't just me. It was created by, a multitude of people over many years as because it had to evolve. But in any event so I left, Ben Israel who you may know, became the, titular head, six months or so.
• 28:19
  The pandemic had a big effect on things. So, every you know, that that had created real chaos everywhere and chaos in the hospital. And, so, you know, they used the excuse that our program was, top heavy bureaucratically, and so I should go. So I went. And I couldn't have lasted another six months with that administration anyway.
• 28:45
  So Ben stayed for a little under a year. He left, and then a couple of young psychiatrists and a young psychologist did their best to run it. And in August of twenty two, they had enough, and they left. And and some of the nurses really tried to keep the something of the program going, but it it couldn't be, and it officially closed at this point as far as I know. That's the unpolitics statement.
• 29:11
  Speaker 2: There you go. I just I wanted to whatever degree was appropriate, say this explicitly because I think it has absolutely had an impact on the community, and I think it is absolutely a shock to people who don't know that all that was transpiring. And Right. There were you all developed such a program that was such an expectation of not just quality care, but of safety. And those Yeah.
• 29:38
  People who landed there the last couple of years were not safe. And, really, really, it has been such a a tragedy, I think, in both clinically and with those with lived experience, just the shared trauma that the loss
• 29:54
  Speaker 3: of it. I I have a lot of feelings about it and just exactly what you're talking about. I mean, it is it it's a tragedy most for the people we treated, the patients. I'm a doctor. I call people patients, but, you know, as far as I'm concerned, that's, in the best sense, that is a very monistic relationship.
• 30:14
  Doctor patient could can be completely abused as can any other relationship. But, yeah, I mean, we created and and I really mean we created a extraordinarily amazingly good program. And I think every, part of the idea was that everybody, every member of the staff, the people who cleaned the unit were all part of the therapy. And that we really, you know, the human beings are thoroughly imperfect, and we were thoroughly imperfect. But we strived to figure out how to keep it not only humane, but safe.
• 30:54
  I mean, there was an incredible culture of safety, and the nursing staff was extraordinary in in maintaining that. It it was like a tag team where multiple tag team of people really caring and watching about safety. And, you know, we tried really hard. Yeah. We I mean, I can assure you we made many mistakes.
• 31:17
  I made many mistakes, but the goal was to create a safe space for people to get help that they could not and did not ever get any place else. So it is a I I have a lot of feelings about it. It's a tragedy. And, but it's also across the country. Colin Ross' program was stopped.
• 31:39
  Judy Herman, stopped her program because of administrative impossibility of continuing. And, yeah. I mean, it's a it is I don't even have words for it really.
• 31:52
  Speaker 2: It's so intense. I the the other thing that well, I just lots of big feelings. So just for me to be able to take
• 32:03
  Speaker 3: big feelings too, and you can tell.
• 32:05
  Speaker 2: Right. Right. And that makes sense. You just poured so much into that. And I watched some of this just very peripherally.
• 32:14
  When the pandemic hit, my friend Peter Baresh started that little group for clinicians to just sort of have space together, and you were in that for a brief time and right as this was happening. And so to watch that from that angle as well. And then the to I I didn't really get to see you again until treatment guidelines meeting, so more meetings that you love. And and then, we've been emailing back and forth about these articles and things, and it's been fun to get to know you more. One of the things I really wanted to talk about, and I I also wanna be careful of your time.
• 32:55
  Speaker 3: It's I I it's cool, my time. But, certainly, we can go for another twenty five minutes or so.
• 33:01
  Speaker 2: Okay. So if if you don't mind, could we talk a little bit? Because we've talked a lot about structural dissociation and why it's not actually a thing, and go from that into, like, your theory on that in your paper. I can talk about your paper more in other episodes as well. But where do you even wanna start with that about structural dissociation?
• 33:27
  Speaker 3: Well, I'll I'll start with metaphor. So the way we think about the mind, because it's ineffable. You know? You can't you can't taste it, feel it. We we live in it.
• 33:39
  We feel it. And and I think I I don't know, but partly Western cultures live in a sort of, subject verb object world. So I think our world may feel that way as if we are a thing. And certainly, the old psychoanalytic papers, you know, talked about the, you know, the ego, the id, and the superego as structures. Apparatus is what they call the great nineteenth century term for the mind.
