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ISSTD Conference Presentation · System Speak: Complex Trauma and Dissociation

• 0:12
  Speaker 1: Welcome to the System Speak Podcast, a podcast about Dissociative Identity Disorder. If you are new to the podcast, we recommend starting at the beginning episodes and listen in order to hear our story and what we have learned through this endeavor. Current episodes may be more applicable to longtime listeners and are likely to contain more advanced topics, emotional or other triggering content, and or reference earlier episodes that provide more context to what we are currently learning and experiencing. As always, please care for yourself during and after listening
• 0:47
  Speaker 2: to the podcast. Thank you.
• 1:07
  Speaker 1: Hello. In the episodes this week, I'm sharing a presentation similar to what I'm sharing for ISSTD in a recent workshop at their annual conference. This is being recorded a month prior to that presentation and is not exactly the same as that presentation, but I thought some might find it helpful or interesting. Otherwise, you're welcome to skip. I open with a quote from Bessel van der Kolk.
• 1:38
  Trauma is the result of exposure to a stressful event that overwhelms a person's ability to effectively cope with the stressor. And historically, ISSTD has focused on the study of trauma and dissociation in the context and through the lens of dyadic trauma, meaning child abuse usually inflicted by the caregiver, such as incest or physical abuse or neglect resulting in the natural traumatic dissociation response, such as DID or other dissociative disorders. In this context, with the not rare exception of victims who continue to be abused into adulthood, dyadic trauma is most often about what happened in the past. Intergenerational trauma focuses on how that cycle continues into other generations. This repeats the dyadic experience itself, whether that is from perpetrators abusing generation, victims being abused into adulthood, victims growing up into perpetrators against others or themselves, or over identifying with their trauma.
• 2:50
  It can also repeat the dynamics of the experience, such as not actually becoming the perpetrator, but marrying one, so that domestic violence repeats the same patterns they endured with their parents or children being abused by their spouses. It can also be repeated internally through reenactments of their trauma. This could look like how historically land was stolen from indigenous people and now in modern days there are high populations of indigenous people who are homeless. Or genocide, where particular cultures or groups of people were targeted and killed, and now those populations have high rates of addiction. It could look like families that were divided, and now those groups of people have high populations in foster care.
• 3:43
  It can also happen externally, like stranger violations, forced migration, or the changing shape of slavery over time. This is an example of it happening communally, where an individual trauma is shared collectively, such as racism. So while dyadic trauma is most often about what happened in the past, intergenerational trauma is most often about what is happening again still. This brings us to collective trauma, and one group that has shared collective trauma is the disability community. For example, the blind community had to fight to prove that they are citizens.
• 4:23
  In 1968, the Braille Monitor quoted, Those of us who are blind, need we say it once again, are citizens as well. We wish to be treated as other citizens are treated for all ordinary and general purposes. The Deaf community emphasized that if we are citizens, then we have rights. In 1878 in Paris, the International Congress of the Education of the Deaf met together to rule against sign language being used in deaf schools, a policy that was not revoked until 2010, and no deaf people were allowed to attend the meeting or testify. Mobility groups had to fight for access.
• 5:10
  Like blind and deaf and other disability groups, they were often assumed to be retarded or intellectually impaired or developmentally delayed and institutionalized, shackled to beds when institutions were understaffed, and targeted for experiments and euthanasia historically and during the Holocaust specifically. These people are still fighting for accessibility access. We have a son who is now 12 years old and still at times needs help in bathrooms or to be changed in a bathroom. He doesn't fit on an infant changing table and yet few restrooms that say they are accessible for mobility that report to be accessible really are. Neurodiversity is another group that has experienced collective trauma.
• 5:57
  They emphasize that if we are citizens with rights and access, we get to decide for ourselves what access looks like. So for example, autism, known for its lack of social skills, managed to develop its own culture and support network. They pushed back against support organizations and the puzzle pieces. They changed person language to reclaim its culture as a part of pride. Autistic person became person with autism and then came back as a matter of pride to I am autistic.
• 6:32
  LGBTQ groups have also endured collective trauma. They were included in experiments and euthanasia historically and during the Holocaust. Their civil rights are precarious at best and dangerous at worst. We endured the HIV and AIDS crisis. There are ongoing aggressions and microaggressions, isolation from social connections such as family of origin and church.
• 7:00
  There's pronoun trauma even though the singular they has been in English since 1300. There's the impact of politics where now it's safe to be who we are and live as we want and then it's not safe anymore And then it's safe again and then not again. And when will it stay safe? So dyadic trauma is about what happened in the past. Intergenerational trauma is about what is happening again.
• 7:28
  Collective trauma is about what happened to us together. Historical trauma are experiences shared by communities like in collective trauma, but are also carried across generations, like intergenerational trauma, and inflicted on specific groups of people, such as race, accrete, ethnicity, gender identity, or disability. The effects linger on descendants and result in cumulative trauma, such as higher rates of physical illness, mental illness, substance abuse, and erosion of families. Historical trauma is not just about what happened in the past. It's about what is still happening because of that.
