Latest / System Speak: Complex Trauma and Dissociation / Guest: Joan Turkus, M.D.

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Guest: Joan Turkus, M.D. · System Speak: Complex Trauma and Dissociation

• 0:06
  Speaker 1: Welcome to the System Speak podcast. If you would like to support our efforts at sharing our story, finding stigma about dissociative identity disorder, and educating the community and the world about trauma and dissociation, please go to our website at www.systemspeak.org where there is a button for donations and you can offer a one time donation to support the podcast or become an ongoing subscriber. You can also support us on Patreon for early access to updates and what's unfolding for us. Simply search for Emma Sunshine on Patreon. We appreciate the support, the positive feedback, and you sharing our podcast with others.
• 0:47
  We are also super excited to announce the release of our new online community, a safe place for listeners to connect about the podcast. It feels like any other social media platform where you can share, respond, join groups, and even attend events with us, including the new monthly meetups that start this month. Go to our webpage at www.systemsbeak.org to join the community. We're excited to see you there! Doctor.
• 1:43
  Joan Turcas is our guest today. She maintains a Consulting and Clinical Practice in Psychiatry and Traumatology in McLean, Virginia. She is the medical director TraumaSci, complex trauma disorders program at Dominion HCA Hospital in Falls Church, Virginia and co founder past medical director of the Center Post Traumatic Disorders Program at the Psychiatric Institute of Washington, DC. Doctor. Turcas has years of experience in the trauma field and maintains a national profile with teaching consultation.
• 2:20
  She is a graduate of Rutgers University with a degree in pharmacy and graduated from the George Washington University School of Medicine with honors. She is a distinguished life fellow of the American Psychiatric Association and a Fellow of the International Society for the Study of Trauma and Dissociation, of which she is a past president. She has been awarded a Lifetime Achievement Award, the Cornelia Wilbur Award for Clinical Contributions, and a Distinguished Achievement Award by the International Society for the Study of Trauma and Dissociation. She's a diplomat of both the American Board of Psychiatry and the American Board of Forensic Psychiatry. She is trained in psychiatry, traumatology, clinical hypnosis, and EMDR.
• 3:07
  She maintains a keen interest in neurobiology, psychopharmacology, particularly in their application to the complexity of post traumatic stress disorder. Welcome, Doctor. Joan Turcus.
• 3:24
  Speaker 2: This is Joan Turcus and I am a psychiatrist and a traumatologist. I've been doing this work, I hesitate to say how many years, but probably thirty at least, and have gradually gained more and more expertise. I was very fortunate when I started to have a mentor who is Frank Putnam. I was actually here in the Washington DC area, and he was at NIMH. And I would often run into his office and say, help.
• 4:01
  And he was very helpful. So that's where I started. And over the years, I've not only had a small private practice, but gradually became interested in creating an inpatient trauma unit with one of my colleagues, Christine Courtois. And I had said the other day to Chris, I think we saw something like 5,000 patients over those years together. She thinks it was actually more like 7,000.
• 4:31
  So Chris has, quote, retired, but not really. And I have started a small unit here in Northern Virginia. So I'm splitting my time. Think among teaching and not doing many podcasts, however, and time at the hospital supervising and a small private practice. So I'm really fairly busy, which is a good thing, particularly in this time.
• 5:04
  I think it keeps me grounded.
• 5:07
  Speaker 1: You also are teaching the one of the master courses for ISSTD.
• 5:12
  Speaker 2: Yes. I've taught that one for a very long time. One of my students said to me, she thinks it's been eighteen years. I started teaching in the professional training program in 02/2002. So at this point, I'm actually doing two courses.
• 5:29
  One is a master seminar and the other one is an advanced class.
• 5:33
  Speaker 1: I am so grateful to have you here to talk to us today and appreciate your time. I know that you are very busy. I have enjoyed getting to know you through our group with Peter, which is how I came to the group. He has been on the podcast, so listeners know Peter a little bit as as that he is my friend and that we met through the podcast. We've had several conversations on the podcast.
• 6:00
  But getting to spend time with you and to learn with you and to endure the pandemic together and all the transitions that that has been has been a really powerful experience. And I just wanted to thank you for letting me be part of that group and also having your voice, a woman's voice, your history that you've brought to the table and sharing with us today your own perspective. I think that so often to give so much to the community in so many ways, and your example of that in all the different ways you have helped is really significant. How did you get involved? I know Putnam was there.