• 34:10
  An apparatus, that's a metaphor. The mind is not an apparatus. So I I find structure metaphors for the mind problematic because as far as I can tell, the mind is process, and the brain is is structure, but it is the there is the processes in the within the structure at multiple levels starting literally subcellularly in atoms and protons and neutrons and whatever all else and up through DNA and RNA and proteins and cells. All of this is process. And I think I quoted in my one of my emails, David Rappaport, who I mentioned, he he said, well, structure is just a very slow process, which is true, actually.
• 34:58
  You know, you think of rocks. Yeah, because they're processes, but they're just slow. And so I think the structure metaphor is, like, parts. And I I you know, this is a term we use as a shorthand. And if people are comfortable clinically deep in therapy using that term, and there are people who are not comfortable using that term, I I'm I don't argue with what shorthand work, but I think in clinical writing, the idea that they're parts gives you the mind the idea of a mind as a machine, as an apparatus, and as and as a thing.
• 35:38
  So from starting out, DID people, have, at a very basic level, been treated as things, as, you know, hated and abhor I'm sorry to be graphic in this way, but hated and and abhorred things, but also very valued things in strange ways. And so I think if you start reify reifying is to make a metaphor as if it is real. Reifying this, you you, weirdly enough, think of people with DID more as things, which is, in my view, a problem. That's a you know, that's not word conceptually where you want to start and what meta metaphors matter. And, you know, people may say, oh, you're being fussy.
• 36:26
  But they really do matter in terms of what they connote and what they denote. For example, talking about a cell state as persecutory and malevolent. Well, it doesn't sound very good. But and helper sounds good. But if you stop and rather think about this as ways a human being had to adapt and what they had to adapt to and how this would emerge out of that adaptation, well, then it doesn't fit persecutory or malevolent superficially.
• 36:56
  Sure. But underneath, it's an attempt to solve the impossible problem of growing up in a DID family, which I actually I realized I sort of did a gloss on Tolstoy and Anna Corona. You know, all happy families are the same. All unhappy families are, unhappy in their own ways. I I guess what I realized was all DID families are heinous in their own way because we always say, well, this is a terrible family.
• 37:25
  And you think, well but they're all terrible. Anyway, so, and I and and talking to some of the structuralists, they don't understand that it's a metaphor. I spoke with one of them and at a lecture and said, oh, you know, and they talk about retraction of the field of consciousness, which is it's all back actually back to in a lot of ways. They they bypass Freud and that's and we don't know where where the adult, nest, but that they I said, you know, well, those are metaphors. And he said, no.
• 37:59
  They're not. And I was like, wait. What do you mean they're not? Okay. So that's the first part.
• 38:06
  The second part is I don't think it is a dissociation of the personality because based on the data developed because of Judy Armstrong and Bethany Brand and my coming along for the ride and, so on, we really discovered that individuals with DID have a unique psychological organization, which we've written about a fair amount, which I we wrote about in that most recent paper particularly. And so you and a lot of the mind of individuals who are dissociative is not dissociated. It's not divided. There are many, many unified processes. So and that's part of part of what I think is hard for people to grasp often is you have to be able to tolerate ambiguity and apparent contradiction.
• 38:56
  How can you be both divided and unified? You know? I I'm cool with stuff like that. Contradiction and ambiguity and and dialectics and things that bend your mind. I I kind of like that.
• 39:10
  I live there, which is probably why I'm good at doing this at one level. But, so that's so I think just from a just the language point of view and the conceptual point of view. And as I mentioned, you know, and I've been writing much more and lecturing about discrete behavioral states. That's the the the thinking that Frank Putnam, Dave Rubenel, and I began with, thinking of psychiatric disorders as state change disorders. So, again, that's a completely different idea.
• 39:44
  So the other thing is most of the the the developmental theories based on the discrete behavioral states ideas and our psychological testing ideas go together. Look at DID from childhood. Look at it. At the Frank Putnam became a child psychiatrist in part because talking to adults with dissociative disorders, he couldn't figure out what what happened in childhood. So he went back to look at children and make sense try to make sense of dissociation and child abuse from a developmental point of view.
• 40:21
  And and so that's where the the theory of DID as having to do with states that develop without the self-concept unity, that developmentally would occur otherwise. And so all the other theories, like structural theories, are derived from looking at adults and reasoning backwards. So that's that's another problem. Then they really, without data, just say, well, all these other conditions are dissociative. PTSD is dissociative.
