Emma's Journey with Dissociative Identity Disorder
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Emma's Top Ten

In the podcast episode, Emma’s Top Ten, she told the story of a baby bird we saw today at the park. Here is our youngest daughter having a little chat with the baby bird:

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Here is the list of ten things Emma shared that she has learned from our therapist:

10. Now time is safe.

9. Now time is different.

8. Memory time does not change now time.

7. She (the therapist, or even ourselves) is real, all the time.

6. We can ask for reassurance; sometimes that’s all you need.

5. You know better than anyone else what you need, and what is right for you.

4. It’s not our secret.

3. You always have a choice.

2. Turn the lights on.

1. You are not a little girl anymore.

All About Attachment

We got to speak again with Dr. Peter Barach, who taught us all about attachment.

He tells the story of being in class with Mary Ainsworth (who developed attachment theory),who was a student herself of Bowlby (pioneer of attachment theory).

Attachment theory explains the infant-mother dynamic, emphasizing the importance of a secure and trusting mother-infant in healthy development.

John Bowlby (1907-1990) was a British child psychiatrist and psychoanalyst, known for his theory on attachment. Key points to Bowlby’s theory include:

  • Infants are born already biologically wired to be cared for and attach to a primary caregiver;

  • Bowlby was influenced by Lorenz’s imprinting studies (baby ducks!);

  • Attachment behaviors are instinctive, which matters to trauma because those early attachment responses can be activated (triggered!) by conditions that threaten closeness or connection: separation, insecurity, and fear;

  • These innate behaviors are part of the survival instinct process;

  • The initial attachment experience serves a lens for all future relationships as the infant grows into a child and then into an adult; and

  • This initial experience provides an “internal working model” that serves as (1) a model of others as being trustworthy, (2) a model of the self as valuable, and (3) a model of the self as effective when interacting with others.

Dr. Barach then also explained the attachment styles identified by Ainsworth, through her strange situation experiment:

This research led Ainsworth to identify attachment styles that could predict behavior and patterns of relationship as the child grew older:

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This, Dr. Barach explains, plays out even with adults, like the model of Bartholomew and Horowitz here:

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Considering that different insiders may have different attachment styles, Dr. Barach discussed disorganized attachment as it applies to DID.

He also provided the example from the Robertsonresearch film “A Two Year Old Goes to the Hospital”. That link will take you to where you can purchase the entire film, but here are some clips:

Dr. Barach then shared with us a new book, Attachment Disturbances in Adults, by Dr. Daniel P. Brown, whom he heard after listening to the Therapist Uncensored podcast. Dr. Barach stated that Dr. Brown’s theory is about how CPTSD comes from disorganized attachment that is then followed by abuse. We have followed up by contacting Dr. Brown for an interview.

Many thanks to Dr. Barach for visiting with us again!

BIO:

Dr. Peter Barach attended Johns Hopkins University and the University of Michigan. He received a Ph.D. in Clinical Psychology from Case Western Reserve University. He is 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. 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 also trained in EMDR and clinical hypnosis.

 Dr. Barach is the author of scientific and clinical articles on dissociation and Dissociative Identity Disorder (DID). He is a 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, Dr. Barach 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.

In addition to maintaining a private practice, Dr. Barach currently works for the Cleveland VA Medical Center, where he evaluates veterans who have applied for disability compensation. He is not appearing on this podcast as a VA employee. The opinions he expresses are his own and do not necessarily represent the Department of Veterans Affairs or its policies.

 You can see the website for the International Society for the Study of Trauma and Dissociation HERE.

 You can see the ISSTD Guidelines for Treating Dissociative Identity Disorder in Adults (Third Revision, 2011) HERE.

You can read his article Multiple Personality as an Attachment Disorder (Barach, 1991) HERE

His website for Horizons Counseling Services, Inc. is HERE

PPWC 2019 Session List
PPWC SESSION: The Polyvagal Theory

In 1884, considering how the emotional processes work, William James put forward the argument that emotional experiences arise from direct perceptions of bodily change. This meant that we do not feel our emotions because we choose them, but because of some neurological process that causes them. This idea that emotional experience does not start with a conscious experience but our experience of bodily changes was shared by Carl Lange (1885). Both James and Lange believed that bodily and behavioral responses precede the conscious experience of emotion, resulting in what it today known as the James–Lange theory of emotion.

In 1927, Walter B. Cannon critiqued the James–Lange theory arguing that visceral changes do not always result in the presence of an emotion. This meant that the first theory could not be entirely true, otherwise we would experience a new emotion anytime our heart rate changed or breathing slowed or sped up, for example. He suggested that the range of visceral changes in the body resulted in too little differentiation to explain the range and variety of emotions experienced by most people under normal circumstances.

In 1983, Cannon’s  claims were questioned with evidence suggesting that emotional responses may at least in part be distinguished on the basis of patterns of autonomic activity (Ekman, Levenson, & Friesen), that separation of the body from the brain can in fact reduce the intensity of emotional experience (e.g., following spinal injury, Montoya & Schandry, 1994), and that artificial stimulation of the viscera (e.g., via intravenous injection of peptides) can induce emotions (Harro & Vasar, 1991).

Then, in 1994, neuroscientist Stephen Porges proposed the Polyvagal Theory. Polyvagal Theory offers an explanation regarding how the vagus nerve, which connects the brain, to the heart, to the viscera (the organs of the belly), relates to our human ability to connect and communicate with each other.  Learning about the vagus nerve helps us understand our physiologic responses to perceived safety and danger.   The latin root of “vagus,” means “wander,” and is used for this nerve because of how it runs throughout the body. 

Picture from Wikipedia, of Stephen Porges in white shirt and tie. He has dark hair, a light beard, and is looking to the left smiling.

Picture from Wikipedia, of Stephen Porges in white shirt and tie. He has dark hair, a light beard, and is looking to the left smiling.

In 2011, he released his book The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation (Norton). This was a year after the National Institute of Mental Health changed their funding to neuroscience only, and researchers latched on to his two decade old breakthrough theory as a foundation for further research and application to treatment model development.

Blue cover of Porges’s book reads “The Polyvagal Theory” at the top right, with brain structure picture in the middle and with subtitle written below. Author’s name is at the bottom center.

Blue cover of Porges’s book reads “The Polyvagal Theory” at the top right, with brain structure picture in the middle and with subtitle written below. Author’s name is at the bottom center.

His work has been a breakthrough in the field of trauma study, giving neurological evidence for the trauma response experience. It’s been huge for clinicians and huge for survivors alike. Though the research is still filtering down into common clinical practice, it has profound implications for understanding and treating trauma - including attachment and dissociative disorders.

In 2018, Deb Dana released her book, The Polyvagal Theory in Therapy, which brought the application of the polyvagal theory to psychological treatment to the forefront. Now the latest research and most popular explanation of trauma responses, it has also provided a way to reconnect trauma treatment back to funding sources. These applications also correlate with shame theory, in regards to connection with others being one critical - even necessary - aspect of healing.

Orange and white book cover, with “Polyvagal Theory in” in orange letters, and “Therapy” in blue letters, with author’s name beneath.

Orange and white book cover, with “Polyvagal Theory in” in orange letters, and “Therapy” in blue letters, with author’s name beneath.

WHAT IS THE POLYVAGAL THEORY?

It’s a theory that explains the connection between the vagus nerve and trauma response, emotional regulation, attachment, and self-expression.

The vagus nerve is the tenth cranial nerve, the longest and most complex of 12 pairs of nerves that go from the brain (CLICK HERE for an illustration). It runs from the brain to every major organ in the body, branching off along the way into “accessory” nerves. So when there are many vagus nerves, they call it “poly” vagal nerve as a whole unit because there is more than nerve that branches off the main nerve as it runs to the organs of the body.

It’s a “theory” because they don’t know for sure that what Porges proposes is true.

Specifically, the theory proposes that there is a connection between this nerve (and all its branches) is the source of visceral experiences and the main body organs: the lungs, heart, and gut - even just in response to the facial expressions or voice tones of others - and is expressed in your own facial expressions and tone of voice, as well.

In The Body Keeps Score, Bessel van der Kolk explained:

The Polyvagal Theory provided us with a more sophisticated understanding of the biology of safety and danger, one based on the subtle interplay between the visceral experiences of our own bodies and the voices and faces of the people around us. It explained why a kind face or a soothing tone of voice can dramatically alter the way we feel. It clarified why knowing that we are seen and heard by the important people in our lives can make us feel calm and safe, and why being ignored or dismissed can precipitate rage reactions or mental collapse. It helped us understand why focused attunement with another person can shift us out of disorganized and fearful states. In short, Porges’s theory made us look beyond the effects of fight or flight and put social relationships front and center in our understanding of trauma. It also suggested new approaches to healing that focus on strengthening the body’s system for regulating arousal.

Thus, the polyvagal theory attempts to combine physiology, behavior, and psychosocial processes in a unified framework (Berntson et al., 2007). According to Porges, evolutionary developments over time have linked together neuroanatomical and neurophysiological connections between the vagal regulation of the heart and the neural regulation of the striated muscles of the face and head (Porges, 1995, 2003a, 2007b). This, Porges proposes, means that the vagal influence on the heart is also related to behaviors that are involved in social engagement (Porges, 2003a). It is important to note that Porges also argues that social engagement is not a learned behavior, but an emergent behavior of neurophysiology - an idea contrary to many of the already established prevailing theories today.

However, he explains his case using fetal development. The vagal nerve originates in the brain stem, and during fetal development projects to and from the striated muscles of the face and head (Patestas & Gartner, 2006). These fibers function to regulate the facial muscles (for facial expressivity), muscles of mastication (for ingestion), neck muscles (for looking behavior), laryngeal and pharyngeal muscles (for vocalization and intonation), as well as the middle ear muscles (for listening to human voice). Porges notes that all of these muscles are also observed to be used in socialization behaviors such as maintaining eye contact, listening to speech, and making appropriate facial expressions (1995). He then makes the polyvagal theory conclusion: that social engagement is contingent upon the self-soothing physiological states - which, he says, are ultimately determined by the vagus nerve (Porges, 2003b, 2009a; Porges & Lewis, 2010). He implies, then, that when it feels like you can’t control your emotions, it’s because you really actually can’t - not without stimulating, or activating, the vagal nerves in some way.

Because it is still just a theory, we must be careful not get swept up in the excitement of its popularity. Taking a critical look, the polyvagal theory has many tenets that have not actually be empirically verified yet. It also has challenges that must be addressed. Some of these are:

  1. the term polyvagal is a misnomer, as polyvagal theory divides the vagal system  into  two  efferent  systems  not  many;  Ritz  (2009)  has  suggested that “bivagal theory” would be a more accurate description;

  2. the term nucleus ambiguous perfectly represents the perplexity of the brainstem, as the name reflects the ill-defined borders of this region (Loewy & Spyer, 1990);

  3. current techniques are unable to ascertain where the vagal outflow originates (Berntson et al., 2007; Grossman & Taylor, 2007), and this has  made it impossible to verify Porges’ claims regarding potential functional differences between the vagal efferent systems, at both psychophysiological and behavioral levels (Berntson et al., 2007; Ritz, 2009), which leaves his entire theory hanging without actual evidence;

  4. much of the research used to substantiate polyvagal theory has been carried out with juvenile rather than adult populations (for example, vagal regulation has been associated with self-soothing in neonates (Huffman et al., 1998), facial expressivity in infants (Stifter, Fox, & Porges, 1989), and emotion regulation in infants and pre-school aged children (Hastings et al., 2008; Porges, Doussard-Roosevelt, Portales, & Greenspan, 1996; Stifter & Jain, 1996)), while the research on adults has been much more subjective (Lower resting (tonic) high-frequency HRV has been linked to decreased regulation of negative affect and maladaptive coping (Fabes & Eisenberg, 1997; Pu et al., 2010), as well as poorer romantic attachment and marital quality (Diamond & Hicks, 2005; Smith et al., 2010). Further to this, smaller changes in high-frequency HRV in response to laboratory stressors have been associated with emotion regulation difficulties (Austin, Riniolo, & Porges, 2007; Hughes & Stoney, 2000; Sahar, Shalev, & Porges, 2001), and inferior social functioning (Egizio et al., 2008));

  5. there is also research that actually refutes the polyvagal theory (for example Gyurak and Ayduk (2008) did not find a direct relationship between resting HRV and emotion control, and Demaree and colleagues have reported that cardiac vagal control does not predict emotional expressivity in response to film clips (Demaree, Robinson, et al., 2004; Demaree, Pu, et al., 2006), although this could be explained by methodology and by how the vagal nerve itself actually works - supporting evidence in healthy adult populations tends to emerge during highly emotional situations (e.g., increased levels of daily stress, Fabes & Eisenberg, 1997), and not situations that do not warrant substantial emotional responses (e.g., passively viewing film clips, Demaree, Pu, et al., 2006), and so it may only be under conditions of actual danger or threat that relationships between ANS function and socio-emotional behaviors clearly emerge in healthy adults;

  6. the polyvagal framework neglects the occurrence of situations where mobilization occurs without fear, such as during play and exercise (Porges now (2009b) attributes this to defensive fight–flight arousal coupled with dynamic VVC activation to insure safe interactions; and

  7. researchers are unable to distinguish the vagal efferents originating from the NA and the DVNX (Berntson et al., 2007; Grossman & Taylor,  2007). This means it is currently impossible to verify Porges’ claims regarding the different qualitative functions of the vagal efferent systems.

It’s application to therapy appears to be useful, however, regardless of whether this is because of the neuroscience behind eye contact and facial expressions or because of the very separate and distinct shame theories regarding the processes of connection and attachment. It may turn out that these do, indeed overlap and explain each other, or it may be coincidence and shame theory is just on target in regards to developmental trauma and chronic shame.

HOW DOES IT WORK?

Both research and personal experience have long shown that our behaviors are guided by our emotions (Davidson & Irwin, 1999). Experiencing emotions biologically means changes in subjective experience, appraisal, expression, physiological arousal, and goal-directed behavior. Still, emotions are not a tangible thing we can touch outside ourselves or even always immediately or easily recognize within ourselves. Experiencing emotions involves several processes: the perception of an emotional stimulus, the production of an affective state and emotional behavior, and the regulation of that affective state and emotional behavior (Phillips, Drevets, Rauch, & Lane, 2003). When emotional stimuli are perceived, messages are sent from the central nervous system (CNS) to the rest of the body, either by nerve cells or chemical hormones. These initiate changes in autonomic, neuroendocrine, and somatic systems. Thus, the experience of an emotion is exclusively internal unless it is expressed outwardly through behaviors. Because of this, the only way to “measure” emotional responses in another person is through facial, vocal, and postural cues. (Hugdahl, 1996; Gross & John, 1995). Recognizing, comprehending, interpreting, and responding to these cues in others are all a vital part of social interactions (Darwin, 1872/2009). We will come back to this piece later, when we talk more about the impact of chronic trauma and related shame.