• 6:40
  You shared that. But how did you first learn about trauma and dissociation in the beginning?
• 6:45
  Speaker 2: I finished my residency, in 1980, and I was very curious about forensic psychiatry. My mother was an attorney, and so I think that influenced me. So I decided I'd spent a short time in forensic psychiatry in one of my rotations, and I was struck by the fact that it was a a very honest, intelligent group of people who would sit down and work things through in a, you know, conference. Because I think there was the sense that you don't go to court without having done this. So it was a multidisciplinary team and a good one.
• 7:26
  So when I started working in the forensic area, I began to realize very quickly that I was dealing well, I was primarily seeing men the time, but they had horrific histories. And there was a part of
• 7:43
  Speaker 1: me
• 7:43
  Speaker 2: thinking more as a physician that nobody was paying attention to this, that it was more as if it were the usual than had usual than had had an impact on what had happened to them and their and how they ended up in the forensic system. So I think that part was always there for me. And it was not too many years into working in the forensic area that I had a patient that actually had, he had migraine headaches. And I referred him to the neurologist, and the neurologist who was a good friend came back to me and said, Joan, I think Frank Putnam should see this patient. And I said, okay.
• 8:28
  Why? And he said, because the voices have names. So Frank did come, and he really identified, I can't remember exactly, but five adult states and probably some children as well. And it was a complex issue because it was also a question of the insanity defense. And I remember you're going to laugh, but I probably ranted and raved for about two weeks and said, I don't know if I can go to court and talk about this.
• 9:01
  So, eventually, it got straightened out there and did. It became the landmark case in the District Of Columbia, you know, using the insanity defense for this man. And it really got him into treatment rather than ending up in a prison. And shortly thereafter, I started working in essentially a treatment unit for post trial patients. So they were ones who had already been found not guilty by reason of insanity.
• 9:28
  And although I didn't understand at the time how to treat trauma, I had some instinct that I should be respectful and kind, which was not the usual prison mentality, by the way. But it just felt as if that were, you know, much more who I am. And and it was amazing to me to see some healing just in terms of helping these men to feel their innate dignity. So that's where it started. And then I had started a small private practice and not surprisingly, women who had been traumatized came to see me, a number of incest survivors.
• 10:11
  And I remember saying, I didn't learned anything about this in my more analytic training. And Frank said to me, well, if you really want to learn, then go to Chicago to the ISSTD meetings. So that's where it started. And I started going in in the late eighties, I think, and have continued since. We actually had a very large eastern regional conference here in those early days as well.
• 10:38
  So I got to meet many of the pioneers in the field for which I'm eternally grateful and continued to learn.
• 10:47
  Speaker 1: It was your forensic experience that we've talked about some when you were sharing with me about the importance of the DSM, for example, with despite the challenges and the difficulties that sometimes comes with the DSM, why it's so important that we have that scientific based agreement as a framework for when we're referencing things. Can you speak to that just a little bit?
• 11:12
  Speaker 2: Well, I think most people do not appreciate what goes into creating a DSM. For example, this last DSM five took 30,000 people, many years, much discussion. I can't tell you how much it would have cost for all these people had they not volunteered their time. They came from all over, not just The United States. And so there were many discussions trying to look at what research did we have, what what did we just know clinically, how are we gonna put that together.
• 11:46
  And I think it's always important to remember, and I think it's even in the first page of the DSM, that it's always a work in progress. It's not a finished product. We're constantly learning. And so we're now working on DSM 5.1. And as you know, there's an international classification of diseases, the ICD.
• 12:08
  And by treaty, we need to synchronize with that throughout the world. So what changing particularly of importance to us is that an ICD 11, which is now being tried out, will become official, I think, the 01/01/2022, that there is a diagnosis of complex post traumatic stress disorder, which I think is really important. So I see it as accepting the best that we can do for now, but understanding that we're always on a growing edge and learning.
• 12:42
  Speaker 1: How do you describe dissociation to patients or when you're teaching about it and explain that and complex trauma?
• 12:51
  Speaker 2: Well, I think that first of all dissociation is on the spectrum And that in in its simplest form, this may surprise you, Emma, but I I think of dissociation as not being fully present to what's right in front of you. And so I think there is a spectrum and not everybody agrees with this in the field, but I think there is a spec spectrum of, you know, almost just sort of usual normal kind of dissociation. We talk about highway hypnosis, you know, that that that experience of driving many miles and not being fully aware that you get there safely. You're kind of daydreaming along the way. So I think those are normal kinds of experiences.