• 40:56
  Well, it it's more complicated than that. The whole literature shows, well, not it is okay. Flashbacks are defined as dissociative in the DSM. So okay. That is hence, it is dissociative.
• 41:09
  But that's really not what we mean. And there really are a subgroup of people who have PTSD and dissociate. And I think many of them have dissociative disorders. Actually, that is something I disagree with with the structural people. But they're usually not tested diagnostically.
• 41:26
  They're tested for symptoms. So they reason backwards. They ignore the and the meta analysis suggests association is either a subtype or a component of PTSD. It doesn't define PTSD. And they they don't have literate they they don't do studies.
• 41:46
  Their ideas are basically, intellectual ideas about, you know, nine reasons why this must be true. The other thing is the terminology is really problematic. So you have the apparently normal personality. Well, a, I don't think it's a personality. And b, apparently, in English can mean something that is readily apparent or something that is hidden.
• 42:13
  Like, oh, it's really apparent that it's raining. Or, you know, we thought he was a good guy, apparently. So that's a problem. Normal is a setting on a washing machine. I mean, we can't define normal.
• 42:26
  Normal is always defined in reference to something. You know? Normal blood count, normal blood pressure, there's no normal. So you're already in pretty deep conceptual trouble calling something an ANP. I won't even get into my reassociation in that.
• 42:45
  And you have the ANP, the apparently normal personality, and then the emotional personality. Well, emotional in no way is adequate to describe the phenomena of traumatized associative people. So and and it again, I think it overly concretizes, and reifies the mind in a very particular way. And they dominated the ICD 11, diagnoses, and they did ex the DSM I I mean, the DSM process is imperfect. But what actually the goal was was to reduce what used to be called NOS, d d NOS, because about forty percent of dissociative diagnoses were NOS, which is not good for a diagnostic category.
• 43:39
  So Paul Dell using the med had about a thousand cases, and he really showed that the phenomena, it fundamentally is the state of multiple overlapping states. That's the core phenomenon phenomenology. And so we tried to I mean, it's imperfect, but the idea was to reduce the number of NOS cases. And ICD 11 literally goes back to that. They have DID and partial DID.
• 44:07
  I don't know what partial DID. I don't know what partial bipolar means or partial schizophrenia. What does that mean? And, actually, their description of partial DID is more realistic phenomenologically than their description of DID, which is based on the structural theory. So from the conceptual level, the sort of hegemonic diagnostic level, and and they very much are concerned with that you believe the theory.
• 44:35
  They really aren't interested in data finally. And, the conceptual vocabulary, the reasoning backwards from adulthood, which is fundamentally problematic, and the way of conceptualizing the mind, all of this for me not only is unhelpful, but not accurate. So have I have I said enough in in politic enough?
• 45:00
  Speaker 2: I love it because it's so much of what I included in my plenary. Like, when we go all the way back to what you even said earlier about the barbarism of psychiatry and the history of trauma in treatment. And and and looking at the impact of that and then sort of this layer where people are talking about something completely different, but people who have not studied the history or the research behind the words even of what they're saying or why they're saying what they're saying, and then just sort of pick it up so that now it's slang, but completely inaccurate. And what happens, like, from a lived experience perspective, is that then you're sitting on the metaphorical, literal couch, right, and thinking, like, I feel like there's misattunant here or there's gaslighting here, but I can't find it. And it's literally with this that someone I've never met.
• 46:05
  And and, I mean, I have since met Kathy Steele and talked to her about some of this. But Yeah. Then then what we get then what we get is this experience that's not congruent with what's being explained, and yet defining ourselves by that is the only way to get help.
• 46:26
  Speaker 3: Yep. Big problem. I mean, it really is a big problem because I mean, the main thing in therapy is to understand the I mean, this is not about any diagnosis. Diagno you know, diagnosis is a helpful set of constructs. And where I came in in training, because this is important in the history, was where that psychodynamic treatment of psychosis ran a ground.
• 46:57
  Because I started out at wanting to be a psychodynamic, you know, therapist to psychotics, and I started working with psychotic people in the VA. Schizophrenics. I worked with a lot of schizophrenics. Dynamic psychotherapy for schizophrenics is cruel and unusual punishment. I mean, that's not helpful to them.
