Latest / System Speak: Complex Trauma and Dissociation / Guest: Peter Barach, PhD (Telehealth Transitions)

Transcript

Guest: Peter Barach, PhD (Telehealth Transitions) · System Speak: Complex Trauma and Dissociation

• 0:08
  Speaker 1: Over:
• 0:11
  Speaker 2: Welcome to the System Speak Podcast, a podcast about Dissociative Identity Disorder. If you are new to the podcast, we recommend starting at the beginning episodes and listen in order to hear our story and what we have learned through this endeavor. Current episodes may be more applicable to longtime listeners and are likely to contain more advanced topics, emotional or other triggering content, and or reference earlier episodes that provide more context to what we are currently learning and experiencing. As always, please care for yourself during and after listening to the podcast. Thank you.
• 1:01
  Speaker 3: Doctor. Peter Barish attended Johns Hopkins University and the University of Michigan. He received a PhD in clinical psychology from Case Western Reserve University. He is a clinical senior instructor in psychiatry at Case Western Reserve University School of Medicine in Cleveland, Ohio. Since 1984, he has been in private practice in the Cleveland area with Horizons Counseling Services.
• 1:27
  His clinical approach is relational and supportive. He specializes in working with people with dissociative disorders and adult survivors of trauma. He also works with depression and anxiety. He is trained in EMDR and clinical hypnosis. Doctor.
• 1:43
  Barish is the author of scientific and clinical articles on dissociation and dissociative identity disorder. He is past president of the International Society for the Study of Trauma and Dissociation. Within the dissociative disorders field, he is known for having first highlighted the link between disordered attachment and the origins of DID. He also chaired the committee that produced the first set of treatment guidelines for adults with DID in 1993 and has participated in revisions of the guidelines. In addition to his writings on dissociation, Doctor.
• 2:20
  Barish served as a script consultant for broadcast media and as a reviewer for several journals. He has also served as an expert witness in civil and criminal matters. Links to his work are available on the blog at systemspeak.org. Welcome, Doctor. Barrett.
• 2:45
  Speaker 1: Hello? Hi.
• 2:48
  Speaker 3: I guess we can get started. Was there anything specific other than what this transition has been like that you wanted to cover today?
• 2:56
  Speaker 1: Well, yeah, I wanted to, kind of interview you to find out what telehealth has been like for you, if that's okay.
• 3:03
  Speaker 3: Oh, fancy.
• 3:05
  Speaker 1: Yeah. I mean, you've done it longer than I have for sure.
• 3:08
  Speaker 3: So this is a backwards interview today.
• 3:11
  Speaker 1: Well, two two way. How about that?
• 3:13
  Speaker 3: We're shaking things up. Yeah.
• 3:16
  Speaker 1: Is that is that okay with you?
• 3:18
  Speaker 3: That's great. Let's do this. So just for context, I have been doing telehealth for about five, six years now. It's interesting that everyone has had to transition to telehealth because of COVID because in the past, I actually got a lot of flack for doing telehealth. And just professionally and culturally, when is it okay, when is it not okay, what is the efficacy, and things like that.
• 3:48
  And I think that like any other therapy, it can be done well or it can be done badly. And so that's definitely an issue, but research shows that when it's done well and with the right issues and in the right context that it can be very effective. For me, I started in telehealth because I live in a very rural area between Kansas and Oklahoma. And then I got the job with the humanitarian aid contracts of doing telehealth in war zones and disaster sites. And for those reasons, the rural health disaster sites and war zones, that that was really their only accessible form of treatment.
• 4:37
  And so in that context, it made sense, and that's why I have experience with telehealth.
• 4:42
  Speaker 1: How much of what you've done have has been phone and how much has been video chat?
• 4:48
  Speaker 3: I do more messaging and more phone than I do video. I am getting better at video. The hindrance to the video has been because my own personal issues with video. Uh-huh. But I recently started with another organization that is also a humanitarian aid group that they required the video sessions, and that really pushed my limits.
• 5:20
  But I appreciated what they were doing differently than other humanitarian aid groups. And because of the extreme issues involved, it was just necessary. So that's part of why, not just for getting our picture taken at ISSTD, but part of why I've really been working on that in the last six months or so. And so have gotten better with my comfort level of it, But that is definitely a newer transition for me as well.
• 5:51
  Speaker 1: I've been doing it since, basically, mid March. The last client I saw in person was on March 9, and had decided after that I was not going to go into the office. So I notified my clients of that, and then insurance companies started to say that they would now cover telehealth, when in the past many of them had not.
• 6:19
  Speaker 3: Right.
• 6:19
  Speaker 1: So our state board of psychology here in Ohio also issued a bunch of rules around the March, saying that people had to get training in it, some kind of continuing ed credit in order to be able to do it, and and there were a bunch of other requirements about getting informed consent from clients. Fortunately, I had had some training in it before when I was working at the VA, although I never used telehealth there and never wanted to. But I found it really quite an adjustment because of the way that I work. A lot of what I do is sort of experiential and in the moment, and it counts on being able to see somebody and notice their breathing and muscle tension and so on. It's really hard to do when you're seeing head and shoulders, if at best, on a camera, and they can't see more more of me than that either.
• 7:15
  Speaker 3: I think I think that's a valid point. And and in talking about the transition, I think it's an important part of the conversation to retain the emphasis that when it's possible, therapy in person is absolutely ideal. And there there's nothing that can replace that or the depth of it or the impact, especially even with what we know neurologically now and and how between neuroception and attunement in different things, the the context of a war zone or a disaster site or now COVID, those are very specific things, but they absolutely have significant limitations.