• 13:37
  I think we all do it, particularly driving. I think we're we're not paying we're paying enough attention not to get into an accident or, you know, and we stay on course. But we're we're not paying attention to every detail that surround us. So I I think that for me, it's just not being totally attentive and present. And, obviously, that as you progress along the spectrum and we now have begun to understand that PTSD, and at least I understand, PTSD in itself is a dissociative experience.
• 14:12
  That if you can go from all the emotion dysregulation and flashbacks to feeling numb and not experiencing anything, that is a kind of flux, you know, dissociative fluctuation. We now know what happens, you know, in the brain when you're able to do that. And for the first time in DSM five, dissociation was included in the, you know, the criteria. So it included things like flashbacks because if you're in a flashback, you're not fully in the present. You're back there wherever it was.
• 14:47
  And I think that it's so obvious to me that as it progresses, it's a creative defense. And I think that I've always seen it that way, that if you can distance yourself psychologically from some trauma, that's incredibly creative. It's a way of getting through impossible things.
• 15:10
  Speaker 1: What do you think has been some of the biggest developments or biggest changes? Either way, you could take it either way. What has been some of the biggest shifts in treatment for dissociative disorders since the beginning?
• 15:24
  Speaker 2: That's an interesting question, Emma. I think actually we have tended to lose some of the things that we knew back when. I think that's why I feel so fortunate to have learned from pioneers in the field who were I think you may know that most of them were analysts. So they had a good sense of psychodynamics and how this may have happened. But I think what's happened over the years has perhaps been losing the basics.
• 15:53
  One of the things that discerns, you know, that that really concerns me greatly is that so many therapists who are younger are not really trained to do long term psychotherapy in a relational way. And really being in there, being empath and understanding, and at the same time, someone through the pain and working through all of this. I think we have tended in more recent years to look for techniques that may help and, you know, sort of speed things up, but not always to the advantage of doing the long term work. So I don't know that all the changes have been good. I do think, probably because I'm a physician, I'm very aware of all of the medical issues that arise and so being able to treat those well and what happens with multiple providers and the confusion that that creates.
• 16:53
  And also, I think we're I'm, you know, I'm I'm really interested in neuroscience. I think we've begun to understand the neurobiology of trauma and what may be useful to us. As an example, I'm a great proponent of doing pharmacogenomics and looking at the ways that we metabolize medications because I have seen so many patients over the years who have been on, if I ask them to fill out a form, it might be 20 different medications, and then they stop working, and it's all very confusing. So I at least like to start out with some scientific basis. And we're discovering that not only the type of medication, but the dose is related to the way that individuals metabolize medications.
• 17:43
  I guess that makes sense. So I think putting some of those things in, you know, in the work or in a more integrative way can be useful. I certainly know of cases where neurofeedback's been useful. So those are just a few thoughts.
• 17:59
  Speaker 1: You mentioned the relational aspect of psychodynamic. How would you explain that to new clinicians who literally missed that in school as opposed to that being their foundation?
• 18:11
  Speaker 2: It's an interesting question. I mean, think I try to shift help them shift a little in looking at the long term issues and doing long term psychotherapy and the willingness to stay in it. I mean, I think that we we know now, I think there are about a hundred studies that indicate that it's the therapist that may be the most healing factor in the work. I mean, obviously, then, you know, the client has to be willing to do the work, but it's it's it's collaborative. I'm always interested, for example, what happens on our trauma unit.
• 18:48
  And we do a number of different kinds of therapies. I mean, we have a, you know, we have a knowledge and skills group. So we're really helping people to understand the human response to trauma and how those skill, you know, learning skills can be useful. At the same time, we do group psychotherapy, which is much more psychodynamic. We have different kinds of expressive therapies.
• 19:13
  But every time we've done a study and we ask the patients as they leave, what's been the hope most helpful piece of all of that, they always say the community. And I remember something that someone said many years ago that this is this is social wounding, so it has to be social healing.