Any nervous system tissue outside of the brain and spinal cord is referred to as the peripheral nervous system. This second system carries motor and sensory information from the brain to the body and then relays information back to the CNS. Although the peripheral nervous system and CNS are theorized as being anatomically separate, they are functionally interconnected (Jessell, 1995). The peripheral nervous system has been further divided into the somatic system, which controls muscular activities, and the autonomic nervous system (ANS), which controls the body’s internal environment: breathing, heartrate, digestion.  (Sequeira, Hot, Silvert, & Delplanque, 2009).

We don’t have to think about these.  They just happen.  It’s unconscious, and not a choice. 

It’s also important to remember that the term “autonomic” is actually misleading. The CNS can actually inhibit or bypass lower reflex mechanisms of the ANS via activity in areas such as the hypothalamus, amygdala, and prefrontal cortex (Jessell, 1995). This piece will come up again later when we talk about trauma response in the brain.

What makes the polyvagal theory unique is that Porges proposes that emotional dysregulation and psychopathology result with abnormalities in how the ANS functions, rather than something being wrong with its structure. To over-simplify, when Porges talks about the “myelinated” vagal nerve, he is referring to the ANS. There are two branches of the ANS: the sympathetic (SNS) and the parasympathetic (PNS).  When he talks about the “unmyelinated” vagal nerve, he is referring to the PNS. He uses this terminology because his theory is based on the writings of John Hughlings Jackson back in 1884, which is based on evolutionary theory. Regardless, the vagal nerve communicates with and connects to all the major organs.

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Sympathetic responses include fight and flight in response to danger, and parasympathetic responses include calming back down again when you are safe.

This is why things like taking slow, deep breaths helps so much: not only does it literally slow down your breathing and heart rate, but it also tells your body to slow it down, too. It shifts that panic cycle to the positive, giving a feedback loop for feelings of safety and calm in the same way anxiety escalated into panic. Further, slow deep breaths activate different parts of your ANS, bringing an actual neurobiological balance back to your body as you breathe in and out.

Every ANS response is in service of survival. It is completely natural, expected to happen, and should be happening.   It’s supposed to happen.  It’s what helps you get out of danger and keeps you safe and then gets you well again as you recover after danger.

We often think of the flight-or-fight as part of the response to trauma, and as survivors who dissociate, we are also familiar with “freeze”. But in 2004, Bracha added the terms “fright” and “faint” to the acute stress response spectrum, making a distinction between tonic immobility (fright) and flaccid immobility (faint).   This was important because prior to this distinction, Porges (1995, 2004a, 2007b) and Gray (1987; Gray & McNaughton, 2000) both used the term freeze response, but there  is  confusion  as  to  what  point  in  the  defense  repertoire  “freezing”  should  refer  to (in  Porges’  work,  freezing  refers  to  refers  to  the  DVC  being  up-regulated and resulting in vasovagal syncope, whilst Gray encapsulated freezing as being analogous to the orienting response (which occurs higher up the hierarchy).

Bracha made a clear distinction between these responses by proposing a freeze–flight–fight–fright–faint hierarchy. The three initial responses in the hierarchy reflect normal responses to acute stress.  The  initial  orienting  response  involves  “stop,  look, and  listen”  behaviors  and   Bracha termed this as the freeze response (in the polyvagal hierarchy orienting occurs when the vagal brake is removed, prior to activation of the SNS). This is followed by flight and fight responses (commonly attributed to SNS activation). The next response according to Bracha is fright, also known as tonic immobility, which is less common as a response to acute stress, and will be discussed below.

This response evolved as an alternative to flight–fight tendencies (Alboni et al., 2008). During fright the body is immobile, but should the chance to escape arise the body will be able to rapidly initiate a mobilization response. This form of immobility can be distinguished from the last stage of the hierarchy which involves flaccid immobility. This last stage Bracha termed faint, and it corresponds to Porges’  description  of  the  body  when  the  DVC  is  up-regulated, resulting in vasovagal syncope (i.e., a temporary loss of consciousness). This final stage in the response hierarchy is the least common form of reaction to acute stress and is usually only initiated in times of severe life threat, with the exception of some clinical disorders.

Later, Schauer and Elbert (2010) added “flag” and “faint” to the response process. Flag is associated with slow heart rate, low blood pressure, corresponding cognitive failure, and emotional numbing. As the flag state progresses further emotional involvement is thought to decrease, which is consistent with a dissociative shut-down response (Schauer & Elbert, 2010). The final stage of the hierarchy, faint, occurs when the PNS (DVC) is up-regulated without SNS activation, which can result in vasovagal syncope. Bracha terms this as flaccid immobility because the body is now shut down and no longer prepared to protect from or mobilize away from danger (2004).

In her 2012 doctoral thesis, Megan Christine Barnsley combines these into the following model:

Figure 2.4. Diagram of Porges’ (1995, 2004a, 2007b) polyvagal hierarchy integrated with Gray and McNaughton’s (2000) revised reinforcement sensitivity theory, and Schauer and Elbert’s (2010) defence cascade. VVC = ventral vagal complex. SNS = sympathetic nervous system. BIS = behavioural inhibition system. BAS = behavioural activation system. FFFS = fight–flight–freeze system. DVC = dorsal vagal complex.

Figure 2.4. Diagram of Porges’ (1995, 2004a, 2007b) polyvagal hierarchy integrated with Gray and McNaughton’s (2000) revised reinforcement sensitivity theory, and Schauer and Elbert’s (2010) defence cascade. VVC = ventral vagal complex. SNS = sympathetic nervous system. BIS = behavioural inhibition system. BAS = behavioural activation system. FFFS = fight–flight–freeze system. DVC = dorsal vagal complex.

In this way, human beings, like all other mammals, are able to automatically adjust to various levels of safety or danger, whether that is internally or externally or even just perceiving threats or dangers. But this is more than just an automatic response: the vagal nerve also acts as a helper in overriding even the automatic response for emergencies when your body needs to respond even more quickly because of danger. So for example, if the vagal nerve withdraws from the heart, that can stimulate the heart rate to increase much more quickly than a message from the SNS can tell the heart rate to increase (Berntson, Cacioppo, & Quigley, 1993a) - that way by the time your muscles get the message to run, your heart is already beating fast and ready to go.

Simplified, your body uses the nervous system to initiate the fight-or-flight response, but the vagal nerve can beat it to the punch, so that all your organs are ready to go at the starting line by the time the race begins.

The vagal nerve can also do the opposite of flight-or-fight, which is known as rest-and-digest, to alert the body when the race is over and you are safe, so it’s okay to calm down. This is sometimes referred to as the “vagal brake” in reference to the myelinated vagal nerve, because it “stops” the flight-or-fight response. In our previous example with the heart, activation of the vagal nerve back to the heart again is what tells it to slow down.

Literally and metaphorically, it is the touching of the heart that brings healing and peace.

Some research seems to support Porges and his theory regarding the vagal brake. Examples confirmed are the process of self-soothing in infants (Huffman et al., 1998), and higher self-regulation in adults (Fabes & Eisenberg, 1997). However, research has not yet confirmed any link between the vagal brake and actual emotional expressivity (Demaree, Pu, Robinson, Schmeichel, & Everhart, 2006; Demaree, Robinson, Everhart, & Schmeichel, 2004; Pu, Schmeichel, & Demaree, 2010). Further, it cannot be assumed that greater vagal activity relates to greater health, because there are clear examples where too much really is too much: infant death syndrome, stress-induced asthma, stress-induced gastric ulcerations, and vasovagal syncope (see Ritz, 2009). The question remains, then, regarding the actual influence of the vagal nerve.

The changes in heart rate variability, or HRV, are one way to measure this influence. When a person has developmental trauma, chronic shame and/or chronic stress, or other experiences that induce repeated patterns of the flight-or-fight response, the power in the low-frequency domain of HRV tends to increase whilst the high-frequency power decreases (Berntson & Cacioppo, 2004). This effect is noted to be associated with anxiety, depression, chronic illness, and autoimmune disorders (Berntson & Cacioppo, 2004; Thayer & Friedman, 1997). However, it’s also true that the same effect happens when either the SNS or the PNS are out of balance, one being used more than the other. This complicates understanding the true impact of the vagal nerve itself, but also explains why safe touch and sensorimotor therapies such as EMDR, equine therapy, progressive muscle relaxation, grounding skills, etc. work so effectively with survivors. We will discuss this further in a bit, but it implies that what needs to be integrated is not actually so much the personality as the mind-body experience itself.

So researchers focus on exactly that: what integrates these systems to work together, in balance, to keep the entire system online.

Thayer and Lane (2000, 2009) proposed a general model of neurovisceral integration for the brain, visceromotor, neuroendocrine, and behavioral responses to explain how the body rapidly responds to environmental stimulation. This model focuses on the function of the entire autonomic network as being implicated in goal-directed behavior and adaptability (Benarroch, 1993; Thayer & Brosschot, 2005). This emphasizes the brain’s link to emotional responding (Benarroch, 1993), and gives the prefrontal cortex the stage in a top-down effect in integrating the mind-body experience.

This is what you experience in traditional talk therapy. You are able to share your experience, think about it, reflect on it, and make meaning from those experiences. It works because engaging the cortex activates the vagal nerve to the heart, sending safety signals back to your brain ((Wong, Massé, Kimmerly, Menon, & Shoemaker, 2007; Milad, Quirk, et al., 2007; Milad, Wright, et al., 2007).

However, it’s also what can make talk therapy difficult. When you have a new therapist that you are still unfamiliar with, or while still establishing safety, or when confronting difficult material, or if you have a therapist who is not attentive or maintaining attachment-connection or who is otherwise unresponsive in some way, it disrupts the process. Literally. Much like the attunement/misattunement research from shame theory, which we will discuss in a moment, there is a same kind of disconnect that actually happens in the brain during attachment rupture or when the frontal cortex gets kicked offline.

A withdrawal of parasympathetic activation and an increase in sympathetic activation, which is consistent with defensive responding, is what causes dysregulation. Dysregulation of these cortical pathways may result in prolonged increases in sympathetic activation, which in the long term could result in potential autonomic imbalance. Prolonged action readiness and SNS over-activity have been linked to deficits in self-regulation and psychopathology (Thayer & Brosschot, 2005). For specific and extensive literature review application to each specific diagnoses, please CLICK HERE for Megan Christina Bensley’s doctoral thesis on the social consequences of physiologic states.

Aside from specific application to DSM-5 diagnoses, Porges explains how these neurophysiological adjustments in our bodies have consequences for daily living. These physiologic states, or “modes”, can be categorized primarily into three groups of purpose or functioning:

Safe and Social (engagement) – located in our face and our heart;

Flight and Fight (mobilization) – located in our lungs and limbs; and

Shutdown (immobilization) – located in our stomach.

We don’t choose to do these.  It’s a sequence.  It happens in a certain order.

We start out in the safe zone, and then when exposed to trauma or a threat of any kind (even perceived), we drop down the “ladder” into flight to try and get away. When we cannot get away, we drop down to fight. When fighting doesn’t keep us safe, we drop down to shutdown. This is the sequence in response to any kind of danger perceived by the body as a threat.

Behaviorally, we see this expressed in many ways. When we are safe, and our body feels safe, then our affects are bright and there is a great deal of range in our tone of voices and in our facial expressions. As we drop down the ladder, the changes in the vagal nerve literally flatten our affect by withdrawing signals to the facial muscles, our voices become more monotone, and our facial expressions are more limited. In the same way, as we move back up the ladder, our affects brighten and our voices and facial expressions have more range in presentation.

Further, they are responses to our external world, our internal world, and the way we perceive the world around us, but they also are the filters through which we see our world - which makes them reinforcing and happen in patterns for some people. This is especially true when we get stuck in one of these “modes”, and begin to filter all experiences through them.

For example, someone stuck in “fight” mode will perceive the world as a more dangerous place than it may be, and/or may find themselves in actual dangerous situations (or reenacting traumas) because they are focused on and looking for those situations that verify their internal experience of the world.

Or, someone in “flight” mode may have difficulty making eye contact, establishing relationships, or connecting with others even in superficial ways.

Trauma survivors experience these modes through triggers. They may feel safe and connected with their partner, or with their therapist, or in their own home, but if they have a sensory trigger like a smell or a sound or something that looks like something from the past, it may trigger a literal change in mode. The survivor then shifts from “safe and social” to “flight and fight”, with increased heart rate and panicked breathing, and maybe even literal running away or fighting against something familiar, or even to complete shutdown and being nonresponsive in a “freeze” or dissociated response.

The insight comes in understanding that switching or a “meltdown” or “spacing out” or some other trauma response may really not be coming from nowhere, but an actual physiological response to a particular trigger.

This perception at a neurological level was described by Porges when he coined the new term “neuroception”. Neuroception refers to how neural circuits in the brain and body distinguish whether situations or people or environments or experiences are safe or whether they are dangerous - such as why we may appreciate a hug from a friend, but not from a stranger. So basically, when this neuroception is faulty, there is an incongruence between whether you feel that you are safe and whether you actually are safe. This faulty neuroception, then, explains the neurobiological process of everything from autism to schizophrenia to anxiety disorders to reactive attachment disorder to dissociative disorders.

Neuroception is our body’s ability to detect risk outside of our body, bring that information in, and accurately and appropriately respond to that risk.

Each “mode” has its own neuroception “key” that unlocks specific behaviors. The safety and socialization mode has the neuroception key that encourages eye contact, prosocial behaviors, smiling, conversation, full range of voice, closer proximity of bodies, and safe touch. The neuroception of danger unlocks fight and flight behaviors such as being mobilized for running away or getting aggressive. But when something is life-threatening, that neuroception unlocks the behaviors of immobilization, or “freeze”, like dissociation.

And, when you are in one mode, you lose access to the behaviors in the other mode. Neuroception unlocks some behaviors in response to what is happening or perceived to be happening. But it also inhibits alternate behaviors that you could choose if you were in a different mode.

That is why, when you are dissociating, it is hard to maintain eye contact. It is hard to follow conversation. It is hard to perceive others around you as safe. It is hard to remember now time.