• 8:01
  Speaker 1: I've been thinking a lot about polyvagal theory, and anybody listening to this who hasn't heard the episode you did some months ago about polyvagal theory, give it a listen. It's really a great introduction to an area has really opened up a lot of doors for me as a therapist. Porges has talked about embodied listening. So my experience with clients in the office is that I get gut feelings or feelings in my chest or tension that I notice in myself, and that gives me some connection to what's going on with the client. And of course, they notice these things in themselves as well.
• 8:44
  So far, this has not happened much with telehealth, although with a couple of clients that I know pretty well, it has begun to happen. So I'm optimistic that that can continue as a way of building more of a deep connection when the information that's coming in is pretty limited on both sides.
• 9:04
  Speaker 3: I think that's a good point too because initially when we're thinking about the practical aspects of transitioning to telehealth, it come the things that we think about are the things that you mentioned, which insurances approve it, and what are the billing codes you're supposed to use, and what are the differences, and how do you sign a consent specifically for video or for phone, and what are the things you need to include in that kind of consent, or which platforms can you use for appropriately and those kinds of questions. But that those are just the practical questions of getting set up. It's almost like starting a whole new private practice office, which is different than the therapeutic process itself.
• 9:51
  Speaker 1: For sure. And I think, I'm not a technophobe, but I know lots of therapists who are and some clients who have found it very, challenging to figure out how to get, a good connection for one reason or another. As as we talked about at the beginning of our talk today, I mean, because of the weather in your area, your voice comes across with a lot of static on it. Although I can understand you perfectly, it's like listening to an old radio, sort of. But one of my clients lives in an area where her Wi Fi signal is weak.
• 10:27
  So the first time we did telehealth, it was like looking at a succession of still images, and then I would hear my voice coming back out of out of her speaker into her microphone about two seconds after I said something. So I knew we were both having a substantial delay. That was really difficult. So how do you how do you find it dealing with those kinds of issues with with clients?
• 10:53
  Speaker 3: I think it part of it is building presence just like you would in the office of joining them in that and sort of acknowledging what you're experiencing. And I think even what you were mentioning earlier about the disconnect on video from the physical presence and feeling things in your own body, I think with time and with practice, that really will improve, and you'll be able to do that differently, almost like building muscles. But it requires acknowledging those same pieces, and that's gonna show up for for everybody. Some people are actually relieved that they don't have to leave their house and that therapy can happen in their home. Other people are very triggered by having video, and it requires a new kind of trust of, is there anyone else in the room that I can't see?
• 11:49
  Or is there are they really paying attention to me? Are they just doing something else while they're listening? Or you know, though you have to attend to presence very differently.
• 12:00
  Speaker 1: I had the experience recently of doing a telehealth with a client and not realizing until partway through that there was somebody else in the room. I wish the client had told me at the beginning. I mean, it wasn't a serious issue in this case, but I should have asked, and I never would have thought to do that.
• 12:18
  Speaker 3: Right. Right. And there's there's the shift in the experience of boundaries as well when we're seeing into our clients' homes and clients see into our homes or or parts of our homes. I know some people are trying to be, very neutral with, backgrounds or very neutral with like just a wall so that there's not a lot of confusion or or in some way trying to set up visual boundaries in that way. And other times neutrality is not helpful and a therapist that has too much of a flat affect can be triggering because going back to polyvagal, they don't read that accurately and so when we're trying to present a safe neutral facial expression or a safe neutral background or presence in that way, it actually reads like danger because they don't have feedback to confirm that it's safe or to know that it's okay or that we're interested in them or or that we're we're present with them.
• 13:25
  They the facial expression thing can really come into play with video sessions because they can read it as danger.
• 13:33
  Speaker 1: That's a good point. I mean, I don't have the most expressive face. There's certainly enough expression going on that it comes across in my office. But on video, I've done more sort of intentionally nodding or moving my head, or if I'm making a hand gesture, making sure that my hands are on camera, all of while trying to look in the camera and not at the screen so that, the client sees that I'm looking into their eyes, which I I am if my camera and monitor are close enough together.
• 14:04
  Speaker 3: That's really important. I I don't wanna get too off track, but I wanna bring that up because I know recently in a different conversation, you were talking about eye contact stopping flashbacks. Can you talk about that just a second since we're talking about eye contact?
• 14:19
  Speaker 1: Sure. This is something I learned from James Chu, who was really a pioneer in the dissociative disorders field, and used to and started the dissociative disorders unit at McLean Hospital. He said that it's very difficult for someone to stay in a flashback when they're making eye contact with someone else. So there are some signs that that clients can learn if they haven't already figured it out, that tell them that they are about to go into a flashback. So now do you want me to talk about that?
• 14:55
  Speaker 3: Sure.
• 14:56
  Speaker 1: So a flashback by nature is dissociative. You're you're here, but you're there. And in order to do that, you have to reduce your contact with your current environment, which is not intentional, and go more into your inner world of images or feelings, sensations, whatever it might be. And when people do that, they are unintentionally going into a light kind of hypnotic trance. So the way that that's apparent on the outside often is that the person the client fixes their gaze.
• 15:29
  They stop moving very much. Their breathing may change. They become more immobile on the outside while all of this is going on the inside. So when I see this start to happen with the client, the first time that I see it, I'll point out that, you know, what's what I see happening in you right now is that you might be starting to go into a flashback. Does that seem right to you?