• 8:12
  Examples of historical trauma include indigenous and aboriginal peoples, transatlantic slave trade, colonization, forced migration, the Jewish holocaust, Japanese internment camps, immigrant labor, misogyny, microaggressions, destruction of cultural practices, loss of native languages, being excluded from PTSD criteria. So dyadic trauma is about what happened in the past. Intergenerational trauma is about what is happening again still. Collective trauma is about what happened to us together. Historical trauma then is about what is still happening to us because of what has already happened to us.
• 9:02
  Patterns of this show up through several different ways. content mindset, such as I can't get out of this. I've always lived in the ghetto or the trailer park or the camps or this tent city. I'm stuck. I won't do better out there or in different relationships or financially or educationally.
• 9:25
  This is how things are always going to be. Defense mechanisms may include compensation, blocking, denial, sublimation, minimization, gaslighting, stonewalling, repeated patterns of unhealthy behaviors such as domestic violence, homelessness, substance abuse, severe mental illness, gang violence, poverty, police brutality, generations of secrets. There may be lifelong parent child conflicts, including communication problems, poor relationships across the lifespan, unmet psychiatric needs, patterns over generations, including trauma bonding, like not leaving domestic violence situations, feeling bonded to abusers, generations of staying with abusers. This shows up through generations of oppositional defiance, and is labeled as such, even with colloquial terms such as thugs, gangs, white trash, or conduct problems. And in response to those labels, there's incarcerations, unchosen prostitution, and treatment programs.
• 10:36
  And maintaining the status quo of that looks like not bettering themselves, being afraid to step out, or anger and retaliation for trying. This causes a downward economic spiral where there are generations of poverty. It gets worse over time because of so called consequences. There's a lower status through aggression and microaggressions. People get comfortable there because it's so dangerous to try to get out of it.
• 11:08
  Intrapsychic turmoil, where it's safer to hide. The trauma of secrets, the impact of misattunement. And all of that comes through the diminishing of the person, which is an illusion of diminished capacity, deterring the person, which is an illusion of reduced alternatives, destroying the person through an experience of lack of resources and dissociation, separating them from escape as possibility or a better life as probability. For those who are interested, genograms are a way to chart family history patterns, and you can use a Transgenerational Trauma and Resilience Genogram or a TTRG to show not just the map of your family and those relationships, but also the layers of trauma in those relationships, in those greater context of those lives. There is also the trauma of war.
• 12:09
  Siegfried Sassoon in a soldier's declaration in 1917 said, I am a soldier convinced that I am acting on behalf of soldiers. I have seen and endured the sufferings of the troops, and I can no longer be a party to prolong these sufferings. We have worked with refugees, and there are so many layers of trauma that they have endured through politics and physical safety, shelter needs, food insecurity, sanitation issues, the red tape of paperwork, waiting on boats or ports to open to help them get where they need, children and families waiting at borders, being separated at borders, the politics of tent cities, the impossibility of finding a job, language access, cultural traditions, and holidays. These are all challenges and layers of trauma for refugees. We have also worked in disaster trauma, and some of those layers are the same as with refugees: physical safety, clothing, food, shelter, sanitation.
• 13:18
  There's also consequential dangers such as rain after tornadoes, illness in shelters, missing medications, and again, the red tape and paperwork. There's also the trauma of the interagency work where requirements of what they are supposed to do keep changing, information keeps getting crossed, paperwork is repeated, and cultural needs are ignored. We saw new layers of trauma in the pandemic. There were some things that, especially for those who were already trauma survivors, such as there being an incongruence with now time is safe, there was a rupture in that layer of safety in the present moment when the present moment was no longer safe. We saw healthcare and janitorial and funeral services overtax.
• 14:07
  We saw responses to the pandemic be politicized. There was a confusion between who are good people and who are contagious people. Contagious people were not bad people, but likewise, good people were not not contagious. There was also a congruence with survivors who got to witness therapists enduring the same trauma with them. There were high stakes decision fatigue, lack of governmental response with housing and job issues and food insecurity.
• 14:41
  There were experiential triggers such as being trapped because of quarantine or lockdown, having to wear masks. And there were triggers about not knowing what was happening, not being able to see it, not knowing how to stop it. And then the overwhelming work life balance in the home and the transition to telehealth. So we saw what was expected as far as clients functioning being reduced temporarily at critical junctures in therapy, because they had experienced symptomatic relapses related to personal safety, trauma memory reminders and reactions, and problems in relationships and life pursuits. In her book, Trauma and Recovery, Judith Herman lays out the most detailed history of trauma, all the way back to the medical writers of the early 1900s who wrote about moral invalids, the World War I British psychologist Charles Myers who identified shell shock, the rap groups of the seventies from the Vietnam Veterans Against War, which was the beginning of group therapy, and then the women's movement using that model as pioneering research on the psychological effects of victimization on women and identifying rape as a problem, and developing the rape crisis centers.