This is part of why, they think, that trauma survivors are so often abused or violated in different ways again and again as they become adults and even into adulthood. Once they are already dissociated, they lose access to the behaviors that would get them away from danger now that they are an adult - even if they could not get away while they were a child.

It’s also why those younger parts or child alters can be so difficult to orient to the present place and time.

This is why, in your therapist office, during your appointment, you may feel connected and strong and present and confident, and then later while on your own feel such a rush of panic or fear or do the opposite of what you had agreed on during safety planning.

This is why it takes domestic violence survivors so many times to actually leave such abusive situations.

When in the mode where your life is being threatened, or you feel (perceive) that your life is being threatened (even if only a trigger of memory time intruding into now time), you literally do not have access to the behaviors that you are able to do just fine when feeling safe and secure.

That’s unhealthy neuroception, when there is incongruence in any of those areas. Someone may be in danger but not recognize it. Someone may be safe, but think they are in danger.

Healthy neuroception is when there is congruence between what is happening and how your body is responding. It means that you are able to accurately to detect whether you are safe or in danger (in the present moment), correctly shift into the appropriate mode for that level of safety or danger, and then respond in a way that matches that mode and that level of safety or danger.

Healthy neuroception looks like connecting with someone safe when you are falling in love. It looks like mutual friendship and connection. It looks like recognizing the right therapist when you finally find them.

It also looks like recognizing red flags and acting accordingly, instead of dismissing what your intuition is telling you to do about it. It looks like setting boundaries when someone is being too intrusive, or when your workload is too much, or in ways that protect your Self, your time, and your energy. It looks like appropriate self-disclosure, by not sharing too much to everyone but also making an effort to connect with your sacred few.

THE CONNECTION BETWEEN TRAUMA AND POLYVAGAL THEORY

When someone experiences trauma, they shift into either immobilization or mobilization, unlocking behaviors of flight, fight, or freeze. We know this. But what we are learning from polyvagal theory, is that these behaviors are neurobiological responses.

When someone grows up with chronic trauma, or ongoing trauma, or gets stuck in one of those modes like dissociation, then that in and of itself becomes traumatic. Now, not only is there incongruence between what is actually happening and what it feels like is happening, but it also feels like you have no choice in how to respond or may even be unable to respond even if you wanted to try.

Here is Stephen Porges explaining it himself, in this video from The National Institute for the Clinical Application of Behavioral Medicine:

So like in his example of having a panic attack even though he wanted to get his MRI, and even though he was really actually interested in the results because of research he studies, he was unable to do it.

Once we are mobilized, or immobilized, it is difficult to shift back into safe mode.

This is why nightmares are so disturbing well into the next day. This is why flashbacks interfere with our functioning. This is why it is so hard to remember that now time is safe, and that memory time really is in the past.

Further, specifically in regards to dissociation, “shutdown” mode (immobilization, or dissociation) is different for human beings than it is with wild animals.

There are two words used to describe immobilization behavior in wild animals: tonic immobility and thanatosis.

Thanatosis is when an animal perceives a predator and “plays dead” - in Texas, we see this with armadillos on the side of the road. It is sometimes called “playing possum” in English. It can resemble a state of shock, but from which the animal can spontaneously recover with no apparent trauma symptoms.

Tonic immobility is a little different, and often called “animal hypnosis”. We see this survival technique everywhere from a kitten being carried by its mother’s mouth to a tiger frozen behind prairie grass ready to pounce its prey. This state of tonic immobility may last from minutes to hours, and again, the animal recovers spontaneously with no apparent trauma symptoms.

If you want to see a more extreme example of this, search “tonic immobility shark” on YouTube, and watch videos of divers seemingly putting sharks to sleep while they are diving. The shark is not actually sleeping, but demonstrating tonic immobility: it is neither fighting for its life or trying to get away. The shark, and the example of the kitten in its mother’s mouth, recover completely and quickly without any adverse affects because they never entered an actual fear response. They are able to jump from immobilization right back into safety mode.

Humans, however, have an added layer of consciousness and awareness, so that when danger happens or they perceive danger happening, they also experience fear. This is a fear-induced tonic immobility, which leaves the body in that state much longer and comes out of that state very slowly. Further, humans cannot move as far as quickly, not enough to flush out all of those chemicals from the parasympathetic response to trauma.

So then, when the trauma itself involves some sort of being pinned down or any kind of confinement, there is even a great degree of immobilization that becomes quite literal externally and not just internally.

Awareness of this is further complicated by other abuse dynamics, including neglect, shame, not being rescued, having no one to tell, and having no one externally intervene.

These are the roots of dissociation from a neurological standpoint: that when in a fear-induced state of tonic immobility, you are also aware of the parasympathetic response to fight or run away even though you cannot physically do so, and those neural circuit signals get sent to your brain because all that information - the sensory input experience, the physical input experience, the memory itself, the parasympathetic response - all of it has to go somewhere.

This is where Bessel van der Kolk writes in The Body Keeps Score, that:

Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think… [There are] automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time…

When we live in a constant state of hypervigilance, it is because of the amygdala, a part of the limbic system in the brain. The amygdala is “a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat” (ibid, p. 33). It warns us of danger and activates the stress response, including the vagal nerves.

When this is activated, another part of our brain, Broca’s area in the frontal lobe, is shut off. That part of our brain is what helps us put our thoughts and feelings into words. This is why it is so difficult to tell our stories, and why it was so difficult to ask for help even if you ever got the chance, and why it is so difficult to jump into talk therapy even once you do find a therapist you feel safe with and trust.

This also disrupts sequencing, which makes it difficult not only to put pieces of the story together, but is part of why memory time and now time can be so confusing. It’s also why we think we are intelligent people, but then in trauma response moments behave in ways that are impulsive instead of logical. It’s why the past feels present, how Littles get frozen in time, and where time goes when we lose it.

The polyvagal theory explains why so many years later, we still organize our lives “as if the trauma were still going on - unchanged and immutable - as every new encounter or event is contaminated by the past” (ibid, p. 53).

Our brains literally do not know that we are safe now, and because of the polyvagal nerves, we don’t, either.

So when we have external information that tells us we are in danger, or internal information (such as a trigger that takes us to memory time instead of staying in now time), all of that sensory information comes into our body through the limbic system, and another part of our brain - the thalamus - is what makes sense of it and sends it on to the amygdala for quick responses and to the frontal cortex for slower responses.

What we learned from the polyvagal theory is how the thalamus can kind of mix up where that information needs to go. The amygdala can process danger signals from the thalamus before we are consciously aware of what’s happening in the frontal cortex, and when this happens memory processing gets split up into separate pieces instead of metabolized as a whole experience. This is when it feels like time freezes, when sensory memories get stored separately from the emotional or physical memory, and the experience of the memory may get stored somewhere else. This is dissociation.

Now we have our experiences separated into “parts”. Some might hold memories, but without the context, or maybe it doesn’t feel like ours. Sometimes we might feel an emotional response, but not have the memory it’s connected to, and the same thing happens with body memories. Or maybe it is something you should remember, but don’t at all remember it. Regardless, the brain is doing this before you are even conscious of it, before the frontal cortex is ever engaged to make choices about how to process what you are experiencing or how to understand what you are remembering.

It means dissociating is something your brain did on its own, not something you did wrong.

It means dissociating is something that’s an automatic process under the right conditions, not because you failed or didn’t try hard enough or weren’t strong enough.

It means dissociating is something your brain did when it was trying to protect itself and your body, which is how it is designed, and not at all “crazy”.

It’s not about logic. It’s not about reason. It’s not something you can think about and decide to do differently. It’s literally the wiring of the brain in response to what is happening to the body in an actual attempt to survive.

This is also why what van der Kolk said (p. 66) is so true: “Flashbacks and reliving are in some ways worse than the trauma itself. A traumatic event has a beginning and an end - at some point it is over. But… a flashback can occur at any time… There is no way of knowing when it’s going to occur again or how long it will last.”

The amygdala is not able to discern between past and present, and so when the polyvagal nerves are sending danger signals to the organs of the body, and the brain gets the message that something life-threatening may be happening, there’s no stopping to ask the frontal cortex to sort it out first.

When the processing by the thalamus is interrupted by the danger signals from the vagal nerves, there is no story of the experience “with a beginning, middle, and end, but isolated sensory imprints: images, sounds, and physical sensations accompanied by intense emotions, usually terror and helplessness” (ibid, p. 70).

When Broca’s area is shut down so that there are no words to describe that terror and helplessness, and no means to connect those sensory imprints, that terror and helplessness becomes very real, with no sense of time to wait it out, sort it out, or crawl out of it back into the present.

But this is also why understanding Polyvagal Theory is so important: because while it explains what goes so terribly wrong internally, and it describes the horrific experience survivors endure, it also gives us hope.

Falling “down the ladder” is a metaphor created by Dana in her book that applied the polyvagal theory to the therapeutic process. What she meant was that we “fall” down from safe mode into danger mode (mobilization, or flight and fight), and then even further into life-threatening mode (immobilization, or dissociation itself). But that also means we can go back UP the ladder, too.

Using the sensory input and connection to engage the vagal nerves, we can use our own bodies as a resource to help us move from immobilization back into safe mode.

That’s powerful.

There are some formal ways of doing this that many are already familiar with: yoga, sensorimotor, deep breathing, progressive muscle relaxation, EMDR, pet therapy, equine therapy, grounding skills, diffusing oils, and other techniques that utilize sensory input to engage the vagal nerves.

And, as it turns out, these all have some things in common: deep breathing, connection with an Other, and some version of physical touch or processing.

And they work, because the vagal nerves don’t just warn us of danger.

They confirm safety, too.

This is why it’s so jolting to look your therapist in the eyes, until you are already regulating more in safe mode on your own. This is why safe touch when appropriate is so powerful and grounding. This is why you don’t just read a note from your therapist or a friend or a partner, but you hold it and touch it. This is why you rub your face or your hands together when you are trying to stay present. This is why petting a puppy or touching a horse is so difficult and first, and feels so far away, and then so intense when you do.

Connecting these aspects to the neurological processes understood by polyvagal opened the door to shame theory, which explains the patterns of negativity and dismissal of anything good in connection to ourselves.

Guilt is feeling bad for something you DID.

Shame is feeling bad for who you ARE.

This goes all the way back to infancy and early years growing up, whether our needs were met or not, and whether or not our caregivers acknowledged our emotional responses by mirroring them, and whether or not they engaged with us in all of those connecting ways: eye contact, facial expressions, and safe touch.

That’s “attunement”, and the vagal nerves were built for it. That’s what confirms safety.

You can see the old video about this “attunement” and what happens when it isn’t given, if you look up the “Still Face Experiment” on YouTube.

A mother and baby are playing.

The mother has good eye contact, mimics the faces the baby is making, and they are touching with their hands.... that's all "attunement".

But then, as part of the experiment, the mother looks away and puts her hands down. Then she turns back to the baby with a flat affect and doesn't make any expressions at all.

The baby does three things: First, the baby tries hard to touch and reach and make the same sounds and faces they were just doing that was so happy for them both.

When that doesn't work, the baby gets angry and tries to push the mother away, because what is happening is so unpleasant.

When she won't go away, but still isn't tuned in, the baby can only resolve the misattunement by matching her, which he does by physically turning away and also making a flat face without expression.

It's so sad, and may even be triggering to some. But it shows how this works, and what is so distressing when we do not have that connection.

For the sake of the baby, at the end of the experiment, the mother does "repair" the misattunement by turning back to the baby and reengaging, so you can feel the relief and the baby is okay.

But if you had a caregiver who was flat and turned away your whole life, or neglectful, or dismissive, or otherwise disengaged, and you had to match that, then it makes sense that these pieces are really hard for your brain. It also explains why you “act out” the way you do sometimes, just like that baby, even though you are grown: asking for help, pushing help away, or matching the unavailability of help by pretending you don’t need it.

Because that’s what is under shame: that your infant self still depended on your caregiver for survival, which is what kicked in the vagal nerves. Because you depended on them for survival, you couldn’t think they were “bad” even when they were not meeting your needs. Instead, you thought YOU were bad for needing in the first place.

But thanks to the vagal nerves, we know that healing comes the same way, and that this can be repaired. Eye contact. Emotional connection. Mirroring back your experience. Being present with you in those trauma responses. Reciprocity of caring and response. Safe touch when it’s appropriate. That’s the stuff of healing.

This matters in your choice of therapist. This matters in your choice of spouse. This matters in choosing healthy and safe friendships. This matters in your choice of parenting style that you so desperately want to be different than what your own experience was like.

This matters because not only do we understand our world through neuroception, but there is also a process called introception - which is our own awareness of our own life, body, and potential to control both.

This is the birthplace of presence, the ability to be oriented to time and place. It is a state of existence, rather than avoidance. It is the ability to reassure yourself, and to know how to connect when you need reassurance from others.

This grows into emotional regulation, which then grows into your internal and external experiences being more congruent.

Only then do we know when we are safe, and where we are safe, and with whom we are safe.

Only then are we safe enough to remember.

Because isn’t just the talking that heals us.

It’s the connection with whom we are talking that confirms safety and holds us in the present, even when we start to remember.

And that’s what helps us connect our Selves.

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PPWC KEYNOTE: The Counter-Conference: A Timeline and Call for Renewal

KEYNOTE ADDRESS

THE TIMELINE:

While this is a Plural Positivity World Conference, I have been asked specifically to speak about the history of Dissociative Identity Disorder (DID) as we understand it thus far. The history of DID is in almost every book about it, but none of them are exhaustive.

While we can review these early cases and the first diagnosis with the “multiple personality” label, it is wrong to assume that these were the earliest cases or experiences. The case studies given credit for the identification and categorizing are only the first to formally document and label them according to modern science as we understand it now and with records available. It does not mean that these pioneers in treating dissociation “invented” it, or that these were the first cases of it. It should be assumed that cases of dissociative identity disorder have been around as long as people (and trauma) have existed.

In her 2019 book, Rachel Robertson reports the history of DID goes back at least 4,000 years. Ancient cultures describe many cases of dissociative identity disorder through their stories and art. Many of these are reframed as “demonic possession” or misrepresented through Westernized and Christianized documents. Some cultures still view their healers and shamans as multiple, without it even having any negative connotation, until they were persecuted through genocide by Western religions such as three hundred years of Inquisition. But for the sake of today’s discussion, and to answer the question about why we even need a “counter conference” in an appeal to the ISSTD and its conference currently happening in New York this year (2019), we will focus on more recent history and the Western medicine perspective.