• 15:52
  And if they say yes, then I will always tell them now you have a choice. You can go with it and go into that flashback, and we can work on it. Or you can stop it, and then you'll have a way to know how to stop flashbacks so you can save them for a safer time and place if they start to happen in your house or when you're out at work or on the street or something like that. And I've never had somebody say, oh no, let's go into the flashback at that moment. So then I'll point out, well what you can do is you can move around, you can jangle up your hands a bit, you can move your eyes around the office, and I'll tell them what I learned from Doctor.
• 16:31
  Chu, which is it's really difficult for someone to go into a flashback when they're making direct eye contact with someone, and then I will move my head a little bit so I can try and make eye contact, or sometimes bend over a little bit, and then it becomes kind of a joke where the person can make eye contact and start to laugh a bit, and then they're back in the here and now. And that's the point where learning grounding techniques is really helpful. Teaching people to start to notice five things around them that they see, or that they hear, or that they smell, and pounding their feet in the floor, walking around a little bit, all of these things that most of us have taught our clients for a long time.
• 17:16
  Speaker 3: I know that those coping skills of, like, the five four three two one things, for example, is such a common grounding technique, but I literally had not connected that it was for the purpose of reconnecting us to the present and the world, the external world. That makes perfect sense.
• 17:39
  Speaker 1: It helps it helps someone get back in their body and in a safer environment than when the trauma happened. So that brings up a question I wanted to ask you. I mean, you are clearly working with traumatized people on audio chat and now on video chat. What's that like as far as when they start to work on their trauma, on past trauma? How how do you manage that and be there for them at that time?
• 18:10
  Speaker 3: There's two schools of thought actually or or two two scenarios really that that I'm experienced with that I could address. One is actually having to go ahead and work on the trauma because there's no other option for that and adapting to do it in the context of video or audio, which can be challenging. Or the other the other scenario is that we work instead on grounding and coping because it's hard to process trauma while you're in another trauma. So I can't tell people in a war zone that now time is safe.
• 18:51
  Speaker 1: That's true. That's for sure.
• 18:53
  Speaker 3: Because it's not. I can rephrase the same concept in a different way and apply it internally while also acknowledging the danger that they're literally still rockets flying through the air. Right? And, but the same thing that's happening with COVID now is that there are some who really for their experience of quarantine or their experience of being home is either triggering enough or traumatic enough that COVID itself is the trauma and it's not the time to be processing trauma. There are people it may just be presenting enough that it's just it really is necessary or that their coping skill is actually maintaining the progress that they were doing and so continuing to work hard on those issues despite what is happening externally, which actually kind of does the same thing of keeping a forward momentum and connection to the present rather than getting lost.
• 20:05
  Because I will tell you, even just in my own personal experience with having the children home from school and the husband and I trying to take turns working while the children are supposed to be having Zoom meetings or class lessons or all of this, our daughter's health issues, and not all of this happening in our home, but not able to go visit friends or to connect with others in the same way or even leave the house or have any kind of respite from any of those issues, I can't change COVID. I can't change what's gonna happen with my daughter or not. I can't go for a walk without my children right now because my only break is when I'm working, and I can't change the cases that are happening on work and how acute and intense everything is. There becomes so much happening that the lines between internal and external somehow are starting to get blurry in a different way where it's hard to remember not just in a now time is safe kind of way, but what's inside and what's outside because it feels like the outside has invaded the inside.
• 21:24
  Speaker 1: Oh, yeah.
• 21:26
  Speaker 3: And at the same time, I can already feel this anxiety of in some ways, it's still easier to just be home. Part of me, that is a more comfortable place and less aware of the invasion into that place. And so I already feel too exhausted to reengage with the world. So when the quarantine is lifted, so to speak, whatever that looks like, that, that concept is overwhelming to me. Exhausting.
• 21:58
  I'm not I'm not ready for it. I don't know how to do the work of transitioning back out when I feel like, for me, my personal timeline of trauma work and therapy became like I was making so much progress. And then all the things I was making progress with, like, it felt like it all just got shut down.
• 22:20
  Speaker 1: That's so hard to hear from from you because I know from podcasts how much work you've done, and I'm so I'm sorry that this has happened.
• 22:31
  Speaker 3: It what what's been it's hard to talk about because it feels I mean, there's always that vulnerability of sharing, but it also feels like it matters now. Like, it matters to me. It matters to listeners. It matters to my family. It matters to my friends.
• 22:48
  So there's this pressure not to fail and not to regress because the only way to hold out hope is to keep trying. And so there are days where they talk about or like the article that we wrote about COVID and the trauma response, that that freeze feeling when there are days that you're really just too tired to function because the freeze response is kind of happening, there are days that's so heavy that I don't know how to get functioning again. Except at the same time, what's fascinating is that I really am functioning. The children are good. The children are well.
• 23:34
  The children are happy. The children are doing school. The children I mean, everything is happening as it should, but it's all happening differently. And so I think part of what I'm unsteady about is how to do that without creating someone new. I don't want to create someone new.
• 23:53
  I'm not trying to create someone new, but also how to hold together the progress that we've made and just let that be a new way that we're doing things, a new structure for doing things without that being a amnesia wall between it.
• 24:14
  Speaker 1: Yes. Because that tool has been there for you for your whole life. It's hard not to use it when you're trying to use something else.
• 24:23
  Speaker 3: Right. Right. I I didn't mean to get off topic, but that's how I
• 24:27
  Speaker 1: see at all. Not at all.
• 24:29
  Speaker 3: I see it. What what has been interesting is trying really hard, like, all the shame stuff we've learned in the last year, trying really hard to hold onto those pieces and so not judging what happens. On a day that we're not functioning well, whether because we're not feeling well or because of that freeze response of just knowing, okay. This is what's happening, and we're just gonna wait it out. We're okay.