• 19:34
  Speaker 1: Oh, I read that. I just read that in I'm in the level two course with PTP program for ISSTD, and I just read that in one of our books, what you just said about how it's a relational wound and so it heals last and that relational piece heals last and requires relationship for the healing, which then was confirmed by the neuroscience of Simone last year at her presentation at ISSTD. That was so powerful. I think that even from lived experience, I see that where the best therapists are the relational ones and the ones who stay present in that process with all the different layers of what makes that healthy and good and healing. And I think that that is part of why bad therapy or technique therapy without that foundation can be so dangerous and retraumatizing.
• 20:35
  Speaker 2: Right. And I think I think you're asking how do I teach young therapists? I wrote an article on the development of therapists some years ago. I'm trying to remember all the things I said, but it's so obvious that we, the we therapists, have to have a a way of being empathic and consistent and admit admit mistakes and, you know, to be a good human being, not just someone who knows how to do the work. And we certainly know from the attachment literature that it is possible with good long term therapy with that kind of a therapist to to have what's called an earned secure attachment compared to the, you know, disorganized one that one may have grown up with.
• 21:28
  And that makes all the difference in them being able to go out to relate to other people in the world.
• 21:34
  Speaker 1: So so through therapy, someone with disorganized or another kind of attachment issue because of trauma and relational trauma growing up can develop that what earns secure attachment with the therapist, then they're able to carry that out to different places in their life.
• 21:53
  Speaker 2: Right. And I think what happens in psychotherapy is there's kind of an experimentation along the way. It isn't if you suddenly get to that point and then you go out in the world. It's learning how to do those things as you work through all of this. Need to learn for I mean, the interpersonal damage that's done is so obvious because we're really talking about interpersonal trauma.
• 22:22
  And so the whole sense of them being able to do something simple. I can remember a patient that really had to learn about boundaries in a good way and to realize that she in her work getting better, she probably had to develop different kinds of relationships. So I don't remember the exact scenario, but it was something like she would have a cup of tea with an elderly woman who down the street Just just have tea and nothing serious, but just to be with. And she also had someone or several people that she might go to the movies with and just watch a film, a good one, and or somebody to take a hike with or, you know, other kinds of activities. And then she might have a very good best friend that knew something about her story, but she learned not to share that with all these other people.
• 23:25
  So I I think it's that kind of flexibility that has to be learned because there's a tendency that, you know, all or nothing and still learning that. And we I think that, you know, in life, we probably, for the most part, learn that. That we may have some people we can share with and others we don't.
• 23:47
  Speaker 1: I'm just I'm reflecting I'm reflecting on my experience with you. I'm hearing professionally what you're sharing, but I'm also feeling it in an unexpected way personally just because of the unfolding of the last year. And for me specifically, that's really the first time that there's been a group of people that I felt safe with and trusted, like a whole group, not just like one safe person or just a therapist or trying with one friend, but several people that I felt safe with and that I kept in my life for a whole year. And there's something very integrative about that in a way that I never would have used that word before.
• 24:31
  Speaker 2: Well, I think, you know, we feel honored, but I think, you know, that's one of the advantages of a trauma program. We had we not only have an inpatient program, but a partial hospitalization one. And it's a for the partial hospital, people come five days a week and they become very close. It's not only that they for the first time, they may be with a small community where they feel accepted and they're they're just like themselves. But they it's a kind of I don't wanna say experiment.
• 25:06
  That's not quite the word, but the whole sense that this is a place to try it out. It's safe.
• 25:13
  Speaker 1: Right. And I think because the healing happens in that relational context, there's something that makes it both powerful and also exponential maybe so that understanding like what you said, the piece about learning how the brain works and the more we learn about that and the more that that's normalized where, oh, okay. So dissociation isn't actually abnormal. It's a normal response to what happened and lifting the stigma and the shame from that because now I have this framework and then having a safe place to practice and share little tiny things or pieces or practice just being human and having permission to just be human, but also without that shame. At first, it's very unsettling and it's very scary because of those trauma pieces.
• 26:08
  But as healing starts to come in, as trust builds, and I know this isn't the same kind of group, but I had that experience in ways I didn't understand. And I've just even reflecting on that or or in a recent episode after after this airs, we will have talked about how our friendship with Peter grew over two years and how funny that was because he was a therapist but not my therapist, but also being able to be professional friends and have friends who understood DID, but also who let me keep growing as a person and keep healing and be a person in my own right, not just over identifying with dissociation. All these pieces, there's something where being able to practice that somehow like, there's so many different layers happening at once, where in the past with dissociation, it feels like there's so many pieces causing division or causing those walls to go up. But then with healing, the same thing happens where when this little piece gets some healing, healing happens over here too. And when healing happens there, it happens over here too.
