Double exposure image of woman on street in two places at once with long blonde hair, looking outHollywood often does a disservice to people with mental health conditions. Consider the number of feature films and television shows depicting people experiencing mental health issues as being dangerous, low functioning, and undesirable. Not only are people with mental health challenges not accurately represented, these inaccurate depictions can also do damage by generating prejudice and creating additional stigma and related stress for those trying to function. The burden of stigma is likely to make the world even more difficult to navigate for individuals living and coping with mental health concerns.

In recent years, efforts to increase mental health awareness and reduce stigma have led to some changes, including more accurate portrayals of mental health issues and those who experience them, but much work still needs to be done. One particular portrayal that fell flat appeared in the movie Split, released in early 2017. In this movie, which was roundly criticized for its portrayal of mental health conditions, a character with dissociative identity disorder (DID) had a dangerous alternate personality. As a counselor who treats dissociative conditions such as DID, the majority of which are not characterized by violent behavior toward others, this was particularly disturbing to me.

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It is imperative we, as a society, receive accurate information about not only DID but all mental health conditions, instead of relying on the distorted information, provided by Hollywood and other unreliable sources, that so often leads to fear and discrimination.

Prevalence of DID

When I was in graduate school, dissociation wasn’t really highlighted. It was only briefly mentioned before we quickly moved onto “more common” mental health concerns. Based on this, I assumed dissociative conditions, DID in particular, were such a rare phenomenon I was highly unlikely to encounter them in practice.

As it turns out, this couldn’t have been further from the truth. DID and other forms of dissociation are far more common than many think. In fact, according to the Institute for the Study of Trauma and Dissociation, it is estimated the prevalence of DID in the general population is between 1 and 3%. In inpatient psychiatric units (including those for adolescents, eating disorder treatment, and substance abuse programs) the prevalence is estimated to be between 1 and 5%.

Factors in the Development of DID

There are varying theories about why a person might develop DID. One theory, based on the work of pioneers in the diagnosis and treatment of dissociative disorders—Pierre Janet, Francine Shapiro, Onno van der Hart, Frank Putnam, Colin Ross, Stephen Porges, and Bessel van der Kolk, among others—is that DID is a way the brain learns to organize itself in order to survive traumatic experiences. This theory, incidentally, describes my own belief about DID’s origins. In my work with people who have developed DID, I have found 100% of them to have experienced some kind of trauma in childhood, including ritual abuse; neglect; sexual, physical, or emotional abuse; and medical trauma, among others.

To better understand DID, we must consider the nervous system and information processing system in the brain. When a person has normal, healthy experiences, the brain is able to take in this information, decide what is important and what is not, and then file it away in the area designed to hold memory. When the person recalls the experience, there likely won’t be much of an emotional charge when bringing up the (non-traumatic) incident.

However, when a person, particularly a very young person, experiences trauma, the nervous system immediately experiences a heightened sympathetic nervous system response (also known as “fight or flight“). When the child—DID typically begins in childhood—goes into this sympathetic nervous system arousal but cannot fight off the pain, perpetrator, or trauma, the next best thing they can do is to shut down into a hypoaroused, numb, disconnected state. The nervous system is in survival mode, and the integrative capacity of the brain is compromised and therefore unable to properly integrate the information. Thus, the traumatic memory stays frozen in time.

As the child grows up, these parts/alternate memory may become more distinct, and subsequent traumatic events may cause the brain to divide further into various parts to hold on to the aspects of trauma. These parts take on distinct personalities and identities.

For people with DID, pain and abuse are experienced again and again. Because these experiences are pervasive and so overwhelming to the nervous system, the person’s brain has to split off the experience(s) so they can continue to survive and function in life. One or more alternate memory networks, or parts, are created in the brain to hold the various components of memory to allow the person to continue to function. In a child who has experienced or is experiencing abuse, this process is particularly helpful as they attempt to survive in an environment where they are being hurt by their caregivers but must depend on those who are abusing them at the same time. Essentially, the process of dissociation allows a person to survive what might otherwise not be survivable.

As the child grows up, these parts/alternate memory may become more distinct, and subsequent traumatic events may cause the brain to divide further into various parts to hold on to the aspects of trauma. These parts take on distinct personalities and identities. This internal dynamic, if not treated, continues into adulthood. Some parts are responsible for helping the person to function in daily life. Other parts continue to hold any unresolved traumatic memories, feelings, sensations, images, thoughts, and beliefs the person experienced at the time of trauma.

A person with DID may or may not be fully aware of the dynamic inside. Often they believe they are “crazy,” but the reality is they are incredibly resilient. They are intelligent and creative. They are generally not at all like the dangerous, unstable characters often depicted in films and television—though viewing these portrayals could lead them to believe they are in fact similar, or at least appear to others as such. In my experience, people who have DID are often high-functioning and highly adaptive. In fact, you have likely met someone with DID and not known—people with this condition are generally adept at skillfully navigating social situations because they have clever parts who learned how to adapt to various challenges.