• 24:57
  Everything is okay. The family is here. We're doing our best, and that's enough, and not worrying about anything else. And then on other days when we're functioning better or differently, using the different coping skills that we already had, like I'm taking a class with the ISSTD. So for me, that is a great coping skill in helping me to have something else to focus on that feels normal, that's not about parenting, that's not about trying to balance work and marriage and parenting all in the home, that's not about distance from my friends.
• 25:32
  I get passes the time. I miss my friends, so this passes the time without them. We are doing a an art project for a friend. So even though we can't see her, it maintains that connection where different parts of us are contributing and can, in some way, hold a connection so that we can remember the things that are important to us even though we're gonna come out on the other side of this altogether different than we went in.
• 26:00
  Speaker 1: What you said is connection is really the keyword, and I know you've said that on a couple of the recent episodes. This is what is so risky for being isolated is to lose any sense of connection. So what you described is really two kinds of connection. One is internal connection that you've been doing by letting in some new information, letting yourself connect with the artistic parts of who you are, taking a class, and the other is external connection, which is making sure you can stay connected with friends, that you're expressing your feelings about them through things you're doing in the context that you make. And I feel like if we don't do that, then there aren't a lot of inner resources left other than to do what we do in emergencies.
• 26:52
  In emergencies, break glass, for you and people with with DID, that that is to dissociate. And maybe that's not a bad thing temporarily, but I don't think coming back from that is going to be as hard as it's been at this point to start to move away from it. Does that make sense?
• 27:12
  Speaker 3: It does. And I think that you gave me words to express it because in some ways, without at all mocking, I'm not at all dismissing or minimizing or mocking the trauma that's behind DID. In some ways this is actually easy for those of us, and I've seen a lot of talk about this on the online community of we're already used to this. We feel like this every day where the outside world feels like danger. We've got this down.
• 27:41
  This is actually not a problem. What what is the challenge is can I am I strong enough? Have I made enough progress? Do I believe in myself, myself, however you wanna say it? Am I strong enough mentally now to use all that I've learned?
• 28:00
  It's almost like a midterm exam or something of
• 28:04
  Speaker 1: of Oh, no. I don't wanna know what's on the final.
• 28:07
  Speaker 3: Right. Right. Can I use all of these things that I've learned and all this progress that I've made and all this strength that I can draw from the connections I've worked so hard to build? Can I do that enough that dissociating temporarily because of COVID as a natural and temporary response is healthy and normal, but that when COVID passes, I'm still here on the other side?
• 28:34
  Speaker 1: There's nobody else to be there on the other side but you taken as a whole. Right. It's gonna be you.
• 28:40
  Speaker 3: Right.
• 28:40
  Speaker 1: So one idea that I've had about dissociation for a long time is that there are there's a threshold of vulnerability for all of us to become dissociative, and the polyvagal theory really supports this idea that if the stress gets high enough, that's that's what our body and our brain will do. For people who have had trauma and maybe there's a genetic element to it, that threshold of vulnerability to dissociate, it's a little lower. It takes a little less stress. So as people become more stressed, they may find themselves being more dissociative as the stress level goes down, less so. So what that suggests to me is the things that we do to reduce stress, especially what we do physiologically, can help to stay grounded and connected in the present as much as possible.
• 29:43
  Possible. So things like relaxation techniques, yoga, meditation, listening to music, singing, dancing, exercising, whatever forms help you to regulate your physiology. Whatever form, whatever means help you to regulate your physiology, can help to lower, to raise that threshold so that dissociation doesn't have to be there as the emergency response so quickly. Does does that make sense?
• 30:15
  Speaker 3: It does. And it's one thing I tell people even in the war zones a lot is that you have to move. Like, that cortisol only flushes out through movement. And Oh. They have such a toxic level of those stress hormones that their body starts to function at a new level where that polyvagal nerve is just on their organs and just staying there is what it looks like.
• 30:40
  And so I tell them, like, you have to move, whether that's dancing or or stretching or even if you can't go for a walk. And and when when we have people who are often down and crouching positions literally protecting themselves from bombs and and rockets rockets and things. Like, you need when it is safe, you need to intentionally stand up and stretch as far as you can and let that your body come out of that position. And the same with with survivors now who are having, to be on lockdown because of COVID and especially if they have entrapment as part of their history. One of our daughters came to us from foster care.
• 31:28
  They had found her in the trunk of a car. And so goodness. She she is very trigger triggered by the lockdown because entrapment was part of her issues. And so we, as often as possible, are trying to get her outside even if it's on the deck and making sure a thing like, you can still be creative how to meet that need. Like, we make sure that she comes in last for bath time and let the others go first so she can be outside the longest or sending her out on her bike first before even if she hasn't done her homework yet.
• 32:05
  Like, just go play while you can. There's no other kids outside. Whatever it takes to undo the trauma response itself and sort of work your way back up the ladder.
• 32:19
  Speaker 1: That makes so much sense. Thank you for sharing that. I'm gonna pass that on to my clients and use it myself. I wanted to talk about one of the insidious things about COVID that creates a trauma, which is the fact that it affects breathing in ways that panic does as well.
• 32:39
  Speaker 3: Right.
• 32:39
  Speaker 1: So I've used this for myself, and I pass it on to clients, but I learned this technique some years ago from a combat veteran, and he called it combat breathing, but it's well known as box breathing. Basically, what you do if you're having trouble because you have tightness in your chest instead of panicking like, oh no, here it is. I've got COVID. The first thing that you can do is try and shift your breathing. And what that involves is picturing a square in front of you, and you do something different as you go around each side of the square.