• 16:09
  As far as a history of diagnostic category specifically, hysteria goes all the way back to ancient Egypt in February. In 1697, England declared hysteria as an emotional condition, which connected it for the time as something beyond just what was happening in the body. In 1859, France noted that physical symptoms were not only medical, and that survivors were impacted by emotional and psychological consequences of trauma. In 1951, the derogatory term of hysteria was replaced with Percocet syndrome. In 1952, the DSM-one dropped hysteria altogether all the way until 1968 and started to emphasize distress as reactions.
• 17:05
  The time it was noted scientifically that distress was a natural response process to troubling events as opposed to something wrong with the person. It was a right response to wrong events. In 1968, the DSM II and ICD-eight specified conversion or dissociative disorders as those reactions. And then in 1977, the ICD-nine separated conversion and dissociation. Multiple personality was added as a dissociative type.
• 17:43
  Depersonalization was including derealization, but was its own neurosis. And other neurotic disorders included Brugette's disorder, which later became somatic disorders. In 1980, the DSM-three included the ICD-nine in the appendix. And as part of this, depersonalization was considered dissociative for the time. The DSM-three also ended the psychodynamic assumption of etiology as the process of distinguishing dissociation, conversion, and somatization.
• 18:23
  The DSM-three is also what shifted to measurable and quantifiable symptoms and symptom durations, separating diagnosis from theory for the time. In 1992, the ICD-ten abolished the not otherwise specified diagnosis. There was no more hysterical neurosis, and dissociative conversion disorders was a diagnosis kept them together, but listed dissociative In 1994 and 02/2004, the DSM IV and DSM IV TR renamed a bunch of things. One of those was multiple personality, which was renamed dissociative identity disorder. This set the stage for the confusion between models of multiplicity, meaning multiple personalities or consciousness, and models of divisibility, meaning division of consciousness or personality into only parts.
• 19:30
  In 2013, the DSM-five added differential diagnosis paragraphs. Dissociative disorders included other references to other diagnoses, but the other diagnoses did not include references to dissociative disorders other than PTSD, ASD, and conversion disorder. This was significant because it resulted in a high prevalence of misdiagnosis due to lack of study, poor clinical discernment, and inadequate education. It also resulted in the assumption of only one personality, which dismissed the millennia of more than one personality understanding. In only two decades, the clinical community shifted from the concept of multiplicity to divisibility.
• 20:28
  And that has been passed down from clinician to clinician and has in some ways become a historical trauma in the clinical setting for the dissociative patient through misdiagnoses and improper treatment. And there is no other diagnosis in the DSM that has to go into the clinical setting or treatment room already knowing the diagnosis in order to receive the diagnosis when dissociative disorders by their very nature are a not knowing experience. This also impacts trauma based disorders because of what happening internally or the reported experiences as symptoms depends on which perspective from whom internally, whether it's an ANP or an EP reporting their experiences. It also forces an external medical perspective on clients who have already endured trauma in a field that traditionally has dismissed or exploited survivors. So let's talk about theoretical models.
• 21:36
  O'Neil and Dell identify three kinds of dissociation with each of those three kinds on their own continuum. So this is not one continuum of dissociation where depersonalization and derealization are at one end at a lower continuum and DID is at the highest of that continuum. No. Let me be very clear. These are three different kinds of dissociation, each with their own continuum.
• 22:09
  The one is depersonalization and derealization. So that continuum from mild depersonalization derealization to more severe, significant or disruptive depersonalization and derealization, it has its own continuum. So if that is feeling detached, then what is detached? Henry Frederick Emile in 1880 in the journal and Time wrote, I find myself regarding existence as though from beyond the tomb, from another world, all is strange to me. I am, as it were, outside my own body and individuality.
• 22:49
  I am depersonalized, detached, cut adrift. Is this madness? And then Ludovic Douglas in 1898 first used it clinically, a state in which there is the feeling or sensation that thoughts and acts elude the self and become strange. There is an alienation of personality. In other words, a depersonalization.
• 23:13
  So then detached from what? One's surroundings, one's feelings, and oneself. Detached how? The neurological research with fMRI is showing that the prefrontal cortex goes offline. There's decreased cortical thickness, reduction in gray matter volume, and lower white matter.
• 23:36
  No structural changes in the amygdala are noticed. Vestibular system disruptions are observed, And this is significant because the vestibular system helps control balance, spatial orientation, motor coordination, but also plays a role in self awareness. We also know from research now, as of last year, it occurs more with emotional abuse than physical abuse. So, detached, why? Psychodynamic theory considers it a defense mechanism against negative feelings, conflicts, or experiences.