• 47:17
  That is if you sit with somebody who's chronic really chronically psychotic as opposed to misdiagnosed dissociative disorder or whatever, that is not a helpful frame for them. They they really even if you're conceptualizing them that way, they need a much more concrete, active, solid human being, which is also true of traumatized people. But what happened was I this is before psychiatry morphed again into everybody gets drugs for affective disorders. In those days, The US Psychiatry diagnosed more people with schizophrenia than anybody in the world, and that was influenced by this group that anybody who had one thought that was disconnected got a thought disorder diagnosis and was diagnosed schizophrenic and put in long term analytic therapy. Good for some people, really not so good for other people.
• 48:13
  And I started working in the Yale Lithium Clinic, which lithium didn't come into The US until quite late. So it's like four or five came in '71 or '72. I'm working there in '76, '70 '7. And I would sit with people, and they would say, you know, I used to spend six months of the year in a state hospital, and then there was lithium. And now I can live my life normally.
• 48:37
  And it's same with mood disorders. We saw people who are severely depressed, who responded to medicine, and for the first time, really, like, wow. My I've been restored. I we had a woman in one of our inpatient units who'd spent two years in a back ward at Chestnut Lodge diagnosed as schizophrenic. We put her on lithium, and in ten days, she wasn't psychotic anymore.
• 49:04
  I and I I realize people don't see this anymore. So what they see is you walk in for your fifteen minute med visit, and they put you on seven meds all at once, which is just crazy on its face. But there is a there is a humanistic use of medications and that there are people whose lives have been saved, and I saw them. And so that the the unfortunately, it it we became an it I mean, it's the human condition. It's either or.
• 49:34
  It's either psychodynamic or it's brain. And Frank the three of us, Frank, Dave Rubinau, and I, we among you, we're both we're all committed to the idea we could be very good psychodynamic, humanistic, psychodynamic clinicians, and we also could be good medical psychiatrists, which means not only knowing who to give what medicine to, but who not to give what medicine to and who to take off of the medicines. And, I mean, it it it is not. It people don't do this anymore. Residents aren't aren't trained how to even think about I I'm appalled because there really is a very systematic and serious way to think about diagnosis and medications in a in a humanistic sense.
• 50:21
  Speaker 2: Well, in keeping it a relational experience, which is where the healing happens. So having the support and the capacity and the connection, but that's different than just turning off symptoms.
• 50:37
  Speaker 3: Absolutely. But, you know, again, the whole point of therapy is an understanding and understanding that your human being across from the human being or therapist. And that is what we're to do. I mean, we we we may have our theories. We may believe certain things, but, fundamentally, it really is a deep collaboration in understanding and trying to, you know, go where you've gotta go to understand and help and keep safe and because there's all kinds of stuff.
• 51:13
  But, anyway so, yeah, I I'm gonna stop because you should always feel free to interrupt me because I can talk forever. So feel free always to interrupt me, by the way.
• 51:23
  Speaker 2: It's it's been so good. Before you go, I wanna add this last piece that's really your piece, but just for listeners to tie it together. So when my first therapist, when I got diagnosed and learning about DID, and this is what DID means, it was like learning to notice these patterns of, okay, that is that one, and this is that one, and this is that one. These not mes. Right?
• 51:53
  So there's that. And I understand that a fundamental, and, again, like, the shorthand language of trying to find ways to talk about parts or people or Yeah. Whatever. This kind of thing. Right?
• 52:04
  Whatever your language is. But now that I have been in therapy for some time and I'm with a different therapist now, and I'm sort of reentering, like, a more advanced phase of therapy, in some ways, it's tricksy because it would be easy in some ways to go back to, oh, this part and that part and this part. And in some ways, I need to because avoidance and all of that. And also, I have learned enough about myself that I can see and experience the process of what you're saying. So recognizing even though I I don't wanna even use the words integration or fusion or anything like that because it's so charged, but recognizing okay.
• 52:51
  So the pattern of this one, when I am feeling this or seeing this or they, whatever, like, however you wanna say it or express it or happens, when I have space to notice it, recognizing just not that one, but literally the process of, oh, my need is this, and I can meet the need this, and I can express that. So thinking about states really changes literally my access to myself, which is why I think I I guess would be the reason I would add to why structural dissociation can be so limiting. Because in some ways I mean, I don't wanna be like, oh, I don't have to identify my parts or get to know my system or whatever, like, the words are. I just need I'm actually at a place where I can access more of myself than I can with only that. So how would you talk about states and explain that before you go?