• 33:17
  So starting at the top left corner and going to the right, if you like. Obviously, you can go any direction you want. You inhale slowly on the count of four. Go down the side of the square, holding your breath to the count of four. As you go around the bottom of the square, exhale slowly to the count of four.
• 33:37
  And before you inhale, as you're going up the final side of the square, you just don't do anything. You don't inhale for a count of four. If you do this a number of times, and it usually doesn't take very long, It tells your body, okay, you've got enough air in there, and you can start to notice a shift in your breathing toward a more relaxed space. There's some videos on YouTube which demonstrate this. The one I found that that looks the best, unfortunately, has somebody breathing Okay.
• 34:09
  Along with a bunch of gentle music. So if you don't wanna hear breathing, you can just turn the sound off if you find that one.
• 34:17
  Speaker 3: That's a good idea. I know there's also there are a couple of apps that support EMDR practice. And while I would caution people to be very careful with that, there are a couple of exercises our therapist has given us that we are able to practice at home using the app because we can't get to her in person. And some people are doing EMDR online, some people are not. And I wouldn't use the app for, like, an entire protocol or something.
• 34:50
  But to just practice whether it's breathing or or remembering safe places or or things like that of, where the there can be balls or different things. There's one we use with our daughter that has an elephant that goes back and forth. And and so so that's an option too of just using tools and resources out there creatively, but also safely in ways that you feel comfortable to do.
• 35:18
  Speaker 1: Yes. There's, there's another I'm not comfortable using EMDR at this point to process trauma, with clients online. I'm just concerned that they'll end up in a place where we don't have enough connection to help them make it all the way through. So other therapists feel better about that. Obviously, it's a very much of an individual decision for a client and therapist.
• 35:41
  But there is an EMDR intervention called the butterfly hug, which doesn't require any apps. Basically, you cross your arms and you put your hands on your biceps or the upper part of your arm, And you can do this with eyes closed or eyes open, but you think of a safe place, whatever that might be for you, real or imagined, and know what it's like to be in that place, and just tap left, right, left, right, left, right for about twenty seconds. Take a breath. Do it again and notice if that can help you calm down. Some people have found that helpful.
• 36:22
  Speaker 3: Our children do that and in fact
• 36:25
  Speaker 1: Oh, great.
• 36:26
  Speaker 3: Two two of my children are on the fifth grade student council for their school and, they made a video for the other students because they were concerned about them and wanted to reassure them that everything was okay. So they made a little video about it and included that in the video that that was one thing you could do to feel safe.
• 36:46
  Speaker 1: Oh, great. That's wonderful. I was just thinking about something you'd said earlier about people who feel okay, safe about being in their home while they're having their therapy online. Just remembering one person who having an intrusion in in where she was in her house and was doing it on her phone. So she's carrying her phone all through her house.
• 37:13
  I'm getting a look at her ceilings and her walls and everything as she's walking through the house, and she's narrating well. This is my hallway, this is my stairs, and here's my dog, before she went to the room where she could get some more privacy. And one one of the one of my colleagues in the group practice who works with children has found that the kids she's doing video chat with, they love to introduce their pets to her on camera.
• 37:39
  Speaker 3: Yes.
• 37:40
  Speaker 1: And that's been really cool for the connection that they make.
• 37:42
  Speaker 3: It's interesting. We've seen that on the Zoom classes as well when our kids are on Zoom for their classes. It's all about pets and connection. They're not actually doing any lessons at all online or any learning. It's all about connection with the teachers and their friends, which I think has been really good for them.
• 38:01
  We've had to be careful about the boundaries both with screen time and because we have so many children and they have so many appointments, like, just for the structure of our day as a family and our family culture. We don't wanna be on the computers all day, and already there's so much stress in work. But a little bit of that has been very helpful. And pets and movies and snack foods have been what they seem to chatter about as far as things to bring them back to safety as a group.
• 38:32
  Speaker 1: So they're not doing math lessons?
• 38:34
  Speaker 3: No. All of that has been through online, programs or packets that we pick up when we pick up their food from the school, but the actual Zoom class time is all just chatter, chatter, chatter.
• 38:50
  Speaker 1: It's all about connection. You're right. That's that's really interesting.
• 38:53
  Speaker 3: I I think I think it makes a difference for everyone. I think that it's it's challenged both clients and clinicians to think creatively, to step outside comfort zones, but then also to do that together, I think has potential for a great deal of healing. I think that when when it's possible to think outside the box a little bit and to be creative and to establish boundaries that feel comfortable for both you and the client. And when those can be more flexible and sometimes in ways they can't, like, know individually with what works with who and what works for them and what doesn't, and they have the right to say that for themselves. But there's such potential of connecting through a hard thing together that somehow solidifies things even though it's very, very difficult.
• 39:56
  Speaker 1: It is. But I think there's also a temptation for many of us who are acting as therapists to not keep the usual boundaries that we keep. Because, I mean, clients are concerned about us and want to know how we're doing. It's I I I wouldn't wanna just throw it back at them as as a Freudian and say, what might that be like for you or some kind of a evasive response. But don't wanna make my business their business any more than I would in the office.
• 40:29
  Speaker 3: I I start every week. So for for us, we work Tuesday through Saturday and then take Sundays and Mondays as our weekend. And so everyone, whether they're messaging or video clients or audio clients, we, every Tuesday morning, take extra time, like, it into our day that I send a message to everyone and say, it's Tuesday. I'm back from the weekend. I just wanted to let you know that I am well.