• 27:15
  Speaker 2: I think the same thing is true when you get to the point of processing trauma. You know, the guideline for me is always that you go from maybe the least traumatic to the most difficult one. It's not always easy to delineate. But but once you go through the experience with the therapist keeping you anchored in the presence so that you're you're not reliving it, you're revisiting and there's a big difference, then you have a sense of mastery, and it's as if that sense of mastery just begins to spread. It makes the rest of the work better.
• 27:58
  I I think we are probably more I think that every time I hear about, well, left brain, right brain, whatever, there's a there's a forgetting that of the fact that we are one organism. You know, we're one whole being and embodied and that things are very finely orchestrated. And I think we have an innate ability for healing. I mean, we even know that scientifically about the brain, for example, where there are things we do that help us to create more it's called BDNF, brain derivative neurotrophic factor, so that that creates healing in the brain itself.
• 28:41
  Speaker 1: That's amazing. And as that healing comes, there's this increased capacity. I remember sending you an email and saying, I don't need anything. I'm okay. I'm just communicating that this is the day my parents died and whatever.
• 28:57
  And just sharing a piece that was like, okay. I'm practicing a new step in friendship or or in relationships of just communicating a piece out loud. And I didn't need, like, some big intervention or, like, an emergency group. Like, it wasn't it was I wasn't in crisis. But to realize I could have a day that was hard and also not be in crisis, but also not be in crisis because I could communicate about it out loud.
• 29:25
  But also in communicating it out loud, I was also able to care for myself. Like, all these different layers of look how far I've come because this is a really big deal even though it's just such a silly thing.
• 29:37
  Speaker 2: I mean, I I suppose it's a more spiritual way of expressing it, but I think that the most healing factor that can happen for any human being is that factor that I call being with. I don't know how to express it better than that.
• 29:54
  Speaker 1: That I think that's a beautiful piece, the being with. And it's it's that attunement piece, but a deeper layer of a solid presence in that attunement, not just the process of attunement, but but there's something deeper and solid than only attunement with that being with.
• 30:15
  Speaker 2: I think it's a welcome to the human community.
• 30:19
  Speaker 1: Tell me more.
• 30:19
  Speaker 2: I think that when we can come together as human beings with limitations and painful experiences and you know, but and still be there for each other. That's what it means to be a human being. You know, who one who's respectful and of other people's dignity. It's it's a very I don't know. It's a very mature higher level quality.
• 30:47
  Speaker 1: It's so incredibly effective. Like it's it is what brings healing connection in those ways is what heals and takes away stigma stabilizes and empowers and all of those things because that being with gives both presence and reflection and you're not alone and you have help and whatever is going on is tended to. And in our case, like just getting through the last year with the pandemic and and all the normal things that every other therapist talked about with their colleagues of transitioning to telehealth and things like that and waiting for vaccines and those kinds of things of just we are humans and we are in this together.
• 31:35
  Speaker 2: Right. And I think one of the other things that I always teach, it's one of the reasons that I stay away from sort of ordinary kinds of skills training because I think it always has to be within the trauma framework. And, you know, we've said for a long time, it's important to have an understanding that this is a human response to trauma that any one of us would have put in that kind of traumatic situation. And so helping people to understand that it's not what's wrong with them, but it's what happened to them. And I think that's one of the areas in which psychiatry has gone a little too far in one sense of looking primarily at symptoms, but not always looking at what underlies that.
• 32:26
  I think that's where we've lost some of our analytic background. That's when that that's what makes it interesting to me that most of the original pioneers in our field were analysts. They didn't lose that.
• 32:40
  Speaker 1: It's not just the root of the problem but the person in the experience of what happened as opposed to the symptoms pointing to what happened.
• 32:51
  Speaker 2: Right. And what we do know is that if if one only deals with the symptoms and gets those under some control, I don't I don't know, doing some CBT or something to to help do that, if you don't ever get to the underlying trauma, the symptoms will recur or the person will relapse and isn't protected in the long run.
• 33:15
  Speaker 1: That almost becomes an ethical issue, it feels like, in trying to do a kind of a this isn't my phrase. I don't mean to put words to what you're saying, but trying to do quick fix techniques that, oh, a person feels better and everything's okay now, except the actual problem's not been addressed. And so it resurfaces and then again and again and again instead of really buckling down to do the hard work and stay present all the way through the hard work so that it really is resolved and healed and healing comes rather than just only addressing the surface of things.