In 1584, Jeanne Fery was the first woman to document her own case of multiple personalities, though these words were not yet used as diagnostic labels. Her documentation preserves the early identification of symptoms that correlate with the modern diagnosis, including multiple alters with their own names and identities, lists of each of their features, and descriptions of their different roles. She described protector personalities, persecutory personalities, and child personalities. These personalities were associated with different sets of behaviors that ranged from self-harm to helping her heal to disordered eating. They all had their own voices, both when she spoke and inside her head. They all had different knowledges, capacities, and skill sets. She herself documented that they resulted from childhood abuse.

Image Description: very old book with worn and tattered brown cover, reading “La Possession of Jeanne Fery” with publication information at the bottom.

Image Description: very old book with worn and tattered brown cover, reading “La Possession of Jeanne Fery” with publication information at the bottom.

Jeanne Fery’s account in a now-ancient text is no different than modern day blog, podcast, or YouTube video series. What feels like validated history to an outsider, seems very familiar to those of us who are survivors. Those of us who share our stories do it to document our progress and make sense of our experiences, not to garner attention from people already too quick to judge or dismiss us.

Ten years after Jeanne Fery, Paracelsus was born in 1541, and grew up to be a Swiss physician, alchemist, and astrologer of the German Renaissance.. He was a pioneer in several aspects of the "medical revolution" of the Renaissance, and lectured at the University of Basel. He spoke and published about a woman who had “amnesia about an alternate personality who stole her money”.

This feels very reminiscent of the modern day case study such as those often shared at clinical or public conferences.

Image Description: drawing of bald man (some curly hair on sides of head) facing right, in high collared old period clothing.

Image Description: drawing of bald man (some curly hair on sides of head) facing right, in high collared old period clothing.

In 1623, the story of Sister Benedetta was published. Sister Benedetta was a woman who was supposedly possessed by three angelic boys who would beat her to cause chronic pain. When they took control of her body, each would speak with a different dialect and tone of voice while using different facial expressions. Benedetta had amnesia for some of their actions, including a sexual relationship that they had initiated. Like Jeanne Fery, Sister Benedetta suffered from self harm and disordered eating. Her parents had also shown signs of dissociation and had been rumored to be possessed, and one of the “angels” was frozen at age 9, the same age at which Sister Benedetta's father had died. Her symptoms had become uncontrollable, and she had been sent to the convent (van der Hart, Lierens, Goodwin, 1996).

“Angels” were the fictives of the 1600’s. Taken from religious texts and cultural experiences and religious beliefs, these characters were apparent alters but in non-human form, much like the “dragons” and “aliens” and “wolves” introjected from modern day cultural exposure.

Image Description: Young Woman in robe and headscarf looking seriously toward the camera (black and white photo),

Image Description: Young Woman in robe and headscarf looking seriously toward the camera (black and white photo),

In 1791, Eberhardt Gmelin published the first known detailed case study of multiple personality, which he called “exchanged personality” in reference to the switching between two or more personalities. The 20-year-old German woman could speak perfect French and speak German with a French accent when she was “the French Woman”, but only knew German when she was “the German Woman”. The French Woman knew everything the German woman did, but the German Woman didn’t know what happened to her while the French Woman was out. Eventually these two could switch intentionally when prompted by him, but only after some time working together - they could not do so early in their discovery.

The judgments for and against this case feel like those that come by harsh clinicians who don’t believe in DID, or from cold clinicians behind microphones that don’t like when DID that looks different than their expertise, or even from within the DID community itself - when survivors cruelly compare stories and judge themselves or each other when in reality they have had different experiences and are in different stages of healing.

Image Description: oil painting of man in period clothing with tight collar. He is facing the viewer, with pursed lips and bright affect. He has straight, unkempt hair. He is wearing white shirt with collar and black jacket. The painting is framed as a photo, with oval brown frame.

Image Description: oil painting of man in period clothing with tight collar. He is facing the viewer, with pursed lips and bright affect. He has straight, unkempt hair. He is wearing white shirt with collar and black jacket. The painting is framed as a photo, with oval brown frame.

Benjamin Rush is known as the “Father of American Psychiatry”, and was the only signer of both the Declaration of Independence and the Constitution. He was the chief surgeon of the continental army, and worked with many children and adults who suffered trauma because of the war. In 1809, he published a four volume set of books about treating mind disorders, called “Medical Inquiries and Observations of the Mind”. In these essays, Dr. Rush included the concept of multiple personalities, which he referred to as a “doubling of consciousness”. He reasoned that the cause of this happening in trauma patients was a “disconnection between the two hemispheres of the brain”.

This was our first sign of hope, that the shame of the impact of DID was not entirely ours to carry, and the first validation we received of the neurobiological impact of trauma.

Image Description: beige cover of old book entitled “Observations” by Benjamin Rush, with “in four volumes, volume 1” printed in the middle, and publication information printed at the bottom.

Image Description: beige cover of old book entitled “Observations” by Benjamin Rush, with “in four volumes, volume 1” printed in the middle, and publication information printed at the bottom.

In 1811, Samuel Mitchel identified both Mary Reynolds and Rachel Baker as multiple personality patients. The most famous was Mary, whom he first wrote about in 1816, with a description of Mary’s symptoms as “preaching in her sleep, as well as writing poetry and music.” While none of those activities are in and of themselves signs of mental illness, these were unusual behaviors for her and activities she was otherwise unable to do.

Dr. Mitchel expanded on this account in 1860, in an article entitled “The Strange Case of Mary Reynolds” in “Harper’s New Monthly Magazine“. In this account, he reported that Mary was born to a devout family in England in 1785. The family later moved to Pennsylvania, and she grew up as a “reserved and quiet and melancholy child”. Then, inexplicably, she became blind and deaf for six weeks at age 19. Three months following this, she “suddenly forgot things she had learned”, even having to re-learn how to read and write. No longer a reserved and melancholy child, Dr. Mitchel described her now as “buoyant, witty, fond of company, and a lover of nature.” Then, just as inexplicably, she reverted back to her quiet and melancholy self, without memory of either of the other two incidents. Dr. Mitchell reported that Mary Reynolds seemed to alternate these three identities, with no memory shared between them, for the next sixteen years. She then maintained her “more excited” state until her death at age 61, but still without recall of what she experienced during the other two states of consciousness.

This was the first case study that described some of the more functional aspects of multiplicity, that many of the separately developed talents and skills are just as valid and not unusual or maladaptive in and of themselves.

Black and white period photo of woman in nightgown and nightcap after her death (common type photo of that era), set in oval frame.

Black and white period photo of woman in nightgown and nightcap after her death (common type photo of that era), set in oval frame.

In 1840, Antoine Despine published a monograph that documented the story of an 11-year-old Swiss girl, Estelle, who initially presented with paralysis and sensitivity to touch. She later displayed another personality who was quite different, could walk, liked to play, and could not tolerate her mother’s presence. Despine documented his treatment course, which he reported cured the child, and many of which are recognized as valid still today.

This was the early description of our body memories, of our differing abilities based on the trauma response in the brain and which parts are active, and the connection between the severity of the impact of Adverse Childhood Experiences and chronic pain illness and autoimmune disorders.

Photo Description: Off white paper with old manuscript handwriting sample mostly unreadable.

Photo Description: Off white paper with old manuscript handwriting sample mostly unreadable.

Eugene Azam, a professor of neurology with a large interest in hypnosis, published the most detailed account of multiple personality in the 1800’s. The woman, Felida X, had three different personalities and he detailed what they acted like, who they were, and what caused them to appear.

Felida X was born in 1843, lost her father in infancy and had a difficult childhood. She exhibited three different personalities, each considering itself to be Felida's normal state and the others to be abnormal. The second personality state first manifested when Felida was 13 years old and suffered none of the physical illnesses that the first personality suffered. Initially, switching was reported to happen almost every day after a pain in the temple and a profound sleep for two to three minutes but the frequency of switching decreased over time to the point that it would happen only every 25 to 30 days and last only a few hours at a time. The third personality, which appeared only on occasion, suffered from anxiety attacks and hallucinations. At one point, the first personality was pregnant without explanation and the second personality emerged and took responsibility for the pregnancy.

Still, even after a great deal of research into the idea of multiple personalities, people who had symptoms like those of dissociative identity disorder were either seen as having epileptic fits or being possessed. He followed the case for 35 years, and published his book about “alternating personalities” in the “double consciousness” in 1887.

This is the early documentation as alters not just presenting as real, but perceiving themselves as real within their own awareness and consciousness. It is documentation of interactions that hint at an inner world with rules and codes and dynamics by which they lived and took turns, whether that was revealed or known or not. It tells the story of explicit switching and passive influence and natural consequences for a shared body.

Image Description: Brown book cover with French words at the top “Hypnotisme double conscience et alterations de la personnalite” with darker brown stripe across the bottom half with words printed “Encyclopedie psychologique”.

Image Description: Brown book cover with French words at the top “Hypnotisme double conscience et alterations de la personnalite” with darker brown stripe across the bottom half with words printed “Encyclopedie psychologique”.

In 1882, the first person officially diagnosed with Multiple Personality Disorder, instead of the previously French diagnosis of “double personality” was Louis Auguste Vivet. He had been physically abused and neglected as a child and had frequent “attacks of hysteria.” One such these occurred when he was 17 and bitten by a snake. He lost use of his legs for almost one year, and when the use returned after a 50 hour attack, he didn’t remember any of the physicians who had been treating him in an asylum for the last month or any of his fellow patients. His manner, morals, and appetite were different as well. Following additional attacks, the next year, his character would change from impulsive and dangerous to calm and gentle. In 1884, he had another attack that left him gentle of manner but unable to walk, and yet another attack returned the use of his legs but left him quarrelsome and inclined to steal as he had done as a child in order to survive. Amnesia for intervals spanning episodes was noted. By 1888, he had been recorded as having 10 personality states, each of which were different in character, memory, and somatic symptoms (Faure, Kersten, Koopman, & Van der Hart, 1997).

This case study tells the story of individual alters, followed and observed over long periods of time, detailing their individuality, their reality, and even their humanity. This was not the delusion of one dominant personality creating a bunch of lesser ones. This was a group of distinct insiders sharing a body, taking distinct turns fronting.

Image Description: aged browned page from a book, with a black and white photo of a young man in a suit sitting in on a stool, perhaps biting his fingernails on one hand. He has dark hair and is dressed nicely, with feet crossed and one foot over the other as if somewhat anxious or distressed. Photo appears to have been taken outdoors. Some French lettering underneath the photo.

Image Description: aged browned page from a book, with a black and white photo of a young man in a suit sitting in on a stool, perhaps biting his fingernails on one hand. He has dark hair and is dressed nicely, with feet crossed and one foot over the other as if somewhat anxious or distressed. Photo appears to have been taken outdoors. Some French lettering underneath the photo.

In 1918, multiple personalities were first acknowledged in the predecessor of the DSM under Hysterical Psychoneuroses, a subgroup of Psychoneuroses and Neuroses that included alternate states of consciousness acting on normally unknown desires, amnesia, and sensory and motor disturbances (“Statistical Manual for the use of Institutions for the Insane,” 1918).

In 1919, Pierre Janet published his work, Les Médications Psychologiques, which included several detailed accounts of multiple personalities. One was the story of Leonie, a poor and “mundane” woman trapped in married life. When Janet began hypnotic regression, she underwent an unprecedented metamorphosis into a lively, boisterous, and sarcastic woman who emphatically repudiated all associations with the ‘normative’ stream of consciousness. As if having escaped her prison, the second personality evoked her quick-wittedness and intellectual superiority in claimed biological and psychological independence from the first; her argument rested on the internal perspective that the cerebral chasm separating the two was far too great to assume that they were one and the same person. She even said that her children belonged to her but that the husband was a complete stranger. In time, a third personality materialized, and she was far more narcissistic and pejorative, even referring to the first personality as “a good and stupid woman, but not me” and the second as “a crazy creature”. After seven months of working with her, Janet realized that the fragmented personality system resembled an actualization hierarchy: the third alter knew about the second and the first; the second only about the first; and the first was completely oblivious of the existence of the others.

Leonie appeared to have three or more personality states including a child alter named Nichette, a childhood name. In the case of Lucie, who also reportedly had three personality states, there was an alter personality named Adrienne who would seem to experience flashbacks of a traumatic childhood event. In the case of Rose, she would suffer from a variety of somnambulistic states. In some, she was paralyzed and in others she was able to walk.

Janet wrote extensively about traumatic memories (primary idées fixes), and how these memories could be subdivided and so cause functional loss, but also cause sensorimotor and perceptual changes (mental accidents). From these changes in sensory experiences, functioning, and perception, he proposed that the mind could then present alternate personalities that were secondary to the first - much like dreams might replay themes from throughout the day. He documented how, in several cases, some “subpersonalities” shared memories and experiences, while others did not. He was also the first to explore which personalities got to “drive” the body (fronting), and why. He was also the first to propose that the severity of fragmentation depended upon the depth of traumatization, an idea which prevails still today.

Image Description: Black and White photo of bald man with beard and glasses looking left and down, wearing white shirt with tie and dark jacket, eyebrows raised in interested expression.

Image Description: Black and White photo of bald man with beard and glasses looking left and down, wearing white shirt with tie and dark jacket, eyebrows raised in interested expression.

In 1906, Mortin Prince published the Christine Beauchamp case in “The Dissociation of a Personality“. Beauchamp allegedly had three personality states including one calling herself Sally who was childlike. Sally differed greatly from a very regressed alter called Idiot. Prince wrote about the case in paper of “The Journal of Abnormal Psychology” which “was the most quoted reference in the history of the illness“. After this documentation, however no further mention of multiple personalities was mentioned n the journal until Prince’s published famous account of Christine Costner Sizemore. In 1957, the case was made into a film starring Joanne Woodward playing the title role in The Three Faces of Eve. 

Image Description: Black and White composite photo from the movie poster of “Three Faces of Eve”. First woman on left is blonde, facing forward, and smiling. Second woman on right is facing right, frowning, dark hair, more matronly. They are in the background. In the foreground is overlapping picture of more elegant woman facing the viewer.

Image Description: Black and White composite photo from the movie poster of “Three Faces of Eve”. First woman on left is blonde, facing forward, and smiling. Second woman on right is facing right, frowning, dark hair, more matronly. They are in the background. In the foreground is overlapping picture of more elegant woman facing the viewer.

It wasn’t until Ferenczi’s “Confusion of Tongues” paper in 1932 that dissociation and subsequent splitting of the personality were explicitly linked to childhood abuse. However, at the time, any theory involving the subconscious mind was unpopular, and few paid attention to what Ferenczi had discovered - and what Jeanne Fery herself had written in 1584.