• 40:57
  My family is well. We've stayed in quarantine, so we're safe. And then immediately go into how are you doing? How is your family? And just say it upfront and redirect right back onto I'm here for you and what we're working on with your stuff.
• 41:13
  Speaker 1: That's a really great idea. Thank you for sharing that.
• 41:16
  Speaker 3: That that way that way it's human and it normalizes and it addresses those anxieties upfront. And so they feel connected in that way, and we can experience that together. But that way, their time is still their time to talk about what they want.
• 41:31
  Speaker 1: That is that is really a great idea.
• 41:35
  Speaker 3: I I feel like there are some clients as well that require more reassurance, and so I sort of bookend that on the weekends as well as well. So on Saturdays, I send I do the same thing. I take more time, and I send another message. And I say, it's Saturday, so I'm going to be offline until Tuesday. What what
• 42:00
  Speaker 1: are your Could you do a podcast episode on how you've managed to find 28 in every day? I I don't I can't understand how you do it at all of this. I really don't, but you're amazing.
• 42:15
  Speaker 3: Well, it's tricky, and everyone's needs are so unique. There are some people that require, like, a lot of information and just want to know things. So I can send with that Saturday message a little thing about a general here's how to counter negative thoughts or here's about the polyvagal theory. Like, something different a little bit every Saturday and just send it to everyone. And some people really appreciate that because over time they learn, and other people are offended because they know that it has been sent to the masses.
• 42:48
  And so Oh.
• 42:49
  Speaker 1: It's sent to at all.
• 42:51
  Speaker 3: Yes. Because it's been sent to everyone, then it's not about them, and it's not about like, it's almost a violation. It backfires because it's not, specific to them. And so for those people, I have to say, this message goes out to everyone. So if it's not helpful to you, just let it go and address that because some people, if it's not directly to them, they don't wanna hear about it.
• 43:20
  They don't wanna be they feel violated by that. And I've seen that online too with, professional pages. We have a professional Facebook page that I have just for work, and it's usually only a memes. I spend one hour, like, a month scheduling them out for three months. I'm not actually on the page very often.
• 43:40
  I don't interact with clients on the page, But sometimes I'll post something and then get this response in the session of, I thought that that was just something we were talking about and now since you're telling everyone, I realized it wasn't just about me so now it's not true. Almost like it was a violation of a dating relationship. There's this transference there that that comes through and has to be addressed. So you have to be careful with that too.
• 44:05
  Speaker 1: Do you get the same reactions, from clients who listen to the podcast that you do?
• 44:10
  Speaker 3: I have only that's a good question. There are a few people who have listened to the podcast and come to us for coaching, but we have encouraged them to maintain therapy with a therapist they're already established with and focus very specifically on just mirroring back what their therapist has asked them to work on and not interfering with that process, which would be a whole different podcast about therapy and coaching and why that can go so badly so quickly when it's not done well or carefully or anyway. But there's only, one person that was already on our a client that we then also told about the podcast. And the reason we went ahead and told them was because it was coming out public with our name, with the award.
• 45:08
  Speaker 1: And Oh, right.
• 45:09
  Speaker 3: This particular person needs that integrity and that connection of I'm telling you this specifically because it would have been more damaging if they had found out on their own. And
• 45:24
  Speaker 1: As if you've been doing something sneaky.
• 45:26
  Speaker 3: Right. Right.
• 45:27
  Speaker 1: Thought that maybe.
• 45:28
  Speaker 3: Right. But otherwise, I don't think most of my clients even know about the podcast.
• 45:35
  Speaker 1: Yeah. Secrets are a trigger. Right? Right. For a lot of people, for sure.
• 45:41
  This I don't know if this is I I don't think this is related specifically to your podcast, but more about knowledge getting out about dissociative disorders of which your podcast is a part. But before COVID hit, our office was getting a lot more referrals for people who said they had DID than we have in years. And that that's really good. If people are willing to acknowledge it and seek help, that's a great thing. I wish there were more therapists who who knew about it and were willing to learn how to help.
• 46:17
  Speaker 3: I'm hoping that word gets out and that that's part of what the podcast helps with. It's a scary thing. It it it's it's a scary thing. There's also a lot of hate mail and a lot of threats against our family
• 46:33
  Speaker 1: Oh my
• 46:34
  Speaker 3: goodness. Sometimes really makes it like, there are days I wanna just take it down and be done because it doesn't feel safe. But as long as I don't know. We have to use our judgment and, try to keep our children safe, obviously. But if if we can maintain safety for our family, then it seems worth the risk a little bit to ourselves to help others if we can as long as we can.
• 47:05
  Speaker 1: Okay. That makes sense too. But I I hope you do take care of yourself that way.
• 47:10
  Speaker 3: Right. We have temporarily taken the Facebook page down for the podcast simply because of energy and time during COVID. It was kind of an experiment anyway. It's only been up for three months, and I don't know if we'll put it back up or not because it's mostly people write in. And so I'm not sure that that's the best use of our energy.
• 47:34
  Speaker 1: I'm I'm guessing that there are a bunch of people who have DID, haven't told their therapists, and have listened to the podcast and have decided to go to their therapist and say, well, guess what? There's something I haven't told you. And I'm hoping that that has happened for those people, that it's helped them feel strong enough to speak out for what they need. And I hope they get what they need.
• 47:57
  Speaker 3: We get emails about it and it's so powerful. It's so powerful. It really, really is. It's humbling in a way, but but also the listeners when they write in and ask questions or give feedback, it helps us too. And so it feels almost very mutual in a way.
• 48:16
  And so I think that's one reason we've been able to continue doing it because it's offering support, which is good for us because helping others is important to us, but also is helpful to myself as well.