• 24:13
  Peter Barish in 1991 identified attachment as one of the sources triggering dissociation. And Orit Epstein narrowed it down. Children growing up with severe emotional neglect lack theory of mind in seeing self and others as having feelings, intentions, and desires, which in some cases develop into an affect phobia as part of avoidant and or disorganized attachment patterns. So when we're talking about depersonalization and derealization, there is an apparently normal personality aware that the emotional personality is missing, but the emotional personality or EP is detached from and unaware of the apparently normal personality or ANP. So somatoform and dissociation has been classified into three categories with memory abnormalities, sensory abnormalities, abnormalities, or into two categories, somatoform as physical and dissociative as psychological.
• 25:28
  And then there's also the sensory motor or somatic categories. So when we look at somatoform, it's the opposite where the emotional personality or EP is detached from but sensing evidence of the A and P. But the A and P is detached from and unaware of the EP's distress while continuing to function. So going back to O'Neil and Dell, the kind of dissociation is dissociative amnesia and or conversion. So when we look at the ANP being aware that the EP is missing, or the EP being aware that the ANP is missing, we see that depersonalization and derealization happens when the ANP is detached from the psychological or affective because the EP is missing.
• 26:25
  And somatoform happens when the EP is detached from the physical or the ANP who is still functioning. Now of course I don't mean piece parts are actually missing, but when we have dissociative barriers and don't have access to the other parts, then the experience is that those other parts are missing. Really they are somewhere else doing their thing, and they may or may not be aware of this part. Right? So that's what we're referencing when I say missing.
• 26:59
  I just want to be clear that I don't actually mean a part is missing missing. Really, they're somewhere and everything is okay functioning as it needs to be. But the experience is that that part is missing. So again in 1991 Peter Barish linked attachment to the traumatic response. With no external support we develop internal support which separates the images of a good parent from the abusive or neglectful parent.
• 27:27
  And then in 1994, Jennifer Freyde developed betrayal theory, which linked amnesia not to just reduce suffering, but to be able to maintain attachment as part of survival. So then when we look at the dissociative barrier between the ANP and the EP, we see from the ANP's perspective it is a dis attachment. And from the EP's perspective, it is a dis association. And what helps these and what brings healing is breaking down that dissociative barrier. So for the ANP, it is about attachment and learning about attachment and experiencing attachment so that the psychological or affective experience becomes I exist and I feel and I am okay and safe when I have permission to exist and feel.
• 28:25
  And then for the emotional personality, what brings healing is when it is able to associate with the AMP so that they gain that physical function. This is me. I can, which is different than feeling like I can't or I'm out of control. Right? So the AMP actually gets healed through top down work and the EP gets healed through bottom up work.
• 28:52
  Okay, so going back to O'Neill and Dell again, the kind of dissociation is actual dissociative multiplicity. So again, this is not on the same continuum as depersonalization and derealization. It has its own continuum from OSDD all the way through DID. Or some might say from the general experience of plurality into OSDD into DID. So this is a model of multiplicity which is experienced distinctly on its own dissociative continuum.
• 29:33
  You have PTSD where there is an ANP and an EP. There's complex PTSD where there is ANP with several different EPs. That may also include disorder of extreme stress or borderline personality disorder. And then there's OSDD and DID where there are multiple personalities or centers of consciousness, which each have their own ANP and EP, or multiple versions of that. But then what changed were the structuralist theory who came along and said that there is only one personality.
• 30:16
  They changed the P in A and P and EP from personality to part of the personality. They said no one is born integrated, that we are naturally divided into parts, and that healthy attachment integrates the parts into one personality as a normal developmental process. Trauma disrupts that process, and the degree of disruption depends on timing of trauma in development. There are lots of good things about structural dissociation. And I think the part about us all being naturally divided into parts, and I think that the degree of disruption depending on timing of trauma makes sense.
• 31:00
  I think trauma disrupting that process of healthy attachment, integrating those parts, all of that makes sense. But I disagree with the ANP and EP being changed from personality to parts, and I disagree with it being only one personality and all of the alters being parts. So in this model, structural dissociation, the ANP is only a part, not a personality. The EP is only a part of the personality, not the whole personality. It also moves OSDD down to be equivalent with complex PTSD and borderline personality disorder.
• 31:43
  So the strengths of structural dissociation include that the meaning of structural dissociation as a way of having a clear definition of how trauma impacts the mind and body. Our field gains clinical and empirical viability, and it is a necessary step for diagnostic credibility. However, even according to O'Neill, there are limitations because of how they define personality. Previously, the average expected or majority understanding of the meaning of personality had to do with the traits, tastes, attitudes, intentions, and styles, the adjectives that describe someone. But this new minority meaning of personality from the structural dissociation perspective references the global mental constitution of a single human being, which makes personality only a noun rather than the adjective describing someone.