There is an unusual gap in the literature, then, following Stengel’s famous statement in 1943 that the condition was “extinct”. This statement is often used to explain the gap in literature, and the poor presentation of the article and misapplication of the conclusion confused many who then misunderstood the article to mean that the condition is no longer studied or believed to happen as previously documented for over four hundred years. This is entirely false, and not the point of his article. It is true that the article was published during the transition between French-speaking psychiatry and German-speaking psychiatry and the development of English-speaking psychiatry as its own field. But also, when Stengel wrote about dissociation, he was referring to the external version (fugues) and the internal version (multiple personality). CLICK HERE for the reference to the original article (Stengel, E. (1943). Further studies on pathological wandering (fugue with the impulse to wander). Journal of Mental Health Science, 89, 224–241.)

But then, in the 1970’s, H. Ellenberger published a paper entitled “The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry” that focused on multiple personality disorder. Many clinicians continued to collaborate and work toward establishing official diagnostic criteria for the disorder. Margareta Bowers along with six other contributors published “Therapy of Multiple Personality” in 1971, which included outlines and rules for treatment.

Image Description: purple book cover with some textured pattern in the background, with white block lettering that says “The Discovery of The Unconscious: The History and Evolution of Dynamic Psychiatry” with the author’s name below.

Image Description: purple book cover with some textured pattern in the background, with white block lettering that says “The Discovery of The Unconscious: The History and Evolution of Dynamic Psychiatry” with the author’s name below.

Further, the 1970’s also offered the first workshops and trainings for how to treat multiple personalities. Pioneers in the field, such as Dr. Wilbur (of Sybil fame), Ralph B. Allison, and David Caul, M.D. developed programs and treatment workshops to teach other clinicians how to recognize, diagnose, and treat the condition - which naturally led to an increase in the number of cases diagnosed and reported, once treatment for it became available.

Image Description: this is a school yearbook type black and white photo in oval frame of a young woman with dark hair curled on top and on each side of her face. She has a bright expression, and is wearing a dark dress that has some decoration around the collar. There is handwritten lettering beneath the photo that says “Shirley Mason”.

Image Description: this is a school yearbook type black and white photo in oval frame of a young woman with dark hair curled on top and on each side of her face. She has a bright expression, and is wearing a dark dress that has some decoration around the collar. There is handwritten lettering beneath the photo that says “Shirley Mason”.

In 1980, this work culminated in the publication of the DSM-III by the American Psychiatric Association, which for the first time created a separate category with the term “dissociative” being first introduced as its own class of disorders. It also officially set forth the criteria for a diagnosis of Multiple Personality Disorder.

When the DSM-III-R was released, the essential feature of dissociative disorders was officially "a disturbance in the normally integrative functions of identity, memory, or consciousness . . ."

Landmark publications quickly followed, including E. L. Bliss' study of fourteen patients, P. M. Coons systematic treatment of making a diagnosis, G. B. Greaves "classic" review article, B, G. Braun's treatment recommendations and S. S. Marmer’s psychoanalytic study. Frank W. Putnam, of the National Institute of Mental Health, published the classic “Diagnosis and Treatment of Multiple Personality Disorder”, which was quickly followed by the research of Colin Ross in “Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment.”

Image description: Blue book cover with yellow block letters says “Diagnosis and Treatment of Multiple Personality Disorder”. Author’s name is at the bottom. In the center is an image of five facial silhouettes facing right and overlapping, with light coming between them.

Image description: Blue book cover with yellow block letters says “Diagnosis and Treatment of Multiple Personality Disorder”. Author’s name is at the bottom. In the center is an image of five facial silhouettes facing right and overlapping, with light coming between them.

In 1994, the DSM-IV was released, changing the name of Multiple Personality Disorder officially to Dissociative Identity Disorder (DID). The criteria for dissociative identity disorder was now:

  • The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

  • At least two of these identities or personality states recurrently take control of the person's behavior.

  • Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

  • The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

The DSM-5 changed this definition in 2013 to allow self-reports and specify that amnesia may occur with regards to everyday events and not just traumatic ones.

1994 (the same year the Polyvagal Theory was introduced) also saw the International Society for the Study of Dissociation (ISSTD) released their 100-page document “Guidelines for Treating Dissociative Identity Disorder in Adults”. Screening instruments, structured interviews and assessments, and specialized mental status examinations quickly followed.

Image Description: green and blue swirled logo is on the left, with the center and right taken up by slim lettering that reads “International Society for the Study of Trauma and Dissociation” and then in smaller letters beneath that it says “Trauma and Dissociation. It heals here.”

Image Description: green and blue swirled logo is on the left, with the center and right taken up by slim lettering that reads “International Society for the Study of Trauma and Dissociation” and then in smaller letters beneath that it says “Trauma and Dissociation. It heals here.”

While not the most authoritative, Wikipedia explains the history of the ISSTD most succinctly:

The focus of the organization has broadened over the years. In the 1980s, the ISSMP&D, the International Society for the Study of Multiple Personality and Dissociation, grouped clinicians and researchers primarily interested in Multiple Personality Disorder (MPD). Dissociative Identity Disorder (DID) had been called MPD since the 19th century, and was still called MPD in DSM-II and DSM-III. In the 1990s, DSM-IV changed the name of MPD to DID, and so the ISSMP&D simplified its name to the ISSD - the International Society for the Study of Dissociation, broadening its interest to include the other dissociative disorders. By the 21st century, the ISSD had broadened its interest to include chronic developmental traumatic disorders (also known as Complex PTSD), and so the name was lengthened to ISSTD: the International Society for the Study of Trauma and Dissociation. Editors of the book Dissociation and the dissociative disorders: DSM-V and beyond describe the ISSTD as "The principle professional organization devoted to dissociation".

As the “principle professional organization devoted to dissociation”, the ISSTD revised their treatment guidelines for adults with dissociative disorders in 2011. These guidelines are available online HERE. This was the third revision, and it was published in the Journal of Trauma & Dissociation , 12:115–187. It includes 15 pages of references (pages 172-187), leaving the guidelines themselves at 56 pages long (115-171, with the conclusion on 172).

The most recent theory of dissociation came from the Netherlands, and has come to be called the Structural Dissociation Theory ("The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization" by Onno van der Hart, Ellert Nijenhuis, and Kathy Steele is what first brought the theory into the limelight and was only published in 2006). This will be discussed later in our conference more in depth, but essentially proposes that all children are born with an identity or personality that is structured with separate states and that it is through attunement and caregiving and being raised in a healthy and safe environment by positive caregivers with good attachment that these states are integrated into one person in “normal” development. However, with abuse and neglect or other severe misattunement experiences, these states do not get to integrate into one “personality”, and instead they remain dissociated (or separated) from each other. This is a shift from the dissociation theory of the 80’s and 90’s that viewed the separate personality states, or alters, as having “split off” from a core personality and needing to be integrated back into that core. While some dissociative systems may still have one who views themselves or is viewed by others as a kind of core, or some systems may have a primary personality who identifies with the body and age and even “host” - fronting the most often - with structural dissociation, even these would also be considered alters rather than some unbroken piece from which the others were derived.

Here’s a graphic designed by Jeff Clark (used with permission) that explains this well (and CLICK HERE for the latest FMRI studies on this, as well as this report from just last December):

Image Description: Letters across the top say “Dissociative Identity Disorder” (DID), with sub-heading of “The Theory of Structural Dissociation”. Graphic is then split in two rows, with three pictures each. Top row depicts normal development: first square shows unjoined paper doll figures (caption reads “We are all born with some elements of our personality, but at birth our personality is not fully formed or unified”; second picture has them closer together and overlapping, with caption that reads “our experiences both good and bad also shape who we become”; final image is brown single person outline with caption that reads “In normal development, these parts join to become one”. In second row, first picture depicts the paper dolls again, but with lines drawn between each figure and caption reads “But severe trauma can stop this process and cause walls to form between parts. This keeps traumatic memories separate from daily life”; second picture adds speaking balloons to divided characters that read “Is there anyone on the other side of this wall? Don’t Talk! Everything is fine! Who am I?” and caption says “This loss of memory is called amnesia. Parts may not even know about each other or about the walls, so it can be confusing.” The third and final picture adds ages to each of the paper doll characters still divided by walls - age 42, age 5, age 16, age 27 - and caption reads “This separation also means parts can have different memories, feelings, ages, and names.”

Image Description: Letters across the top say “Dissociative Identity Disorder” (DID), with sub-heading of “The Theory of Structural Dissociation”. Graphic is then split in two rows, with three pictures each. Top row depicts normal development: first square shows unjoined paper doll figures (caption reads “We are all born with some elements of our personality, but at birth our personality is not fully formed or unified”; second picture has them closer together and overlapping, with caption that reads “our experiences both good and bad also shape who we become”; final image is brown single person outline with caption that reads “In normal development, these parts join to become one”. In second row, first picture depicts the paper dolls again, but with lines drawn between each figure and caption reads “But severe trauma can stop this process and cause walls to form between parts. This keeps traumatic memories separate from daily life”; second picture adds speaking balloons to divided characters that read “Is there anyone on the other side of this wall? Don’t Talk! Everything is fine! Who am I?” and caption says “This loss of memory is called amnesia. Parts may not even know about each other or about the walls, so it can be confusing.” The third and final picture adds ages to each of the paper doll characters still divided by walls - age 42, age 5, age 16, age 27 - and caption reads “This separation also means parts can have different memories, feelings, ages, and names.”

Besides being the first developmental model of how dissociative identify disorder occurs, it also clarified several issues. One is that serious and significant trauma prior to the age of six is more likely to develop into a trauma response like dissociative identity disorder, while serious and significant trauma after age nine is more likely to develop into a personality disorder. These may overlap in presentation, and the structural dissociation model explains this by labeling different internal parts as ANP (“apparently normal parts”) or as EP (“emotional part”). There may or may not be amnesia between these parts, and the degree of amnesia correlates to the specific diagnosis along the dissociative spectrum.

Another explanation that came out of this model was the idea of how different dissociative systems are organized based on the type of trauma response. For example, an adult who dissociates in response to one traumatic event in adulthood may separate themselves from the memory or emotional response to that event; on the other hand, an adult who had a series of traumatic events may have multiple separations of memories or emotional responses to those events; and then an adult who grew up with ongoing abuse and repeated traumatic events while also being unable to integrate ego states during childhood development may have several presenting adults as well as the multiple emotional states.

Image Description: Heading reads “The Structural Dissociation of the Personality” and gives three types in overlapping circles. The first is Type 1, or Primary, and has only an ANP and an EP, with its caption labeled as PTSD. The Second is Type I, or Secondary, and has only one ANP but multiple EP’s, with its caption labeled as OSDD or Borderline Personality. The third is Type III, or Tertiary, with several ANP’s and multiple EP’s, and captioned as representing complex PTSD and DID.

Image Description: Heading reads “The Structural Dissociation of the Personality” and gives three types in overlapping circles. The first is Type 1, or Primary, and has only an ANP and an EP, with its caption labeled as PTSD. The Second is Type I, or Secondary, and has only one ANP but multiple EP’s, with its caption labeled as OSDD or Borderline Personality. The third is Type III, or Tertiary, with several ANP’s and multiple EP’s, and captioned as representing complex PTSD and DID.

Kathy Steele, International speaker on dissociative disorders, rejects the ANP and EP terms in favor of her own model. She uses “DL” for “daily living parts” (ANP’s), and “TF” for trauma-fixated parts (EP’s).

The other big research getting a lot of attention in the field of dissociative disorders is The Polyvagal Theory, which will also be discussed in future sessions of this conference. The vagus is a nerve that runs from the brain to all the major organs by branching out along the way, and so thus called the “polyvagal nerve”. We will talk about this more in depth in the session about this topic, but for now there are two things to know about this theory.

One is that it helps explain why “bottom up” approaches help survivors of trauma so much. “Bottom up” means working with the body itself through a variety of ways to help the amygdala regulate the physiologic response to trauma - even trauma in memory time being felt in now time. So “bottom up” approaches are things like meditation, yoga, EMDR, pet therapy, equine therapy, sand tray, art, sensory therapies, etc., as opposed to “top down” approaches like talk therapy that work through activating the medial prefrontal cortex. The best, and most effective, is a bit of both “top down” and “bottom up”.

The other thing that this theory brought to light is that healing from trauma and shame require a social aspect to the therapeutic approach. Healing requires connection with an Other. There has been an understanding that emotional safety is part of creating the space in which therapeutic work can happen and progress be made, but now that “emotional safety” is defined as including attunement, specifically. Attunement is being in tune with and reflected by an Other: being heard, being seen, feeling held in someone’s heart, and there being some level of reciprocity (see also The Body Keeps Score by Bessel Van Der Kolk, 2014).

But here’s the funny thing about The Polyvagal Theory being all the rage: it’s isn’t new! It’s not new at all! Stephen Porges introduced the idea all the way back in 1994!

That brings us to another piece of history to that matters: changes in the National Institute of Mental Health (in the United States) for funding research. The change started in 2010, with the “From Discovery to Cure” report, which basically stated that traditional research with traditional clinical trials and decades of follow-up research was simply too costly.

They simply stopped funding psychological and psychosocial research. Period.

Starting in 2014, they cut off all those projects, and now only funds neuroscience research.

This did two things.

First, it shifted funding back to biological and neurological research. This is why some of the brilliant psychological researchers of the 80’s and 90’s suddenly disappeared or started publishing research in other fields. They simply lost funding. It’s also why we saw the resurgence of research with things like the Polyvagal Theory, which was biological enough to count for funding, as well as new focus on new technology like functional MRI’s and neurofeedback.

The second thing it did was create opportunity for new people wanting fresh money now made available. The buzz word became “evidenced based”, which was a way to tie research back to science rather than psychological studies and experiments. At its best, that gave us some new techniques that have been really helpful and are widely accepted now; at its worst, it began a pattern for repackaged fad-therapies being branded and marketed as the latest thing and “evidence-based” but not actually including appropriate application or sample sizes or well-developed studies.

This has divided clinicians into two camps of thought, often with heated exchanges between them.  One camp is the traditional therapies camp, who thinks the other group is simply out to make money from the funding and from clients by coming up with “miracle” cures that are short-term and fast-acting treatments, but don’t actually have any long term studies backing them up.  The other camp is the new short-term therapies camp, who thinks the first group are the ones just trying to make money off of long-term treatments. Stuck in the middle are survivors themselves, either doubting or buying into these different treatments without really knowing what is best or how to even tell which approaches are best for them.