• 48:31
  Speaker 1: Good. Glad to hear it.
• 48:33
  Speaker 3: What what else about your transition to telehealth? Is there anything that we have not covered or talked about?
• 48:40
  Speaker 1: Yeah. When can I stop and go back to my office? That's I really I I miss no. I'm I miss seeing people face to face and working together in that way. That's all.
• 48:51
  And I know you don't have that answer.
• 48:53
  Speaker 3: Well, it but I feel you, and I feel that frustration. We had just reached a level of functioning and a level of courage, to be honest, to get back into private practice and had located an office with people we felt comfortable with and were literally we had an appointment to go sign the lease the week that our town, our city went into lockdown.
• 49:23
  Speaker 1: Oh, wow.
• 49:24
  Speaker 3: And so it's very difficult to find office space here. She's holding it for us right now, but we've not paid for it yet because we don't have clients we can go to and see. And so I don't know how that will play out. I want to still have the courage to do that after. It was an an interesting process of being brave enough to go explore office space and talk to different people.
• 49:50
  And I was really grateful for the podcast because to have more experience talking to other people and connecting professionally again, I think you and the ISSTD and the people I've learned to interact with through the podcast has given me more practice with that. And so I was able to do that. It was actually not a big deal. I didn't even have to talk about it in therapy, actually. I just kinda went and did it.
• 50:18
  And so
• 50:18
  Speaker 1: That's great.
• 50:20
  Speaker 2: Yeah.
• 50:21
  Speaker 1: Yeah. You must be really proud of the progress that you've made when you're not busy, getting mad at yourself for not having made enough progress.
• 50:33
  Speaker 3: Right. It all feels a long time ago. It feels far away. And at first, I was concerned about that. Like, are we just blocking out something that we need to be addressing?
• 50:43
  But if it's just in the past and it's okay to let go, maybe that's okay too.
• 50:49
  Speaker 1: Yeah. I think so. I mean, what you said about how we're all in a trauma right now, a number of people, a number of therapists who are doing podcasts about COVID have said the same have made the same point. And many of them are saying this is not the time now to be working on past trauma, even though it is definitely triggering for some of those things. This is about finding a way to feel as safe as possible now, even though now time isn't completely safe.
• 51:20
  Speaker 3: Right. Right. I think how we're handling it right now is we did finally I don't know what you've heard on the podcast thus far, but we have finally gotten a therapist that we can stay with for a while despite COVID.
• 51:33
  Speaker 1: I I could not believe that story about the therapy dog that bit you. Oh my goodness.
• 51:38
  Speaker 3: It's been a nightmare.
• 51:40
  Speaker 1: That is terrible.
• 51:41
  Speaker 3: Well, and to be so in the thick of things and making such good progress in therapy and then sort of just by circumstance be out of therapy for six months, it was really, really brutal. I had no idea it would be such an ordeal to get started with another therapist. I really thought we had everything lined out and it would be okay.
• 52:01
  Speaker 1: That's that's just so unfortunate. Oh my goodness.
• 52:05
  Speaker 3: It was hard, but we have someone now. We don't do notebooks like we used to do. I am able to I really have this goal and effort of some teamwork and some I just wanna talk about this piece and getting pieces out even if I'm getting pieces from other people, so to speak, inside, and processing and trying to stay present and hold on. Like, I have just let go of the need to connect with the person. Like, she's nice.
• 52:38
  She's fine. But I don't have I don't wanna waste I don't wanna say waste. That's terrible. I'm not going to invest in her the way I did the other therapist, and I'm not going to spend three years feeling safe before I start talking. I Okay.
• 52:53
  I understand that that is needed. And if I didn't feel safe, I wouldn't be there talking. But I have consciously chosen that this therapist has all the things that we need. She's good enough, strong enough, safe enough. So I'm not going to spend time not talking.
• 53:11
  I'm just gonna go there and work and come home and leave it at therapy, and EMDR is helping with that. And so that feels good, but we're doing that instead of the notebooks. I don't write to her like we wrote before, but we are doing some writing, actually in a book. I don't Wow. I don't know if we will actually publish it or not or if it will get published or not, but it's been a way through COVID and all of this transition to continue to get things out and to continue to communicate and try to honor all of those individual experiences, but still integrate not I don't mean people, but that memory and the feeling and the emotions and the responses and put pieces together.
• 54:03
  So we are actively writing that, not notebooks. Okay.
• 54:09
  Speaker 1: So here here's what I'm thinking about, you know, the decision you made about how to manage the relationship with the new therapist. Those three years, you're not leaving them behind, they're portable, and you have that way of going, of taking that forward with you as an inner resource that will always be with you. I know it's that way for me with the last therapist I saw, even though I'm not seeing this person now, there are times when I just can remember the feeling of what it was like to feel understood and safe with someone in the present. And that helps me to to feel more grounded today even though I'm not seeing a
• 54:51
  Speaker 3: therapist now. Right. Right. She has been incredibly, I don't know, tolerant. Tolerant.
• 55:01
  Patient, supportive in the transition. And we've had just by default of experiences, some really solid transition experiences that have helped. And so I think that's good. I think that I was concerned at first that there was so much of that that I didn't remember. But then my husband said, you weren't the one that was in therapy.
• 55:28
  And so integrating that kind of through our writing and then building a different transitioned relationship with her post therapy through like, for example, she this morning on the podcast, what was released was her videos that she's done about COVID and Oh. Gave permission for us to share those. And so so just just different unique ways of of it's different. I'm okay. This was not an ending that was a betrayal or a or a a forever or a it was not.