• 53:51
  Speaker 3: Okay. Well, first of all, the other things live in states. We call it, we have all kinds of language. We call them emotions or moods or, you know, or states. But if we pay attention, we we're really if I'm in this I'm in my sort of semi professional talking through a screen mode here, which is a mode that I have.
• 54:17
  And so call it a mode, but it's really a state. And if I'm in another situation playing with a grandchild on the floor, I'm really in a I'm still me, but I'm in a very different sort of me. And I'm also in a different relational context with the states interacting with the states of the other person. So states are we're everywhere. I mean, the simplest thing is I actually, as you know, I had I was sick for six weeks or so.
• 54:47
  And when I came out of it, I was in a different state. And I it's really hard almost to remember what it was like to be sick in that state. And I was talking to a friend of mine, and we're catching up, and I realized, oh, I completely forgot to tell him I've been sick for six weeks because I kinda forgot what that was like. And I really don't particularly wanna be in that state. It was awful.
• 55:08
  So I I'm trying to you know, it's a it's a simple concept, and it's a complex concept. And states can be understood at every level from molecular to interpersonal states because we're affected socially. Our states are affected by our social milieu, by our cultural milieu. I mean and we're we're interactive beings. We're we're social beings, so our states are shared or not shared.
• 55:37
  Anyway, I does that make help at all with what your answering your question?
• 55:43
  Speaker 2: Yes. It it does explain it, and I think it's something that we see, like, why therapy is hard sometimes and why it's good sometimes, why making friends is hard sometimes and good sometimes. Not just because, oh, this one is good at that and that one is good at that, but literally because interactions with others change us. Because, interactions with memories or feelings changes us. Like like that molecular again, is still trying to make it a structure.
• 56:14
  Right? But that molecular structure example, when different atoms connect to make different molecules, it's a different thing than what it was by itself.
• 56:25
  Speaker 3: Well, I don't think you can totally ignore structure ideas, but I think that you have to be self conscious of the implications of of process metaphors too. I mean, they these are metaphors. But, I mean, the state's conversation is a much it it's, obviously, a longer one. But I think it it helps. Oh, so let me just jump back to I I think it any therapy that has a box that says the person opposite the therapist must be such a way or come out at the end such a way is a big problem.
• 57:05
  Speaker 2: Yes.
• 57:06
  Speaker 3: I mean and and I can say that as a, you know, grown up psychiatrist, blah blah blah. If I was 20 and going into therapy and I didn't wouldn't know anything really about it even coming from the background that I did, I didn't really understand it. And some therapist said, this is how it is. Even if I felt very uncomfortable about it, it would be very difficult for me to assert or even find words as you're describing for that discomfort. And, and there is no way around the fact that any therapeutic process is a one down situation, at least, for the person coming for help because they are simply in a position of needing help.
• 57:49
  They don't know all the things they would need to get help. The other person has the authority and so on. I think it's one of the things It it doesn't mean that that has to be bad, but we all have to own that that is a reality. And so therapists have to be deeply aware of though that they are in a power dynamic relationship and have to be respectful, particularly with trauma survivors because the the trauma especially childhood all trauma, but childhood trauma, you grow up in power differentials, and that is powerfully important to acknowledge. Not to pretend it isn't there, but to acknowledge it and work with it.
• 58:28
  But, hey, man. I think just to try to be concrete. So I I think that there are times in work I I think, at this point, I kinda think of working with the ideas as knowing a different language than I learned growing up. And it's a way of translating themes and sequences of phenomena and fitting that to trauma adaptation, if that makes sense to you. But concretely that, I mean, at a point in time, you're talking directly with a self state as if you are doing therapy with a separate person.
• 59:06
  Sometimes you're talking to systems of selves, which is often mostly, I think, where I work. And then you're talking across the I this people with DID are human beings and share all the stuff that human beings have. And so you're talking to a human being and trying to find where those levels make sense, but also holding in my mind, hey. I'm a human being. I'm talking to a human being.
• 59:35
  So human being's mind is divided in ways maybe mine isn't, but I need to understand the themes and the language and what is if this happens here and then someone comes out and someone else influences somebody, what is that telling me? What are the themes that run through that? How to how to make sense of that as a process? So I don't know. Did that help you at all?
• 59:59
  Speaker 2: Well, I appreciate being a human being more than a thing.
• 1:00:04
  Speaker 3: Well, I think that's right. And I I that's the problem with structure metaphors in and of themselves. I mean, structures exist. Rocks exist. Computers exist.