In addition, Susan Pease Banitt points out trauma studies cannot be “evidenced based” by the very nature of trauma. Evidence-based therapies only are studied for an average of six to nine months - because, remember, long-term studies lost funding. Extensive trauma histories will take longer than that to build enough safety and connection to even start disclosing trauma. Further, she also points out that trauma is often triggered by anniversary dates or external factors, so many issues may not even come up for a whole year into treatment.

This is not only bad practice, but also an injustice for the client, when poorly studied and barely tested models are being applied to trauma treatment for survivors who have already endured so much.

But not only do treatments change, the diagnosis itself continues to change. The upcoming release of ICD-11 will classify Dissociative Identity Disorder as:

Dissociative identity disorder is characterized by disruption of identity in which there are two or more distinct personality states (dissociative identities) associated with marked discontinuities in the sense of self and agency. Each personality state includes its own pattern of experiencing, perceiving, conceiving, and relating to self, the body, and the environment. At least two distinct personality states recurrently take executive control of the individual’s consciousness and functioning in interacting with others or with the environment, such as in the performance of specific aspects of daily life such as parenting, or work, or in response to specific situations (e.g., those that are perceived as threatening). Changes in personality state are accompanied by related alterations in sensation, perception, affect, cognition, memory, motor control, and behaviour. There are typically episodes of amnesia, which may be severe. The symptoms are not better explained by another mental, behavioural or neurodevelopmental disorder and are not due to the direct effects of a substance or medication on the central nervous system, including withdrawal effects, and are not due to a disease of the nervous system or a sleep-wake disorder. The symptoms result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

It will also be adding a “partial dissociative identity disorder” diagnosis, presumably to replace OSDD. This diagnosis also contains new language regarding switching (ANP to EP) as a “dissociative intrusion”. It also refers to passive influence, or the influence of other alters without them presenting directly or fronting completely or co-consciously. While not yet confirmed, it appears based on common interpretation thus far that this distinguishes secondary dissociation as PDID (previously OSDD), and tertiary dissociation as DID explicitly. The ICD-11 will also shift fugue to a general “dissociative amnesia” category.

Despite the release of the DSM-5 two years later in 2013, the upcoming release of the ICD-11, the latest theory of structural dissociation, and the renewed emphasis on the Polyvagal Theory, the ISSTD still has not updated its guidelines since 2011 and even that update did not include any references or research past 2009. making their treatment guidelines outdated by an entire decade.

Our specific concerns in regards to this included the language of using the word “patients” instead of “clients”, the diagnostic manual changes, and the need for functional multiplicity to be included as a treatment option.

However, last week I spoke to Peter Barach, who helped write the treatment guidelines for the ISSTD, and asked him these questions directly. He responded in several helpful ways to communicate and explain the ISSTD stance on this issue. This is my understanding of his response (not quoting him directly - please refer to that podcast to hear him speak in his own words).

  1. Most of the original treatment providers were medical doctors or psychiatrists, and the original context of the treatment guidelines were for insurance panels approving inpatient hospital stays. In these contexts, “patients” was the appropriate use of the word, which I concur based on my own years of working in hospitals and residential treatment programs.

  2. The Latin roots for the word “clients” means “to lean on”, which ultimately made both clinicians and survivors uncomfortable with the use of that word, so “patients” remained the better option out of those choices.

  3. The changes brought about by the DSM-5 were not the expected changes. It was expected that Developmental Trauma Disorder or Complex PTSD would be added as a diagnosis, and it wasn’t. This chain of events is described well in The Body Keeps Score (Bessel van der Kolk, M.D., 2014).

  4. What did change in the DSM-5 was self-reporting symptoms becoming “acceptable” and DDNOS becoming OSDD; however, neither of these changes impacted treatment itself directly, and so did not require an update in the guidelines.

  5. Functional multiplicity happens naturally already in the treatment process, as communication and cooperation improve as a system. In that way, most ethical and good therapists understand this as a goal for part of treatment, even if it is not explicitly stated in the guidelines. It should be expected that we attain this as part of the treatment process naturally, both through treatment itself and through our own work as a system that we do outside of or in addition to the treatment setting.

  6. That said, functional multiplicity is not an “end goal” for treatment for two reasons, both of which are related to the ACE’s research and long-term follow-up studies which are new for the first time and were not available in the 80’s and 90’s. The first reason is that it leaves the survivor at a higher risk of being retraumatized or revictimized in some way, not because the survivor is not functioning with a positive quality of life, but because they remain in a dissociated state which leaves them - by definition - with decreased awareness of themselves and their surroundings in some ways. The second reason builds on that, in regards to both the liability and the ethics of “leaving” a client in that high risk state and a more vulnerable position.

Thus, from a perspective of beginning a conversation between the clinical and survivor communities about these issues, the survivor community is concerned about agency (ability to choose) and intentionality (the choice itself), while the clinical community is concerned about safety and increased adaptability (rather than continuing to rely soley on dissociation) . Survivors seem to voice an opinion that is in regards to quality of life and wanting to measure their own progress, while clinicians are expressing concerns regarding what would put that quality of life at risk.

While there are clearly some differences of opinions in these perspectives, the biggest “trigger” for survivors may simply be facing the “we know what’s good for you” approach that feels generally oppressive despite its reportedly good intentions. This may be what is more difficult to resolve than the differences themselves. Clinicians will need to find sensitive and respectful means to support the survivor during later phases of therapy, including ways to honor both agency and intentionality as part of the healing process. Survivors will need to continue to advocate for themselves in ways that effective, while also continuing to engage in the therapeutic process.

Finally, the latest research continues to be in neuroscience because it can get funding, and much of it is focusing on what we are learning from functional MRI’s. The first fMRI with documented switching was back in 1999 (Condie, D., Wu, M.T., Chang, I.W. (July 1999). Functional Magnetic Resonance Imaging of Personality Switches in a Woman with Dissociative Identity Disorder, Harvard Review of Psychiatry 7(2):119-22). Just a few months ago, in December of last year, the British Journal of Psychiatry released spectacular results on the fMRI studies. Neurscience news reported that fMRI’s “were able to distinguish, with 73% accuracy, neurobiological differences between those with dissociative identity disorder and those without the condition.” They wrote:

This research, using the largest ever sample of individuals with DID in a brain imaging study, is the first to demonstrate that individuals with DID can be distinguished from healthy individuals on the basis of their brain structure.

DID, formerly known as ‘multiple personality disorder’, is one of the most disputed and controversial mental health disorders, with serious problems around under-diagnosis and misdiagnosis. Many patients with DID share a history of years of misdiagnoses, inefficient pharmacological treatment and several hospitalisations.

Dr Simone Reinders, Senior Research Associate at the Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London led the multi-centre study involving two centres from the Netherlands, the University Medical Centre in Groningen and the Amsterdam Medical Centre, and one from Switzerland, the University Hospital in Zurich.

Commenting on the research, Dr Reinders said: “DID diagnosis is controversial and individuals with DID are often misdiagnosed. From the moment of seeking treatment for symptoms, to the time of an accurate diagnosis of DID, individuals receive an average of four misdiagnoses and spend seven years in mental health services.

“The findings of our present study are important because they provide the first evidence of a biological basis for distinguishing between individuals with DID and healthy individuals. Ultimately, the application of pattern recognition techniques could prevent unnecessary suffering through earlier and more accurate diagnosis, facilitating faster and more targeted therapeutic interventions.”

Further, using what has been learned from polyvagal theory, shame theory, and structural dissociation theory, there is renewed interest in the actual neurobiologic mechanisms of how DID develops. Some of this also builds on fMRI’s, where brain structural changes are noted. In DID, reduced volumes in the amygdala and hippocampus (Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD, 2006) and parahippocampus (Ehling, T., Nijenhuis, E.R., Krikke, AP., 2008) were found. Smaller hippocampal volumes may be related to early life trauma: the hippocampus has a high density of glucocorticoid receptors and is highly sensitive to a heightened release of the stress hormone cortisol—therefore, chronic traumatic stress may lead to cell damage in this area (Bremner, J.D., 2006; 2009, 1999). Reduced hippocampal volumes in PTSD may therefore stem from a history of trauma rather than specific to the diagnosis (Daniels, J.K., Frewen, P., Theberge , J, Lanius R.A., 2016; Karl, A., Schaefer, M., Malta, L.S., Dorfel, D., Rohleder, N., Werner, A., 2006; Woon F.L., Hedges, D.W., 2009; Nardo, D., Hogberg, G., Lanius, R.A., Jacobsson, H., Jonsson, C., Hallstrom, T., et al., 2013).

Building on this, there is a “Coalescence Theory” that explains how the structure of DID happens neurophysiologically. This theory links Default Mode Network (DMN) to both default mechanisms and altered states of consciousness. The DMN is a group of interactive brain regions whose activity is highly correlated (they work all at once together) (Buckner, R. L.; Andrews-Hanna, J. R.; Schacter, D. L., 2008). Bouncing back from earlier criticism, the DMN has now been mapped not only on fMRI’s, but also PET scans and electrocorticography. The DMN is most active during “wakeful rest” such as daydreaming, mind-wandering, and dissociation. Thanks to recent fMRI research, we now know the DMN also contributes to aspects of experiencing one’s role externally, as well as the ability to think about ourselves and remember the past. In the infant brain, there is limited evidence of the default network, but default network connectivity is more consistent in children aged 9–12 years, suggesting that the default network undergoes developmental change (Broyd, Samantha J.; Demanuele, Charmaine; Debener, Stefan; Helps, Suzannah K.; James, Christopher J.; Sonuga-Barke, Edmund J. S., 2009). This seems to confirm theories about extreme trauma responses prior to age 9 developing as DID, and trauma responses after age 9 developing as personality disorders.

CALL FOR RENEWAL:

There are many differences amongst us in the community. DID presents differently in everyone, and is experienced differently by everyone. Some of us have been working at our healing for many years, while others of us are just getting started. Still others don’t yet remember trauma, while others deny having any trauma background at all. Sometimes our awareness changes simply depending on who is out.

But today, this weekend, at this first counter conference, we unite together to use our voice in a way like never before.

We stand together against being silenced by clinicians who are neither properly educated nor properly trained.

We stand together against being silenced by government funding agencies who ignore our declarations that they have long been part of the problem - and, in some cases, caused the problem.

We stand together against being silenced by dissension in research camps where politics argue over money like fighting parents, where funding unethically determines access to services, and where clinical pirates reproduce old research for credit and money at the expense of our healing being put on hold for decades.

We raise our voices to say, “Nothing for us, without us!”

This was our discussion at the recent Infinite Mind conference in Florida, when 15 plural systems met together over several days that weekend to discuss concerns experienced while at the conference:

  • Sign language interpreters were refused, and alternative handouts and transcripts promised were never provided, and videos used (like on the ISSTD website also) were not captioned, despite that being federal law as well, for years now, all together making the conference inaccessible to Deaf and hard of hearing survivors;

  • Seeing-eye dogs were twice kicked out of the conference, and powerpoint presentations did not include image descriptions, making the conference inaccessible to the blind and visually impaired survivors in attendance;

  • Following these slights and legal violations against the disability community, that conference organizer was asked to present about disability and trauma at the ISSTD conference this weekend, rather than someone from the disability community themselves, which again is cultural appropriation;

  • Presenters openly mocked animal, feral, fictive, alien alters during their presentations, despite redirection by survivors that the appropriate term for these are “non-human alters”, and without consideration that any such introjects would have developed in the minds of intelligent and creative children based on their own unique traumatic experiences as well as their own specific cultural references growing up in the 1990’s and 2000’s - which provides a very different presentation than those who grew up in the 60’s and 70’s and 80’s, but makes them no less legitimate;

  • Presenters continue to follow the ISSTD Treatment Guidelines which state that survivors ought to be isolated from each other, with no contact outside of group, and present themselves as both dismissive and disrespectful to those who do attempt to educate and connect and support other survivors; and

  • Presenters and organizations are attempting to aggregate and monetize online educational resources, which is unethical appropriation… and worse, feels like organizational abuse, which many of us have already endured, as our call for information and access and connection is dismissed while they then take control of disseminating information and resources while excluding those of us who have been doing it already for years.

This is not 1980.

It’s been more than forty years since 1980.

More than half of your survivors were barely even born in 1980.

DID is not going to look the same, sound the same, or present the same now as it did in 1980 because those clients grew up in the 1940’s and 1950’s and 1960’s. The cause may be the same, and the process may be the same, but the presentation comes in a whole new generation - four decades later. Introjects look different, persecutors look different, and inner worlds look different. That doesn’t make any of it less valid, and it is cruel and re-traumatizing for anyone to dismiss survivors because the culture we grew up in and had access to during childhood and adolescence was different than it was almost a hundred years ago.

It’s 2019. More than half of us grew up in the 80’s and 90’s and 2000’s and 2010’s.

This is the digital world, and you cannot keep us isolated from each other. We no longer grow up in a world never having met someone like us. DID is everywhere. It is mis-portrayed in mass media, misunderstood by pop culture, and mis-represented by old texts and outdated treatment models.

We are survivors, keen on discernment and gifted with hypervigilance. We grew up in the digital age, and we know that not everything on YouTube is true, and not every DID channel is real. We know there is a difference between those who share their stories online in helpful and educated ways and those who fake it for click bait and quick money. We know that some support groups on Facebook will be healthy peer support like no other place available to us, while others are nasty pools of trauma dumping. We know that Twitter and Reddit and Tumblr can be opportunities for connection and education and advocacy, or places of terrifying drama and cyber-bulling. We already know these things, and most of us can discern the difference.

Stand with us, instead of leaving us alone in it.

Collaborate, instead of letting us drown on our own.

Teach us, instead of dismissing us.

Empower us to heal, even through connection and attunement, which is exactly the message of all the latest research on shame.

We are just asking you to see us, and hear us, and to please not become the bad guys.

We agree with the concern of a person or system or part of a system over-identifying with their role online, rather than progression through the healing journey, so support us as we focus on the healing aspects such as communication, cooperation, and collaboration - inside and outside the system.

These issues are not only the modern age of clinical cultural competence, but also an opportunity for compassion.

This is what led us to organize this counter-conference, intentionally timing it simultaneously with the ISSTD conference happening this weekend in New York.

Let me clear. We are not protesting that conference, nor we arguing against the ISSTD.

We declare our legal rights for accessible treatments and trainings, as well as our ethical right to culturally competent treatment for these new generations.