• 33:53
  Speaker 2: I think it's important to remember that there is a kind of hurry up and get better sense that people want, both therapists and patients. And I know that one of the things I have to do, which is very hard, is to sit down with people and say, you cannot come here and pour it all out and then you're going to be better. It doesn't work that way. I I view it like metabolism, you know, sort of like food that you have to chew up and keep what's useful and get rid of the other. It's it really is a process.
• 34:32
  And so I think there is always that desire to make it faster. People joke with me and call me doctor pacing. And I go through this over and over again and say, well, in the long run. Try to listen.
• 34:51
  Speaker 1: How does a clinician today who wants to learn more about dissociation and to learn more about psychodynamic treatment and the relational aspects of treating dissociation, how would they get appropriate training that's more helpful?
• 35:05
  Speaker 2: Well, think that's really the effort we've made in ISSTD's training program where we have integrated the psychodynamics as well as looking at the process of doing the work. And I think that's where when we have therapists who've not had any psychodynamic training, we ask them to get some, do some reading, work through some of these things so that they understand that. I think that what I know, and it's interesting to me in the training program, is to have people say, you know, I never knew about this. I didn't learn anything about this in my training. And I think you know as a, you know, what's happened in training is we're not teaching these things anymore.
• 35:49
  Speaker 1: That's really frightening.
• 35:50
  Speaker 2: No. It is. It is actually. Even for psychiatric residents. I mean, there's so much emphasis on psychotropic medication and not enough on psychotherapy.
• 36:03
  Speaker 1: How does someone who has DID or another dissociative disorder or struggling with trauma in some way, how do they find a therapist that is safe to work with?
• 36:15
  Speaker 2: I think by asking some questions about experience and approach. I mean, I were a DID patient and I certainly wouldn't want to go to somebody who only do cognitive behavioral therapy.
• 36:29
  Speaker 1: Right, Right.
• 36:31
  Speaker 2: Right. So I'd I'd want to know something about experience and training. I think also there probably is a I think a network. I I mean, I I can't tell you how many calls I get looking for referrals. So I have a select group of people that I know have had the training and are good people.
• 36:53
  They have to be both in my mind.
• 36:56
  Speaker 1: Right. I think it really makes a difference. It really makes a difference.
• 37:00
  Speaker 2: Wanna add more one more thing to that, Timna? Yes. Other issue is finding good physicians because that's another issue that's a big part of this. That even though physicians are theoretically trained to deal with trauma, they're not always so aware. So I find myself not only choosing referrals but also helping patients to find a way to finesse things or being the liaison.
• 37:30
  For example, if I were going to send a woman with DID to a GYN, I would certainly call the GYN first, and I would ask that the patient be seen in the office first, not immediately go into an exam room because I think that's incredibly traumatic. And so try to create a little bit of a relationship first and have a discussion about, you know, exactly what should be done step by step. So I think there's that part of it too for me. So it's not only a therapist, but I think you may realize I mean, generally most of the DID patients that I see have three or four different providers, not just one.
• 38:15
  Speaker 1: Right. How do you see what's happening in the field right now and looking into the future and new guidelines and or as Peter says, the guidelines are the same, but we're talking about changing the language or the updates that group is working on right now. And I know you're not in that, but but what changes do you see happening in the field besides the neurological piece, which we talked about a little bit?
• 38:37
  Speaker 2: Well, I think we probably have to be better researchers. I think one of the things that we well, it's actually very hard in mental health. I mean, I think we really need to do good outcome studies so that we can better identify what has helped. I mean, many of us know it anecdotally. So, for example, is what I'm telling you about the therapist or the community.
• 39:03
  But I think being able to prove that is important. And I think we're all pressured economically with managed care and insurance and and the realities of life. So I think there are those pieces I think it's not only the guidelines but I think also our being willing to examine what really helps.
• 39:27
  Speaker 1: There are so many layers to documenting that because there's the research itself. There's insurance panels which is really where the guidelines came from in the first place. Peter tells that story about how the guidelines developed because we were trying to justify therapy with insurance panels and so there are those demands and the managed care pieces like you said. And that's so much when the therapy itself is about the relationship. There's all these practical pieces happening at the same time in the room, but not in the room.