• 32:43
  It also divides semantics into division versus multiplication. Traditionally, dissociative identity disorder, or OSDD, referred to multiple personalities, each with their own traits and preferences and development and experiences. But the structural theory model is a division model where there is one personality with different parts with each part experiencing only part of those preferences or aspects of identity. Moving to a model of division is what pushed the years of the integration focus in the treatment model. Because if there is one personality divided into parts, then what healing means is those parts healed together to be undivided.
• 33:42
  And that's different than a multiplicity focus of communication, collaboration, and cooperation so that there is a flow between and within and amongst personalities. This year in 2021, I saw Kathy Steele speak again, and someone asked her at this presentation if there was anything that she regretted or would change about the structural dissociation model now that it's been ten years since it came out. And what she said is that she no longer focuses or use language to talk about ANPs and EPs. And I think that that is huge in several ways. Number one, it shows her own cultural humility of learning from feedback and listening to some of the discussions we've had.
• 34:42
  And number two, I think that that reemphasizes ego states, which better describes a multiplicity model and resolves the problem that was left unsettled with the structural dissociation model. Because I think if you keep what's good about structural dissociation and fix this one piece that was not sitting right with lived experience, I think it is a more congruent description, and that adapted version makes more sense. And so what she's teaching now is going back to ego states, which I think makes more sense. So when you have ego states and it's only ego states without the dissociation or amnesia, there are permeable boundaries. I feel happy in this moment about this thing, but I'm aware that I also feel sad about this other thing.
• 35:38
  There's no separate autobiography. I know that this is all my story. They're not experienced as several parts. But with complex PTSD and OSDD, so still bringing those together instead of putting OSDD with DID, there are less permeable boundaries, some amnesia for the past but not for the present, a greater sense of literal not me, I know they are me, but it doesn't feel like me, and somewhat separate autobiographies that are centered around fixated defenses because of response to trauma, which is normal and healthy and the exact right thing for your brain to do. And then with DID, there are impermeable boundaries, amnesia for the past, sometimes in the present, not me, that phobic avoidance of that is not me, she is not me, experience of having separate histories, increased autonomy, and elaboration may also involve functions of daily life, which previously would have been discussed as more than one ANP.
• 36:49
  So I think that is a significant improvement in the structural dissociation model, and I think that it needs to be acknowledged publicly and discussed openly so that we aren't just reverting to the same discussion from ten years ago, but seeing the improvements and noting how it continues to evolve as clinicians continue to research and hear our stories and as we continue to share lived experience. That brings us to the ICD-eleven, which is out now for clinicians to be practicing and in the research for those participating in the research. It is expected to be released in January of twenty twenty two. What's different in ICD-eleven is CPTSD, or complex post traumatic stress disorder, which is differentiated from PTSD by alterations in affect and behavioral regulation, interpersonal problems, dissociative symptoms, and somatizations. Salter and Hall in 2021 said, CPTSD is linked to concepts of developmental and attachment trauma and associated disruptions in the child caregiver bond.
• 38:07
  So if we look at the epigenetics of this, back in 1914 Walter Cannon put forward the fight or flight model, which described the body's response towards stress. In the 1950s, we got the general adaption syndrome, which was about how chronic stress can induce a non specific response in the body, such as increased heart rate and blood pressure. In 1996, the intergenerational trauma was recognized in Holocaust survivors descendants. In 2003 transgenerational trauma was documented in descendants of slaves, native Americans, war survivors, refugees, survivors of interpersonal abuse, and many other groups. And in 2015, we were able to confirm alterations in the brain, DNA, and blood chemistry.
• 39:04
  In neurological research in 2020, Simone Reindeers presented that temporal regions of the brain had been identified as possible neurostructural biomarkers for DID, distinguishing multiplicity from other diagnoses that include dissociation. Her research confirmed Dallenberg's twenty twelve trauma model, which includes the theory of structural dissociation. It also confirmed DID as a complex trauma related disorder, but distinctly different from other complex trauma such as PTSD. I want to be clear that I'm not talking about plurality in general. I am not talking about pleural systems who report that they have no trauma.
• 39:52
  We are talking about DID specific. We have been able to neurologically, with fMRIs and actual testing, confirm in the brain that DID specifically is a trauma based disorder and can be distinguished from other trauma disorders, including borderline personality, including PTSD, and differentiated from factitious or malingering cases that are not actually trauma based DID. This is huge. This is huge. It is an actual diagnostic tool available now that you can be tested and confirmed that you have DID.
• 40:44
  Now it is not yet a practical or openly used tool because that's expensive testing and not accessible everywhere, right? But it's a development in research. It's new. It's huge. It's a breakthrough.
• 40:57
  And there is lots more coming because of this. And we'll talk about those things in another session. Neurological research in 2021 shows that neurofunctional biomarkers of pathological dissociation, which we would rather be called traumatic dissociation, are dorsomedial and dorsolateral prefrontal cortex, bilateral superior frontal regions, the cingulate posterior association areas, and basal ganglia. Neuro structural biomarkers of pathological or traumatic dissociation are decreased hippocampal volume, basal ganglia volume, and thalamus volume. Psychological markers for traumatic dissociation increase oxytocin and prolactin, and decreased tumor necrosis factor alpha are proposed.