Some of the issues we would like addressed by the clinical community include the following:

  • The decade old Treatment Guidelines by the ISSTD need to be updated, such as “patients” should be changed to “clients” or “survivors” (while we now understand their origin better, it has been decades since the hospitals were closed, and we are not a generation that grew up inpatient, and “client” has a more modern feel despite its unfortunate Latin roots; research should be updated; terminology for non-human alters clarified; functional multiplicity included as a viable and valid treatment outcome -or at least acknowledged as part of the process; and using other language such as “metabolizing” experiences (Lynne Harris) rather than “integrating” them, now that integration has such a negative connotation that it's actually become triggering verbiage in and of itself.

  • While we understand the difficulty with “parts” language and the need for emphasis of the functional whole, and we do even agree that the term “emotional parts” is severely limited, “trauma-fixated parts” is not a valid replacement for the EP term due to the inference of intentionality (implies blame, which is shaming), and those parts stuck in time or trauma loops is not the same as “fixating” on their trauma, nor is it helpful for those parts to be shamed further for their experience.

  • The general attitude regarding survivors having contact with each other needs to change, especially in regards to the online community. For years we have been isolated from each other and it was recommended we not have contact with one another. There is no other physical or mental illness given those recommendations. All other physical and mental illnesses include treatment recommendations for support groups and community of others who understand - which is consistent with the most recent research on attunement and shame and healing through connection. We understand that isolating only within that group is not healthy, as mentioned under the “Safety and Reciprocity” sub-heading in chapter five of The Body Keeps Score. But these generations growing up online anyway cannot be expected not to reach out and find others who understand them, and its culturally incompetent to expect that. What would be more helpful would be supporting those who are trying to do it well, and providing safe places, and disseminating accurate information as best they can to so many desperate for resources. We know not everything on the internet is true, or real, or safe, and we are probably better than you are at spotting abusers. Let us have our safe spaces in which we can rest and connect with others who understand. When you have those rare occasions of those who “copy cat” others that they witness online, then treat them as you would any introject - just like from a parenting figure or a comic book or a book… this generation of introjects is digitally based and a very different presentation than those twenty years ago. It doesn’t make them less real or less valid or less important.

  • We know, in differing degrees, but especially once we have been in therapy, that we are “parts of a whole”. Please interact with us as we present, just like you would for any other client. There is a reason why we function that way as a system, and listening to us will help you understand us more, and help us trust you more quickly.

  • Please stop referring to working with individual parts as “joining the delusion” - dissociation is not the same as a delusion, and it is oppressive and shaming when you say so, which is a rupture to our connection with you.

  • Emphasize more in your education, and trainings, and publications, that healing is a journey. Kathy Steele said that integration is not a fixed moment, but a process, and no different for you than for us - other than our dissociated starting place. You aren’t finished, either, so have some empathy for us and compassion for our struggle with the process. None of us are the same person we were yesterday. Metabolizing experiences, feelings, and memories should be the focus of therapeutic work, along with safety and stabilization (including sensorimotor / physical grounding work), as well as compassion and connection to address shame issues. This is what brings about functional multiplicity, and improves both internal and external communication, cooperation, and collaboration. I like what Peter Barach told me last week, that David Caul had said: “it seems to me that after treatment, you want a functional unit, be it a corporation, a partnership, or a one-owner business”.

We stand with those clinicians who see us, and hear us, and treat us ethically and compassionately.

We stand with those clinicians who do their own work enough not to be offended by the cultural shifts in dissociative presentations, the expression of DID in younger generations with different cultural experiences to draw on as they dissociate, and new styles of introjects based on global access to digital literature.

We stand with those clinicians who are receptive to feedback, who share the reigns with new and qualified colleagues, and who collaborate within the community as a whole, and not just the professional world as a place to hide or establish power over those already victimized.

We stand with those organizations who respond to feedback, who include survivors on their boards and advisory panels, and who support fresh ideas for connection and healing instead of dividing the community further.

And we are calling for a renewal, to reclaim our healing environment from the last twenty years, and pleading for a bridge to be built between the clinical and survivor communities.

We don’t need you to be magic. We don’t need you to integrate us into one. We have never asked for any of that. Some may choose it, but it ought not be forced on any of us. Nothing should be forced on any of us.

We want to be safe.

We want to feel connected.

We want to be able to function, and have access to all parts (aspects) of our lives.

Plurality doesn’t bother us; we have always been this way. It takes ages to get diagnosed, even longer to find a good therapist, and even longer to get well. Being plural isn’t even the hard part about DID.

What bothers us is the getting hurt, and the not knowing, and the shame.

And when you stop and think about the current DSM-5 criteria, Dissociative Identity Disorder is only a disorder when you are distressed by it and can’t function.

Help us not to be so distressed. Help us function. Then we won’t be disordered.

We can handle the rest.

There’s a lot of positivity about being Plural.

CLICK HERE FOR THE PLURAL POSITIVITY WORLD CONFERENCE 2019 SCHEDULE OF EVENTS & SESSIONS

REFERENCES:

  1. “About the ISSTD.” International Society for the Study of Trauma and Dissociation. Retrieved January 4, 2018.

  2. Altrocchi, J. (1992). “We don’t have that problem here”: MPD in New Zealand. Dissociation, 5, 109–110.

  3. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders ( 3rd ed. ). Washington, DC:.

  4. American Psychiatric Association (1993). DSM-IV draft criteria. Washington, DC.

  5. Bagley, C., and King, K. (1990). Child sexual abuse. New York: Tavistock/Routledge.

  6. Banitt, Susan Pease (2019). Presentation at An Infinite Mind conference in Orlando, Florida, and discussed on related System Speak interview as well.

  7. Berger, D., Saito, S., Ono, Y, Tezuka, I., Shirahase, J., Kuboki, T, and Suematsu, H. (1992). Dissociative symptomatology in an eating disorder cohort in Japan. Paper presented at the Japanese Stress Science Conference, Tokyo.

  8. Bernstein, E. M., and Putnam, E. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.

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  67. Ross, C. A. (1992). Childhood sexual abuse and psychobiology. Journal of Child Sexual Abuse, 1, 95–102.

  68. Ross, C. A., and Dua, V. (1993). Psychiatric health care costs of multiple personality disorder. American Journal of Psychotherapy, 47, 103–112.

  69. Ross, C. A., Heber, S., Norton, G. R., and Anderson, G. (1989a). Differences between multiple personality disorder and other diagnostic groups on structured interview. Journal of Nervous and Mental Disease, 177, 487–491.

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Guest: Peter Barach

This week’s guest was Peter Barach, with whom we connected so well and learned so much that we ended the podcast we even more questions and can’t wait to have him back again for another episode.

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Dr. Peter Barach attended Johns Hopkins University and the University of Michigan. He received a Ph.D. in Clinical Psychology from Case Western Reserve University. He is 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. 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 also trained in EMDR and clinical hypnosis.

 Dr. Barach is the author of scientific and clinical articles on dissociation and Dissociative Identity Disorder (DID). He is a 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, Dr. Barach 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.

In addition to maintaining a private practice, Dr. Barach currently works for the Cleveland VA Medical Center, where he evaluates veterans who have applied for disability compensation. He is not appearing on this podcast as a VA employee. The opinions he expresses are his own and do not necessarily represent the Department of Veterans Affairs or its policies.

 You can see the website for the International Society for the Study of Trauma and Dissociation HERE.

 You can see the ISSTD Guidelines for Treating Dissociative Identity Disorder in Adults (Third Revision, 2011) HERE.

You can read his article Multiple Personality as an Attachment Disorder (Barach, 1991) HERE

His website for Horizons Counseling Services, Inc. is HERE

Guest: Lynne Harris, LPC
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We interviewed Lynne Harris, a Licensed Professional Counselor (LPC) in the states of Georgia and Florida in private practice. She has worked in the mental health field since 2000, and in health care for over 15 years.

Her post graduate specialty training includes:

  • Advanced Trauma Training from the Institute for Advanced Psychotherapy Training and Education - 2007

  • Somatic Imagery and Ego State Psychotherapy from the Center for Healing and Imagery - 2009

  • Dialectical Behavioral Therapy (Level I and II) - 2009

  • EMDR Level I and II  - EMDR of Greater Washington - 2010

  • Level I Sensorimotor training/Training for the Treatment of Trauma - Sensorimotor Psychotherapy Institute - 2010

  • Level II Sensorimotor training/Attachment, Development and Trauma - SPI - 2013

Her clinical experience includes a wide range of settings and populations. She has experience working with young children, adolescents, adults, families, and groups. Prior to private practice, she worked for 10 years within the Inova Health System, including as an Outpatient Family Therapist at The Kellar Center, an adolescent treatment facility, and as an Addiction Counselor at Inova Addiction Treatment Program (formerly CATS) where she was involved in treatment at different levels of care – detox, day treatment, outpatient and residential. She has extensive experience conducting assessments and leading group therapy.  Earlier in her career, she held positions in psychiatric hospital and school settings. 

In addition to clinical work with clients, she enjoys doing clinical supervision. While at Inova, she provided supervision for interns seeking their graduate degrees, and currently supervise graduate level Master's candidates in their practicum work.

Prior to becoming a therapist, she worked in health care management, and earlier in international relations with a focus on former Soviet countries. She is also an artist.


Her education includes:

Marymount University, Falls Church, VA -   M.A. Counseling Psychology
George Washington University, Washington, DC - Graduate Certificate Art Therapy
Columbia University, New York, NY - M.P.H. Health Policy and Management
The Johns Hopkins University, School of Advanced International Studies, Washington, DC - M.A. International Relations
Bryn Mawr College, Bryn Mawr, PA - B.A. Cum laude

Her professional affiliations include:

American Psychological Association - Division 56 Trauma Psychology
EMDR International Association
American Counseling Association
American Art Therapy Association
National Board of Certified Counselors
Georgia Licensed Professional Counselors

You can see her website HERE, as well as the website for Sensorimotor Psychotherapy HERE.

Molly's Timeline

In the Maladaptive episode, Sasha read a letter in the therapy notebook. The letter was written by Molly to Em in response to Em’s concerns about being a “part” in a “system”, or a part of the greater whole. In the letter, Molly encouraged Em to consider the idea that the “whole” was not one of the others inside or even part of the system, so much as the “whole of time”. In this explanation, she included some timelines, which Sasha attempted to describe. On the previous pages, the timelines are the same, except specific alters are named under the ages on the timeline. On this last page, Molly changed the alters names to refer to specific experiences instead.

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Five Piece

In a three part series, we interviewed the writer and director from the 2019 film Five Piece. The main character in the movie, Brandon, has dissociative identity disorder. Here’s the synopsis.

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DIRECTOR - MATTHEW ROTH

Chicago, IL native, Matthew Roth attended Full Sail University in Winter Park, FL, to pursue filmmaking, learning all aspects of the craft in under two years. Upon receiving his Bachelor’s Degree in Film, Roth embarked to Los Angeles, CA, shortly after, where he worked on various productions. The following year, he raised money for his first feature film The Man Who Collected Food which went onto win numerous awards at various film festivals and find distribution though Media Blasters.

Then, while seeking financing for other projects, Roth had a chance meeting with Writer/Director Martin Donovan (Apartment Zero, Death Becomes Her) whom he worked with for the next few years, developing scripts, filming sessions with actors, and learning even more about the art of film.

Roth then decided to make his next film and wrote one with a small budget in mind, Five Piece. With a cast consisting mainly of actors Roth met through Donovan, he shot Five Piece on a shoestring budget and completed it in late 2017.

Filmography:

The Man Who Collected Food (2010)

Five Piece (2018)

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We also interviewed two of the actors from the film, Tory Despres and Robert Paul Taylor.

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Tory Despres is an actor, writer, producer and director.

He got into acting participating in high school productions of plays and musicals. After high school, he attended Loyola Marymount University majoring in Theatre.

He studied at Playhouse West for five years under teachers such as Wolfgang Bodison, Kathleen Randazzo, Holly Gagnier and Scott Caan.

His feature film debut was in FIVE PIECE which has gone on to win Best Picture at multiple film festivals around the country.

The first short film he directed, wrote and starred in, LOVING DEATH, is currently making the rounds in the film festival circuit and just recently got accepted into The Playhouse West Film Festival. He feels blessed to get to do what he loves for a living and is excited for what the future holds.

On television, Robert plays Remy Ramirez in Season 2 of Hulu's Emmy Nominated 'East Los High'. Taylor has guest starred roles on 'Mixology', 'Brooklyn-Nine Nine', 'New Girl' and plays Ronaldo on 'Fresh off the Boat'. Overseas, you can find Robert as Raul on Russia's Mega-hit 'Chernobyl' Season 2.

On the silver screen Robert stars in "Five Piece" (2018), "Mask of Janus" (2018) and "South 32" (2016). Taylor also appears in a series of acclaimed festival films such as LA Film Fest winner "In Her Place", "Opening Night" and Outfest LA favorite "The Forest".

As a screen writer Taylor has co-screen-played features: 'Mask of Janus' (2018), 'South 32' (2016), 'By The Rivers of Babylon' (2016) 'Table 18' (2018) and the miniseries 'The Bathroom Diaries' (2014).

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Here’s the trailer for the film:

Guest: Jane Hart from A&E DocuSeries "Many Sides of Jane"

In episode five of season three, we interview Jane Hart, the woman with DID featured in the A&E DocuSeries “Many Sides of Jane”.

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A&E NETWORK CHRONICLES THE JOURNEY OF A 28-YEAR-OLD MOTHER OF TWO

LIVING WITH DISSOCIATIVE IDENTITY DISORDER

IN THE GROUNDBREAKING DOCU-SERIES

‘MANY SIDES OF JANE’

A&E PARTNERS WITH NAMI, THE NATIONAL ALLIANCE ON MENTAL ILLNESS,

TO SHARE INFORMATION AND RESOURCES FOR THOSE AFFECTD BY MENTAL ILLNESS

New York, NY – December 18, 2018 – A&E Network’s new, six-part original docu-series “Many Sides of Jane” will explore what life is really like for one young woman living with Dissociative Identity Disorder (DID), previously known as Multiple Personality Disorder, as she juggles parenting her two young boys and navigating her complicated relationship with her mother and her past. This is the first series of its kind that showcases this disorder in such an intimate light. Jane graciously allows cameras into her private day-to-day life, including her intense therapy sessions, to capture every moment as new memories emerge helping Jane as she continues to unlock mysteries surrounding DID and her childhood trauma that caused it. “Many Sides of Jane” premieres on Tuesday, January 22 at 10PM ET/PT on A&E.