• 39:59
  Speaker 2: Right. I mean, I think I've learned a certain level of advocacy. I'm not so hesitant with an insurance company to call up the medical director of the insurance company because they have those. Or in in my state, we have an insurance commissioner. So I really try to advocate for what people need.
• 40:20
  And I know I know that's hard for young therapists.
• 40:24
  Speaker 1: So part of it, just even educating new therapists how to do some of those practical things that, again, they're missing out in their training in a way that was taught before but isn't now.
• 40:35
  Speaker 2: Well, I don't know that all those pieces were taught, but I do think then some of us know and could talk about those things because I think it becomes an ethical issue. If if I were pushed into doing inadequate treatment, that would not be ethical. And then what what I do? It's a real quandary.
• 40:56
  Speaker 1: Right.
• 40:56
  Speaker 2: But I think that DID was, you know, was has been misdiagnosed often. I think the original studies that Frank Putnam did, I think that people were I don't remember exactly, but they've been in a mental health system for eight years, for example, with 3.6 erroneous diagnoses until the right one. Right. That's That's a normal, but not normal, usual story that I hear all the time.
• 41:27
  Speaker 1: And really when we're talking about people, that's a whole lifetime. A whole lifetime of a decade of getting misdiagnosed, a decade of trying to find a good therapist, a decade of being in therapy. Like, I mean, that's very broadly speaking. I'm stereotyping that a little bit. But generally speaking, that adds up to a lot of years, a big chunk of someone's life.
• 41:51
  Speaker 2: Right. And I see that in groups where older people are in the group and then they're so incredulous looking at somebody in her twenties who's been correctly diagnosed and getting treatment and saying, oh my, I've lost those decades. That is part of the grief.
• 42:11
  Speaker 1: Is that also some evidence that things are getting a little better even though there's still more work to do that we do have so many younger people diagnosed?
• 42:21
  Speaker 2: I think it's not, I would say, and it's not only DID, I think in some bizarre way that nine eleven uncovered a great deal that suddenly there was this awareness of trauma and in the military and, you know, it's happening everywhere and look at the pandemic. And so I think that we're there's gradually more if you wanna say that's cultural awareness everywhere. And so I think there's more willingness to you know, PTSD was not even a regular diagnosis until DSM three, I think in 1980. And it was the Vietnam Vets and the women's movement that pushed that. It wouldn't have happened otherwise.
• 43:10
  So I think that gradually there is more and more acceptance, which is helpful. That it's not something that is so far out, but beginning to understand that it's everywhere.
• 43:23
  Speaker 1: Is there anything else that you want to share while we still have you on? I so appreciate you.
• 43:29
  Speaker 2: Now do you have any last minute questions? I feel as if I've done so much talking.
• 43:34
  Speaker 1: It was so fabulous and I'm so grateful for you taking the time. I know you are a wealth of knowledge so there's a thousand questions I have, but I wanna respect your time.
• 43:44
  Speaker 2: Okay. Well, I'd certainly be willing to come back sometime if there's something else we want to focus on.
• 43:51
  Speaker 1: Oh, I would love that actually.
• 43:54
  Speaker 2: Okay.
• 43:55
  Speaker 1: That's very kind of you. Really, it is. I so appreciate you. And and this I when we started the podcast, I didn't know it was going to take off like it has. And adding the clinical interviews in has given it a shape to help bridge that community a little bit.
• 44:14
  I think the clinical community and the survivor community, I think there's so much, again, generally speaking, there's so much pain left from the nineties that there's many, many it's part of the relational wound for all of us as a community. And there's such a wariness of who is safe and who is not, and and new people now being diagnosed differently and more easily in some ways even though we still have so much further to go. And the clinical interviews have just become part of that history and part of that unfolding and giving people permission to talk with each other differently. And I think it's just become powerful in a way that was not expected. And I really wanted you to be a part of that conversation.
• 45:01
  Thank you so much.
• 45:02
  Speaker 2: You're welcome. So you've enriched my life.
• 45:06
  Speaker 1: Oh, thank you. Bye. Thank you for listening. Your support really helps us feel less alone while we sort through all of this and learn together. Maybe it will help you in some ways too.
• 45:27
  You can connect with us on Patreon and join us for free in our new online community by going to our website at www.systemspeak.org. If there's anything we've learned in the last four years of this podcast, it's that connection brings healing. We look forward to connecting with you.