• 41:46
  There are no clear directional effects found for psychophysiological or genetic. So when we talk about epigenetics, it literally means above or on top of genetics. It refers to external modifications to DNA that turn genes on or off. To simplify, the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself. So just to break it down, cells are fundamental working units of every human being.
• 42:23
  All the instructions required to direct their activities are contained within the chemical known as DNA. DNA from humans is made up of approximately 3,000,000,000 nucleotide bases. These are known as A, C, G, and T. You can see more about this on our blog. The sequence or the order of the bases is what determines our life instructions.
• 42:51
  And within those 3,000,000 bases, there are about 20,000 genes. Genes are a specific sequence of bases that provide instructions on how to make important proteins. These proteins are what trigger various biological actions and responses. And again, we have a picture of this and more details on the block. So our brains classify stress into good, bearable, and toxic.
• 43:22
  Good stress have acute effects and can be coped with by physiological mechanisms encouraging healthy growth. Bearable stress has delayed effects and may eventually be turned into a homeostasis through successful interventions. Toxic stress has long term effects and are characterized by prolonged or frequent activation and dysregulation of the stress response pathway inducing long term changes and damage not only to the brain but also to the rest of the body. So in summary of epigenetics, the structure and processes are different things, but both of them matter. In 2021, the Biobank study was released.
• 44:10
  50,000 people were studied for the structure and no specific gene for any kind of mood disorder was identified. But epigenetic markers are triggered as a response, the process to trauma, specifically the relational trauma experience, not just a defense from the physical sexual incident. And this is one of the most important things that has come out from some of the work by both Reindeers and Curtis, that the neurological impact of trauma is not just the physical or sexual incident of harm. The neurobiological response to trauma is specifically in response to the relational aspect of trauma, which includes relational trauma that is emotional or relational in nature only, even if there is no physical or sexual component to the trauma. This is huge and completely changes our understanding of trauma.
• 45:18
  Childhood trauma impacts children to different extents. It can be dose dependent: how much trauma, when the trauma happens, how frequently the trauma happens. There are variances based on vulnerability. Physical stressors mainly impact the brainstem and hypothalamus. Psychological stressors mainly impact regions that regulate emotion, learning, memory, and decision making, such as the hippocampus, the amygdala, and the prefrontal cortex.
• 45:47
  Long term stress and acute stress have different effects on the brain. We also want to offer some cautions of epigenetics in understanding the trauma as damage to cells. There are sometimes bits of damage that cannot be undone, such as our son who has cerebral palsy. Some damage cannot be fixed right now, such as our daughter who could have some surgeries to address some issues right away and other surgeries that had to wait until she was older. Some damage can heal over time, like when you get a cut or a bruise or a broken bone.
• 46:29
  Some damage needs nutrients and resources to be able to heal, such as my sons with autism who function better when they have the support they need, or my daughter who needs a G tube and oxygen, or my son who needs braces on his legs and his arm. Other damage can be reframed to improve functioning, such as my sons with autism who only need people to understand how their brains work and what resources they need to function, and they do very well. Other damage needs significant intervention that is ongoing or repeated to improve quality of life, such as my daughter who has airway reconstruction as her body grows. So we need to remember these things we have already learned from physical traumas because relational traumas are going to have similar impacts. There are some things that we can't undo.
• 47:31
  We can't undo that relational trauma that's already happened. There's a relational scar there. It may heal. It may strengthen even, but that damage happened. We can't undo what happened in the past.
• 47:46
  We also can't fix everything. My parents did what they did and also they are dead. I can't go back to the past and undo that trauma, but I also cannot repair that relationship further than we did because they are dead. Their opportunity for that is finished as far as our mortal experience is concerned. Other damage can heal over time.
• 48:12
  My understanding of that impact of my trauma and my capacity to share about it, to do something good with it, to use it in some positive way so that it's not only damaging me in negative ways, that can heal over time and with the resources and support I need as I learn to reframe things. So this is very similar to what we know about the physical damage to cells, but the actual damage from relational and physical and sexual traumas are also very similar. This is important because clinicians cannot just assume that with enough therapy and with enough talking or enough processing or enough technique or skills or whatever, that we can just make every complex trauma client better or look like a textbook picture of what someone else said they should look like. It's going to be very unique, very specific to that person, and both the treatment process and the treatment goals should be unique to that person and their experience. And if you need an easier way to understand this, you can think about a rock and a crystal.
• 49:31
  Both the rock and the crystal are the same kinds of molecules, but the crystal molecules are aligned in a way that lets light through. In the same way, our DNA has amino acid onoff switches that can be more jumbled like the rock or more aligned like the crystal. Emotional contaminants jumble us. Healthier environments, decisions, and relationships help align us. So the takeaway from epigenetics is that the impact of our trauma is passed down to us at a DNA level, including the trauma that our parents and their parents have gone through.