Treatment for DID

Although they navigate the world skillfully, people with DID experience real suffering. The parts or alternative memory networks holding the trauma may become activated and bring about various challenges:

These parts are not malicious in their intentions. They are merely operating with the information they hold, which is not complete. Often, these parts do not know the trauma is over. They are not aware the person got out of the situation and became able to act on their own and do things to keep themselves safe. Essentially, the whole system wants to feel better, but sometimes parts are not on the same page. This is where therapy helps.

The great news for those who have DID is that the condition is treatable. Good therapy treats DID (as well as the underlying trauma) not by attempting to “get rid” of parts. Instead, a well-trained therapist will help the system orient to the present, work with the person seeking treatment to explore each part and help them learn to together, and help the system work through the memories that could not be integrated at the time of trauma.

If you want more information on the realities of dissociation, a good resource for research-based, accurate information is the Institute for the Study of Trauma and Dissociation.

The next time you see an example of any mental health issue (not just DID) in the media, suggesting people with that condition are unstable, dangerous, or undesirable, remember to consider the reliability of the source and seek out the truth from experts and reliable organizations.

References: 

  1. Chu, J. A., Dell, P. F., Van der Hart, O., Cardeña, E., Barach, P. M., Somer, E., … & Twombly, J. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115–187. Retrieved from http://www.isst-d.org/downloads/guidelines_revised2011.pdf
  2. Nedelman, M. (2017, January 23). What Shyamalan’s Split gets wrong about dissociative identity disorder. CNN. Retrieved from http://www.cnn.com/2017/01/23/health/shyamalan-split-movie-dissociative-identity-disorder/index.html

Young adult with red hair and beard, wearing light blue buttondown shirt, lies on grass with eyes closedPeople seek counseling for any number of reasons, but something every person I have ever seen had in common is wanting to feel better quickly. I can hardly blame them. When I am not feeling well or things aren’t going right, I want things fixed in as little time as possible.

It is part of our human nature to seek solutions. When we are in pain of any kind, the brain immediately starts scanning to find a way out of the discomfort. The reality is that, for most of the people I work with in therapy, it takes time to work through and resolve the issues at the root of their pain. A longer-than-expected timeline for relief can be discouraging for the person seeking help. To give a person some degree of relief in the present moment, it is necessary to implement stabilization and coping skills so they can begin improving their quality of life and functioning.

There are so many options when we starting talking about coping and stabilization skills. Go to the self-help section of any bookstore and you will see several selections for coping with life. I have a bookshelf and a file drawer full of countless options, and it can be overwhelming to decide where to start. Each skill has its benefits and strengths, and it’s handy to have a variety of tools for handling life’s stressors. That said, I have a favorite: the simple, yet powerful, breath.

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This is where I start with most people: just breathing, paying attention to the breath, and noticing the depth and rate. It sounds so easy, right? As straightforward as it may seem, the breath has serious influence when it comes to calming the nervous system.

Let’s talk about science for a moment. Bessel van der Kolk (2012) does an excellent job of explaining how the nervous system operates in his book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. In the book, van der Kolk discusses Stephen Porges’ Polyvagal Theory, which is all about the role of the vagus nerve in arousal and social engagement.

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It comes down to this: We have two branches of the nervous system. The sympathetic nervous system, which can be considered “the accelerator in the nervous system” (van der Kolk, 2012), controls levels of arousal and the fight-or-flight response so we can effectively respond to threats. When this part of the nervous system is activated, the heart rate goes up, breathing becomes shallow and fast, and blood rushes to the extremities in preparation for fight or flight following the cues being sent from the sympathetic nervous system.

By connecting to the breath, you are able to be in the moment, becoming more mindful with what is happening now as opposed to engaging in the mental chaos that so often distracts us from what is actually happening around us.

Of course, this reaction is not activated only in response to actual threats to safety. It also happens in response to life’s stressors, including any core issues or traumas we haven’t yet worked through. Therefore, we end up experiencing all of the physical and mental consequences when are in a state of chronic sympathetic nervous system arousal (van der Kolk, 2012).

The other branch of the nervous system, the parasympathetic nervous system, is “the brake of the nervous system” (van der Kolk, 2012). The vagus nerve controls this part of the nervous system and can be broken down further to the dorsal vagal complex and the ventral vagal complex. The dorsal vagal complex is designed to drop your body into a freeze-and-flop response when the sympathetic nervous response is unsuccessful in achieving fight or flight. This is the state of shutdown or hypoarousal (van der Kolk, 2012).

Similarly, the ventral vagal complex also slows the body down, but it differs from the dorsal vagal complex in that its main function is not to respond in an extreme way to a threat or high levels of stress. Rather, it activates a relaxation response and helps the body to grow, heal, and digest. It also helps us to seek out and connect with others. When the ventral vagal complex is activated, we can feel a wide range of emotions but the nervous system is not overwhelmed and thus does not have to enter the shutdown response.

Here is where the breath comes in: When you breathe out slowly and mindfully, the ventral vagal complex is activated and your body is able to relax. More blood is directed to the parts of your brain that are involved in problem solving, and you are able to enter the state of social engagement. By connecting to the breath, you are able to be in the moment, becoming more mindful with what is happening now as opposed to engaging in the mental chaos that so often distracts us from what is actually happening around us. By specifically paying attention to exhaling, you are simultaneously calming the body and the mind (van der Kolk, 2012).