• 56:06
  There was no harm. There was no harm. I was not hurt. She's probably relieved. No.
• 56:13
  No. The there's
• 56:16
  Speaker 1: Are you sure?
• 56:16
  Speaker 3: It was not right. It would there was not about any harm. There was nothing of where something went wrong and it's a new trauma. There was nothing traumatizing about it other than the grief itself. But because of the transition, I think it's been beautifully done.
• 56:32
  I feel confident in that connection as it's transitioning and as it transitioned from that being in the past to this being in the future, what's challenging to me is like, even you, I consider you a friend that I've made over the last year through the podcast, and I'm so grateful. That is a gift you have given me, and I am so grateful for that. But I know that it's still challenging for me to actively connect in that because I live so far in my head. So I literally don't know. It's been three days or three weeks since I've talked to so and so.
• 57:11
  Like, time I don't have a sense of time yet. And so that's still I know as far as being a friend, I still have more skills to learn and to practice. But everyone's been very gracious and supportive.
• 57:26
  Speaker 1: Well, I'm I'm honored to be your friend, and I consider you a friend as well.
• 57:30
  Speaker 3: Thanks, man.
• 57:32
  Speaker 1: Yep. Of course.
• 57:33
  Speaker 3: This is big. How are you how are you coping with the stress of that transition and having such a big change? Like, for example, one thing that we talked about off the podcast was how doing therapy by video or by phone is exhausting in a different way because it's using a different kind of energy that doesn't have muscles built up like you do from all your years of in person. How are you managing all of that either physically or mentally?
• 58:08
  Speaker 1: I take breaks. It does it does feel more tiring to do it. So the most that I have done is five in one day. I've always left lunch break for myself, and I always have left time in between appointments to make notes and leave that behind and just breathe before going on to working with the next person. And I guess I'm lucky because I don't have to see 10 people a day.
• 58:38
  I I know some people working in agencies who are doing something like that every day, and I don't know if I could keep up with that. So spacing it out and taking care of my own needs is easier since I don't need to work full time right now.
• 58:55
  Speaker 3: Right. I know that. I won't say names because I don't wanna lose my job being a whistleblower on a podcast, but there are two companies that I work for that do messaging, audio, and, video sessions that have changed their policies without telling, like, the insurance companies they contract with or anything so that therapists are paid by word count and by number of how many words the client types. And so, like, one, we basically are only paid a dollar a day per person even though people pay a hundred or $200 for their plans. And another
• 59:51
  Speaker 1: That's outrageous.
• 59:53
  Speaker 3: It's awful. And another one has just changed starting April, has changed their plan so that not only is there a word count, but they only will take half of your words or, like, you can't they only take half up to how many your clients do. So if you type a hundred words but your client only types 50, you only get paid for the 50 that you typed. You don't get paid for the whole hundred. And then both companies both companies have a max.
• 1:00:31
  So if the client uses all of their words in the first week or first two weeks, you have to finish that month with them because you care about your client and you're an ethical therapist, but you're not actually paid for those other two weeks.
• 1:00:44
  Speaker 1: That is somebody's gonna get sued.
• 1:00:46
  Speaker 3: And It's it's bad.
• 1:00:47
  Speaker 1: It's really, really bad.
• 1:00:50
  Speaker 3: And I've I've been with them for four years, five years, because I started with them having to transition online because of the rural area where I lived. And because my daughter was in the hospital so much, I couldn't maintain an office. And so I that's why I was doing the telehealth in the first place and originally they they actually took really good of their therapists. In fact one of them I've even been to their headquarters in New York because we went there for my daughter's Make A Wish trip, and they hosted, like, our family to come see the headquarters, and they fed us lunch and gave her balloons and did all this stuff for the children. And it was really lovely, and I even spoke for them for a while.
• 1:01:33
  Like, they would send me to different states to talk about how telehealth can be done well, and now, like, I don't even know what's happening except that I know that the the first company that only pays a dollar a day, the CEO from there now has moved into leadership at the other one, and no one understands that they're connected. So even though they're different companies, my paychecks from them both are both from
• 1:02:08
  Speaker 1: That that's that's just appalling. It really is.
• 1:02:12
  Speaker 3: Yeah. It's it's a nightmare. So so I work for hours and hours each morning just because right now, we're in such crisis. I can't afford not to do that even though Uh-huh. I mean, it's it's so abusive.
• 1:02:26
  Speaker 1: It really is.
• 1:02:28
  Speaker 3: Anyway, was that too much? Is there anything else you wanna add?
• 1:02:32
  Speaker 1: No. I think, is there anything you wanna add? Because I think it was kind of a mutual interview.
• 1:02:38
  Speaker 3: I don't think so. I hope I didn't get too off topic. I I sometimes I don't mind sharing my lived experience perspective, but I also don't need to take over from that or share too much.
• 1:02:51
  Speaker 1: Well, we we agreed at the start. This was gonna be, both of us interviewing each other, and I think we've done that. So
• 1:02:57
  Speaker 2: Okay.
• 1:02:58
  Speaker 1: Okay?
• 1:02:59
  Speaker 3: It was so good to talk to you. Thank you so much.
• 1:03:02
  Speaker 1: Oh, thank you. I really enjoyed talking to you. You take care.
• 1:03:06
  Speaker 3: Okay. Bye. Bye.
• 1:03:24
  Speaker 2: Thank you for listening. Your support of the podcast, the workbooks, and the community means so much to us as we try to create something together that's never been done before, not like this. Connection brings healing, and you can join us on the community at www.systemsspeak.com. We'll see you there.