• 50:13
  And that happens through gene expression. But we are not condemned to the effects of our trauma. We are not condemned to the trauma passed on to us. Trauma absolutely has an impact. And relational trauma has a greater impact neurologically than physical or sexual abuse.
• 50:35
  This brings us to a hinge point in treatment. When we interviewed CLUFT in 2020, which aired in 2021 on the podcast, One of the things that we talked about was how therapy in the past was a single point focused experience, the only outlet and the only safe space to talk about trauma. But now, these days, therapy is only part of a diffused focus experience because the survivor also has access to published works and online resources, virtual support groups, Zoom, Facebook groups, peer advocacy groups, social media, and YouTube, blogs and podcasts, conferences, both professional and lived experiences, and organizations of resources by survivors themselves. The neurological research of Simone Reindeers also reminded the clinical community that in the average time from seeking treatment to receiving a correct diagnosis of DID, the average person receives four incorrect diagnoses, spends seven to twelve years in mental health services, experiences years of inefficient pharmacological treatment, and endures several experiences of hospital admission. These years of isolation from appropriate and effective treatment are a collective historical trauma experienced by survivors reminiscent of the dyadic trauma dynamic.
• 52:07
  Further, it is documented in research that there is implicit bias in the part of clinicians. Associations outside our conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender or diagnosis. The therapist must avoid assuming that he or she knows the correct answer in advance. The therapist's role is not to lead the client to a particular conclusion, even treatment goals, but to walk with the client step by step through the process. The systematic study of psychological trauma therefore depends on the support of a political movement, powerful enough to legitimate an alliance between investigators and patients and to counteract the ordinary social processes of silencing and denial.
• 53:03
  That's a quote from Judith Herman. She also said, To hold traumatic reality and consciousness requires a social context that affirms and protects the victim, and that joins the victim and witness in common alliance. This is not without clinical precedent. All the way back in the century, the psychiatric ward doctor that is often overlooked by Western medicine was in Tehran, and he focused on the character of clinicians, that they would be modest and wise rather than known and knowledgeable, emphasized personal communication with patients rather than information about the illness insisted healing came from a cheerful countenance, encouraging words, and authentic connections rather than treatment modality was the to include a version of aftercare. And aftercare was necessary and intentional as part of the treatment process.
• 54:02
  When clients were allowed to guide staff to what was important to them, safety and a sense of security and connection became ones the client regained or reclaimed. But rather than being reestablished, these needed to be developed for the time. This applies even to goals for treatment, such as whether to choose integration or not. The role of the therapist in this enterprise is to guide the client through the process of thinking something through to a conclusion while leaving the outcome or actual conclusion in the hands of the client. This is particularly salient in the treatment of patients with complex traumatic stress disorder because the injury for which they seek treatment is essentially an interpersonal one.
• 54:52
  Clients recognize that they have the opportunity to become active agents for change in their own behalf. Salter and Hall in their 2021 article addressed this dignity. Shame is the emotional correlate of attachment failure, child abuse and neglect. However, it is also a socially located and politically structured experience that is exacerbated by public policy, professional practice, and government decision making. Dignity describes the felt experience of being valued, while the innate human vulnerability to shame and injury is acknowledged and addressed.
• 55:32
  Dignified environments and processes are those in which both human value and human vulnerability are acknowledged and accommodated simultaneously, producing the experience of being recognized. The National Institute for Health and Care Excellence in November of twenty twenty said, The patient voice, patients who experience symptoms, are often dismissed or misdiagnosed with relapse or diagnosed with a new medical condition. And yet there is a history of citizenship in lived experience. We are people that came from the indigenous people and the abolition of slavery. We are people here as citizens.
• 56:14
  That came from the blind community. If we are citizens, then we have rights. That came from the deaf community. If we have rights, then we need access. That came from the mobility community.
• 56:28
  If we have rights and access, then we have choices. That was the LGBT community. If we have rights and access and have choices, then we have a right to choose. And so we, as survivors are saying now, if we have rights and access and have choices, then we have the right to choose our therapist, our therapy, our treatment framework, and our treatment goals. We need to listen to plural voices in language.
• 56:55
  We can say traumatic dissociation rather than pathological dissociation because it focuses on what happened to us instead of what is wrong with us. When dissociation is a natural and exactly right response to trauma. We can say plurals because it encompasses positive identity. It dissociates from the stigma of multiple. It includes those still in denial or perceiving themselves to be without trauma.
• 57:23
  It provides identity exploration. We can recognize resources, Healing Together Conference with Infinite Mind, Beauty After Bruises, the Plural Association Warm Line, DID Awareness Day. We can also accept survivor input on treatment guidelines. Survivors should be able to review the guidelines for shame based language and cultural humility. Functional multiplicity could be stage three, making stage three stage four of treatment.