“A&E Network is dedicated to transcending television by inspiring dialogue and perhaps even changing perceptions like we have with our Emmy-winning series ‘Born This Way,’ ‘Intervention’ and ‘Leah Remini: Scientology and the Aftermath,” said Elaine Frontain Bryant, Executive Vice President & Head of Programming for A&E. “We are proud to partner with Jane as she bravely opens up her private life to our viewers to ultimately remove the stigma attached to Dissociative Identity Disorder, help spread awareness and hope, while showing the world that they are not alone when it comes to their own mental health struggles.”

In the new series, produced for A&E by Renegade 83, “Many Sides of Jane,” a 28-year-old mother of two from Boise, Idaho who was recently diagnosed with DID allows cameras to follow her journey. Her more than nine identities, ranging in age from 6-28 years old, can appear at any time and are typically triggered by stress. Diagnosed only three years ago, she is on a journey to understand what caused her DID as well as figure out how she can best co-exist with her many "parts" as they each emerge to try and make themselves heard.

Throughout the series, Jane will be coming to terms with past abuses that occurred during her childhood and her relationship with her family under the watchful care of her clinical psychologist. This is a raw, unfiltered look at an extraordinary young woman who is learning how to live her life again with a commonly misunderstood disorder known as Dissociative Identity Disorder. Jane has nine distinctly identified “parts” although there are more inside that are either not as developed or haven’t felt safe making themselves known at this stage in therapy. Her nine distinctly identified “parts” thus far include the following:

• Janey is six years old, innocent and childlike, and has no memory of Jane’s abuse nor had to endure it.

• Beth is 10 years old, reserved and soft-spoken. She is scared and traumatized from enduring a majority of Jane’s abuse.

• Jaden is an 11-year-old tomboy and very defensive of Jane’s abusers.

• Alexis is a 17-year-old energetic, fun, party girl. She is the rebel and loves flaunting her sexuality and being in control.

• Madison is a 28-year-old lesbian who wants nothing to do with men. She is assertive, direct and is a protector of Jane and all her “parts.”

• Jerry holds all the anger about Jane’s past abuse and prevents her from fully feeling the emotion of anger.

• Ashley is 19 years old and has only recently made herself known in therapy. She is beginning to establish a good rapport with Jane’s therapist so that she can begin to tell her story.

• Jeffery is a male part who is still a bit of a mystery.

• A new non-verbal “part” has just started to emerge unexpectedly. This “part” comes out in association with new flashbacks and does not yet have a name.

A&E has partnered with NAMI, the National Alliance on Mental Illness, the nation’s largest grassroots mental health organization, to share information and resources for individuals and their family members who may be affected by mental illness. These resources include an on-air PSA featuring Jane Hart, end-card information with NAMI’s HelpLine, a discussion guide and more.

“Many Sides of Jane” is produced by Renegade 83, LLC, an Entertainment One (eOne) company for A&E Network. Executive producers for Renegade 83 are Jay Renfroe, David Garfinkle and Erica Hanson. Executive producers for A&E are Elaine Frontain Bryant, Shelly Tatro and Brad Abramson. A+E Networks holds worldwide distribution rights for “Many Sides of Jane.”

Jane Hart is a 28-year-old loving mother of two, an author, a public speaker and mental health activist. Born and raised in Boise, ID; Jane currently resides there with her two beautiful sons. Three years ago, Jane was diagnosed with Dissociative Identity Disorder (DID), previously known as Multiple Personality Disorder, which has impacted her life in ways she never could have imagined. One of the exclusive causes of DID is repeated childhood trauma to which Jane has unfortunately endured throughout her life. Dubbing herself a “human information sponge,” Jane has spent countless hours researching the effects of trauma on the brain as well as learning as much as she can about DID in the hopes of helping others.

Receiving her diagnosis was tough on Jane both mentally and physically, but sharing her condition with a close friend was a turning point for her. Despite their close relationship, her friend assumed Jane was dangerous; damaging their friendship and leaving a lasting impact on Jane. This pivotal point in her life has inspired Jane to shine a light on the cause to diminish the stigma of mental illness, especially those living with DID.

In June 2016, Jane wrote an article sharing her knowledge of DID and her personal struggle which led to a speaking opportunity on a well-known psychology podcast “Shrink Rap Radio”. This opportunity led to a life-changing journey; the opportunity to chronicle her life living with DID on the new docu-series titled “Many Sides of Jane” airing on A&E. Under the guidance of her therapist, Jane has currently identified over nine distinct identities or “parts” (as Jane refers to them) and she’s working to unlock the mysteries surrounding her trauma and to find internal harmony between her many sides.

Upon agreeing to participate in this rare and raw series, Jane made a promise to herself to be 100% open, real and honest, letting the world see that those suffering from DID still have the same hopes and dreams as everyone else. Jane’s goal in opening her life to the cameras is not only to erase the misconceptions about this highly stigmatized disorder but to also normalize mental illness and to spread truth about the silent epidemic of child abuse and its lasting effects on the human brain. Jane feels there is power in sharing her story and it is her mission to help others realize mental health is just as important as physical health. Those suffering from DID are special, smart and unique; they deserve compassion, kindness and understanding.

Healing Together

We are at the conference in Florida!

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It’s been super intense, with lots of triggers and difficult content.

But it’s also been amazing, watching people care for each other well, survivors support one another, and seeing friends practicing such good self-care. We are really blown away by it all! It’s been too much for us for very much social interaction, but we have learned a lot and are proud to be here.

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We attended one session this morning and one session this afternoon. You can here about it on Dr. E’s podcast, Healing Together, Part 1. We tried to take lots of notes for our therapist, and will talk about them with her, but also shared with you what we learned. Here are some of the graphics we discussed in the podcast:

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One thing that was completely unexpected about this conference has been the sense of community.

Here, people are very open about their DID, and there is a movement of “pride” within the plural community.

It’s been touching to see the power of connecting with others, even within our own limitations, and the vulnerable sharing of participants in different sessions.

It’s given me new insights, even, into our own podcast and why we started it - not just to face fears about recording ourselves, or to educate via podcast since we had only found YouTube videos, or even to document our own progress… but also to simply speak up, to break our silence, to use our own voice.

That’s been a pretty powerful realization, no matter what we learned today or what we learn tomorrow.

Meeting Minutes

In episode 14 of season 2, Emma shared the minutes from our first internal meeting. This was huge progress, and really took a lot of time to pull off and a lot of energy to figure out how to do. We have been working on this for over a year with our therapist, and then the last month in group as well. Our first big effort as a system was this meeting about meetings as we planned what our meetings would look like, and how we would gather people to come to the meetings. It was really a lot of work! It was also exhausting, and we slept for almost twenty hours after our first meeting.

But here’s what Molly’s Meeting Minutes looked like:

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You can see it was fairly simple in the beginning, just noting the date and where we were and who was present. We also noted a few that watched without participating. The main section, then, was the actual minutes from the meeting, which Molly typed as they happened. At the close of the meeting, there were assignments made for everyone attending, as well as a list of topics brainstormed to cover at the next meeting.

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Maybe that gives you some simple ideas for starting meetings for your system?

Be sure that everyone is invited, even if they cannot come!

It’s the same for those who do not wish to come - they are still invited, even if they don’t want to come.

But no one has to come. Everyone always has a choice. That’s a really important thing for everyone to know.

Guest: Susan Pease Banitt, LCSW
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It was a profound experience for us, specifically for Dr. E in confronting her own diagnosis directly for the first time, and to be received with such compassion and understanding. It was the exact opposite of shame, which we have been talking about and studying recently. Our deepest gratitude to Susan Pease Banitt, for just being her.

Susan Pease Banitt, LCSW, is a social worker, psychotherapist and author who specializes in the treatment of severe trauma and PTSD. She has worked in the field of mental health for more than four decades in diverse settings: inpatient, outpatient, and medical with adults and children, and trained in the Harvard medical teaching hospitals in Boston, MA. She is a Reiki Master, Kripalu trained yoga teacher, and shamanic healer in the Celtic tradition. Susan’s book The Trauma Tool Kit: Healing PTSD From the Inside Out (2012) won several awards including; the Alumni Media Award for Written Work by Simmons College School of Social Work, and the Silver Nautilus Award for Health and Healing.  Susan speaks internationally on the psychological and holistic treatment of PTSD. She lives and has a private practice in beautiful Portland, Oregon with her husband and a menagerie of pets. Her second book: Wisdom, Attachment and Love in Trauma Therapy: Beyond Evidence-Based Practice (2018) has just been released!

You can read her blog HERE, and she has podcasts HERE.

AIM "Healing Together" Survey

We are so excited to be heading to Orlando this week for the Infinite Mind “Healing Together” conference this next weekend!

As we mentioned on the podcast, they have a survey up for anyone with a dissociative disorder. It’s a great opportunity to (safely) participate in good research. CLICK HERE for the link!

The survey was pretty triggering for us, just as a heads up. There were flashing faces that you saw quickly and had to choose the emotion being expressed. While not a difficult task, this was really triggering to us, and we aren’t sure why. It felt in part due to the flashing pictures, and in part to some of the expressions we saw. None of it was in and of itself anything terrible or inappropriate or unsafe by any means, but somehow the process triggered something that did not feel good.

After that section, there were a series of surveys about different topics. One was just general demographic information, some of which was kind of funny because we would answer it differently depending on who was out. Another seemed to be about depression type symptoms, and for us those all go to our insider who is the mother of the outside children. The other questions were about trauma, which actually caused a switch for us because they were so direct and heavy (and Emma doesn’t remember all that anyway), and different experiences regarding dissociation. It was not so hard that we couldn’t get through it, but it took us almost an hour and a lot of self-care.

Be sure to participate if you are able, as it is very helpful and they have a goal of getting 200 responses.

But also remember good self-care during and after, as always, due to some of the content in the survey.

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A Love Story

You guys! You guys!

This was the most AMAZING love story! CLICK HERE to listen to episode 10 of season 2!

We thought we were interviewing an author about their book written for (outside) children about DID, but it became about their journey of love while discovering DID.

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These two grew up together, and dated throughout high school and college, and then finally got married and started their family. Listen to their story! It’s so touching, from him being a witness to some of what she endured to her fighting through medical dramas and even having surgeries to find out what was wrong to ultimately being diagnosed with DID. Deciding together to make this a part of their life, rather than feel like their lives were disrupted by it, they looked for a way to talk about it with their (outside) children. That’s when they wrote their book: The Patchwork Quilt (CLICK HERE TO SEE ON AMAZON).

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Beautifully illustrated by their niece, The Patchwork Quilt is an excellent resource for both outside children and inside Littles. Simple but profound, it’s also just a wonderful metaphor for explaining DID to adults and other support people, as well. We are so grateful for Jeff taking the time to tell us their story-behind-the-story!

GUEST: Dr. Warwick Middleton

Our guest in Season Two Episode 8 is Dr. Warwick Middleton.

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Professor Middleton has had substantive ongoing involvement with research, writing, teaching (including workshops and seminar presentations), supervision and conference convening. He has made substantial and ongoing contributions to the bereavement and trauma literatures and was with Dr Jeremy Butler author of the first published series in the Australian scientific literature detailing the abuse histories and clinical phenomenology of patients fulfilling diagnostic criteria for Dissociative Identity Disorder. He was the first researcher to publish systematic research into ongoing incestuous abuse during adulthood. He is a Fellow and Past President of the ISSTD, is Co-Chair of the ISSTD Membership Committee, and Vice-Chair of the ISSTD Scientific Committee. Prof Middleton chairs The Cannan Institute. In 1996 he was a principal architect in establishing Australia’s first dedicated unit treating dissociative disorders (the Trauma and Dissociation Unit, Belmont Hospital). He has authored many papers and book chapters and has been the co-editor of two books based on journal special issues. He holds Professorial appointments at the University of Queensland, La Trobe University, the University of New England and the University of Canterbury.

The ISSTD is, of course, the International Society for the Study of Trauma and Dissociation.

You can learn more about their upcoming conference in March by CLICKING HERE.

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With Royal Commissioner Bob Atkins on the occasion of presenting him with his ISSTD Media Award, Brisbane, 2nd May 2018.

Professor Middleton also shared his poem song written by himself, recorded by his son Hugh.. The song is shared at the end of the episode.

He also shared one of his paintings with us, a self-portrait!

The 8 F-Words

If you listened to episode seven of season two, you heard Sasha talk about being in four sessions of group with The Crisses from Liberated Life Coaching. We are excited that they will soon be a guest on the podcast!

But one thing we mentioned in this episode was that The Crisses had identified EIGHT panic responses to trauma or other triggers. Most people know about fight, flight, and freeze. Fight means dealing with it head on, and flight means running away from it, and freeze means hiding in some way.

Some people are also now getting more familiar with the fawn response (being “too good” in hopes for safety).

But The Crisses have also identified four others:

Follow - going along with the abuser or trigger, like joining in with them for safety;

Fortify - making higher “walls” and stronger defenses than before;

Fabricate - changing the story so it’s not so scary (including denial);

Facilitate - empowering yourself for positive change and healing in even little ways.

These are amazing! CLICK HERE to listen to their podcast about the 8 F’s!

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More About Littles

Sasha wanted to add more to the discussion about Littles. In episode six of season two, she shared her own perspective about how time applies (and doesn’t apply) inside a DID system. We did learn after the previous episode that the video the listener was reference was this one, by The Entropy System:

Sasha shared some about how some Littles stop aging due to a traumatic event, and others stop aging when they aren’t required to function as much in the external world anymore. Other times it happens due to a new alter taking over that role due to new trauma or some other reason. There can be lots of reasons, and each system will be unique both in how this happens and their understanding of it.

One thing she is becoming aware of, though, is how much you can learn from Littles within your own system. One example of this she gave was John, who helps us notice when we make positive changes. He likes to pass out “badges” (stickers he got from the therapist) to us and to the husband when we make healthy or empowered choices differently than we would in the past. We promised a picture, and here you go!

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Internal Age and Psychosocial Development

In episode five of season two, Dr. E answers a listener’s question about Littles and how they age (or don’t age) within a DID system. The question was in response to a video the listener saw on YouTube about Littles and others inside, and their different ages. The video referenced Erik Erikson’s stages of development.

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But she shared specifically about the impact of trauma on psychosocial development, including the recovery model that goes parallel to Erik Erikson’s theory. CLICK HERE to read more about the recovery model.

EDITED TO ADD: Listeners sent THIS LINK as the video discussed in the listener’s question that prompted this episode.