• 1:00:15
  Bodies exist. I mean, it's not that they aren't we aren't structures and processes. I'm emphasizing the importance. If you use a structure metaphor or process metaphor, you're using a metaphor. This is you're not describing what's really going on in a human being's brain mind.
• 1:00:33
  We have to find a way to talk about it. And if you use a metaphor, you have to know that what it connotes and what it denotes and what it what that means you are implying by using that term and being humble, if you will, about, well, maybe that wasn't the best language, finally, for this, and maybe we should think of a different language. So, but I think the structural theory is is just conceptually flawed. I think its therapy theory is not that different, finally, from other therapy theories, but the, and and often good therapists have ideologies and wind up behaving relatively similarly if they're good therapists. But, I think the model is it is meant to be prioritized over exploration and data, among other things.
• 1:01:25
  And that is a real problem. I went to Europe and tried to give them a different idea. They're they're they're all hung up. You know, they've all been taught about this, and they try to get people into it. And if you're fitting people into models, it's a real problem.
• 1:01:38
  I mean, you gotta and you gotta own what your models you also have to know. I have to know, okay. I have certain models. I have certain belief systems. I have certain personality characteristics.
• 1:01:49
  I have a certain history. I bring all that to therapy. I need to be conscious of that when I'm working because, otherwise, I'm not gonna be fair to the person sitting across from me in terms of owning my own whatever my biases are, whatever perspectives I have, whatever I come with, I have to know them and or try to know them. You know, everything from, well, I'm not feeling very well today, so I probably don't listen as well to something else, something else. So I I I very much don't like the idea of people being fitted into boxes somehow and told to come out a certain way or not a certain way.
• 1:02:29
  That just doesn't fit my view of what the nature of therapeutic interactions
• 1:02:35
  Speaker 2: are. I think it's that intrinsic misattunement that happens when you do that, when you shove someone into a box like that that causes, like, the process to shut down. Because there's there's no room for process.
• 1:02:52
  Speaker 3: Yeah. No. And and, also, I think it leaves out I mean, I I, you know, I I'm pretty open as a therapist, not about, oh, let me tell you about my personal life. But if I feel like I blundered and and I'm not gonna you know, I wrote somewhere that, you know, self disclosure is not the same as confessions if you're a therapist. But that I have to own my presence as another human being rather than, you know, I know best and whatever's going on with you is your transference or whatever as opposed to, no.
• 1:03:30
  We're two human beings in a room bringing what we bring, doing something extremely difficult together. It's very, you know, that takes I think of the ID folks entering therapy as somebody, like, trying to grab a flying trapeze going by and thinking, you know, there's no net under here, but I think I'll somehow keep maybe this will be okay. And that's pretty scary, and therapists should really respect that. And so I I'm comfortable with being fallible as a therapist. And I I I don't mean I, you know, go out of my way to screw up.
• 1:04:06
  But when I don't say something correctly or I really misunderstand something and it has an impact, I think I need to talk about that, and that is really helpful. Connie Dahlberg wrote this beautiful book, Countertransference and Treatment of Trauma. And that's what the trauma traumatized people said. That is one of the most important I not don't do it because Connie Dahlberg found this, but that's the one of the most important things that the person is is human and fallible and and is with you, but also a professional who has to stand aside and try to help you make sense of what you can't make sense of because you're in it. And that's true if I'm in therapy.
• 1:04:46
  I, you know, I can't make sense of stuff unless I have a professional helping me.
• 1:04:52
  Speaker 2: Well, then I think that's what transforms us from things, whether bad treatment models or objectified abuse history. Right? That's what transforms us from things to human beings is being in space with other human beings who treat us like one also.
• 1:05:13
  Speaker 3: Yeah. Very true. I I I I would really write that down and put it in put it out there if you haven't already because that is certainly it it seems obvious, but it is very much the truth.
• 1:05:28
  Speaker 2: Thank you so much for talking with us today. I'm honored and delighted to talk with you all. Oh, I am grateful. Thank you so much.
• 1:05:39
  Speaker 3: Thank you. I'm really grateful for the opportunity to talk with you and to your listeners. And so you take care.
• 1:05:45
  Speaker 2: Bye.
• 1:05:53
  Speaker 1: 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 @www.systemspeak.com.
• 1:06:15
  Speaker 2: We'll
• 1:06:15
  Speaker 1: see you there.