• 57:54
  And that would also document functional multiplicity explicitly as a valid treatment goal. In the question of plurals identifying as plurals who report they are functioning well are not distressed by their multiplicity, and therefore are not disordered, including plurals who identify as not having any trauma history, the treatment guidelines do not apply to them. But they could still be treated for any other distressing condition for which they sought treatment, such as anxiety or depression. And in language, this makes a person with dissociative identities a reference to the person, not the disorder. And it leaves disorder intact for those who are distressed by it or whose functioning is impacted and so diagnosed with the disorder itself, while still providing plural as an overarching inclusive term in general and specifically when survivor chooses and or identifies as part of pride and dignity instead of stigma and shame.
• 58:59
  So with plurals who identify as plurals and who also report they are functioning well and not distressed by their multiplicity, they are not disordered and the guidelines do not apply, and therefore they don't need input into guidelines that treat the disorder because it does not apply to them. But this still identifies and recognizes the group in literature as part of cultural humility. And again, they may safely seek alternative treatment for things such as depression or anxiety. Self identified plurals reporting no trauma history also have not been researched, have no standardized assessments, and so do not meet criteria for dissociative identity disorder, and so the DID treatment guidelines do not apply to them. But even for those with DID, OSDD, or PTSD, or other dissociative disorders, or complex trauma, Plurality can be a part of radical acceptance.
• 1:00:01
  To accept is not to be passively resigned or hopeless, but to be actively involved in understanding things as they are rather than as one wishes or demands they should be. Plurals should also be able to participate in research ethically and appropriately, including compensation, given credit for the participation, acknowledged in treatment guidelines such as with the 2020 Blue Knot Foundation guidelines, be included in the development of framework to prevent and reduce ruptures in the therapeutic alliance to co lead solutions and because lived experience best understands barriers. The Lancet Journal reported in 2020 that long COVID treatment guidelines need to include lived experience input and feedback. CPHQ clinicians also made five requests from clinicians to their organizations to be heard, to be protected, to be prepared, to be supported, and to be cared for. Plurals could make the same five requests to clinicians and organizations.
• 1:01:09
  Hear me, listen and act on lived experience to understand and address concerns to the extent organizations and clinicians are able. Protect me, reduce the risk of additional trauma from poor quality and uninformed care that dismisses my trauma and experiential response to it. Prepare me: Provide training and support for high quality care in different settings. Acknowledge my experience in treatment guidelines and theoretical frameworks. Care for me.
• 1:01:42
  Provide holistic support for my internal world, my external world, and my other world. From political activists and disability trauma research, and then used by HIV and AIDS activists, we say, Nothing for us without us. We need a phenomenological model of multiplicity that holds to the original theory that rather than having one personality divided into parts, there are indeed multiple personalities. Physical dissociation includes anaesthesia of body parts or sensation of them, and dissociation from motor function and conversion symptoms. Psychological dissociation includes affect, feelings, drive, impulse, and memory.
• 1:02:29
  Depersonalization and derealization are on a separate continuum of their own as one kind of dissociation as reported by O'Neill and Dell, which may or may not be experienced differently at any given time by any of the personalities, and those symptoms may come and go. This multiplicity model of plurality applies to DID and OSDD one. And the primary underlying issue of CPTSD is betrayal, just like the underlying issue of borderline personality disorder is abandonment, and the underlying issue of PTSD is fear. It is the too much that causes the disintegration rather than only dysregulation. Ellen Jepsen said in a 2020 conference for ISSTD that there's a difference between dissociative functioning and dissociative processing.
• 1:03:24
  Externally, people are dealing with ANPs, but internally the experience is EP. When ANPs inhibit or stuff the feelings, EPs are where that goes. So if we keep structural dissociation theory and the ideas that everybody is born with it, but adapt the ego states development that Kathy Steele mentioned in 2021 with the phenomenological model of lived experience of it being more than one personality rather than divided into parts of a personality, with Ellen Jepsen's A and P as external presentation and EP as internal experience, and Koi's contextualizing instead of pathologizing, then we get a model of structural plurality. These plurals refused to be forgotten. Moreover, they refused to be stigmatized.
• 1:04:19
  They insisted upon the rightness, the dignity of their distress. Thank you for listening.
• 1:04:33
  Speaker 2: Thank you so much for listening to us and for all of your support for the podcast, our books, and them being donated to survivors and the community. It means so much to us as we try to create something that's never been done before, not like this. Connection brings healing. One of the ways we practice this is in community together. The link for the community is in the show notes.
• 1:05:01
  We look forward to seeing you there while we practice caring for ourselves, caring for our family, and participating with those who also care for community. And remember, I'm just a human, not a therapist for the community, and not there for dating, and not there to be shiny happy. Less shiny, actually. I'm there to heal too. That's what peer support is all about.
• 1:05:28
  Being human together. So yeah, sometimes we'll see you there.