Harnessing the power of the breath is something we all can benefit from at any time. Regardless of whether a person is in therapy, we all need to calm the nervous system from time to time. Being mindful of the breath can help a person to deal with everyday stresses that we all inevitably encounter. Simply paying attention to breathing can help us to focus better and, therefore, make us more productive and effective in our lives.

Reference:

van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking.

A young professional hides face in hands while leaning against a fenceShame has a bad reputation. Let’s face it: it doesn’t feel good. I mean, who really wants to feel shame? It’s uncomfortable, even downright painful at times.

Here is something to consider, though: shame (closely related to guilt and regret) is an essential part of our survival and functioning and, in fact, is a gift from Mother Nature.

Let’s back up here a bit and first talk about the functions of emotions generally. Emotions are hardwired into our brains and help to warn us, facilitate connections to other people, and work through challenges. “Positive” emotions such as joy, pride, and love tend to feel good, while “negative” emotions such as anger, shame, and sadness tend to cause discomfort. It is easy to want to push away and avoid the “negative” emotions, but it is important to note that both types of emotions are necessary in order to function in the healthiest way possible.

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Now let’s get back to our friend, shame. Shame’s function is pretty important. Basically, it helps to keep us in check. Shame is a signal that there has been some sort of action that could harm others or ourselves. This could be an action that hurts a relationship with a loved one, something that could get us in trouble somehow, or a behavior that would be dangerous or harmful to us.

When we utilize shame appropriately and feel the right amount all the way through, it can be corrective and preventative in that it helps us to not make the same mistakes again. Having shame also helps us to repair when an action has caused harm to relationships. It helps us to identify and take accountability for our actions, and when others see we are experiencing some degree of shame, defenses usually go down and healing conversations can take place. When we feel shame about something self-inflicted (drinking, drugs, putting ourselves in dangerous positions, etc.), we can assess the steps we need to take in order to prevent doing future harm to ourselves.

We all do things that warrant feelings of shame, guilt, and remorse. It is part of the human experience. Making mistakes is an important part of learning, and shame is an excellent teacher.

As great as shame can be, sometimes we can have too little or too much. In doses that are too small, we do not get the full opportunity to learn from the experience. Our system is not able to fully register that we have engaged in a behavior that warrants some degree of remorse. As a result, we may be more likely to engage in the damaging behavior again, possibly with negative life consequences.

Too much shame can overwhelm us and distort the experience. We may blame ourselves for things we should not take accountability for (like someone else’s actions) and end up in an impossible position where we are trying to learn someone else’s lesson. The system becomes confused when shame is distorted because we are not able to control or prevent future actions of others.

Finding the right dose of shame is key. When assessing whether you have too much or too little shame, ask yourself: Did I engage in a behavior (or behaviors) that caused harm? If the answer is no, it is important to assign correct responsibility and to check in with yourself to make sure you are not taking on another person’s lesson. If the answer is yes, ask yourself: How much harm was caused by the behavior and would it be harmful if repeated? It is often helpful to use objective others as sounding boards when assessing your level of shame so you can learn from the situation and move forward.

We all do things that warrant feelings of shame, guilt, and remorse. It is part of the human experience. Making mistakes is an important part of learning, and shame is an excellent teacher.

Person looks over shoulder while running“Why do I feel scared even when I’m not in danger?”

This question, or something approximating it, is one of the most commonly asked by people seeking treatment for trauma, many of whom describe an intense fear when they encounter something that isn’t, in reality, a threat to their safety. These people are aware of this fact cognitively. They can articulate the truth of the situation, but it doesn’t take away the intense symptoms that are experienced.

There is a very good reason for this—and it lies within the structure of the brain and nervous system.

First, let’s talk about fear and its function. Fear is a hard-wired emotion in the brain. We are born with it, and thank goodness. Think of fear like an alarm system. It alerts us to threats in our environment so we can respond effectively and keep ourselves safe. This comes in handy when there is an actual threat. When there is a risk to our safety, the fear circuit is naturally engaged to alert to danger.

Under normal circumstances, we are able to check in with the situation to determine if there is a real threat. For example, if you are walking down the street and hear a loud sound that startles you, your body responds and you look around to see what made the sound. If you discover it was a car backfiring, you see there is no threat and you are able to continue on, recognizing that your safety is not compromised. If it is something truly threatening, such as someone with a gun, you go into survival mode of flight, fight, or freeze. Once the threat has passed, ideally you would be able to talk about what happened, process through it, and know that even if you weren’t safe at the time, you are safe now that the threat is gone.

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Although the fear response is normal and key to survival, the fear circuit can get stuck in a type of feedback loop and over-coupling with danger, which tends to cause a person to experience the common symptoms associated with trauma. When a traumatic event is experienced, certain structures of the brain go offline because traumas are intense and the brain goes into survival mode. As a result, the traumatic memory is not stored like a normal memory. It is instead stored in an isolated, fragmented, and frozen way. Because it is isolated from other memory and knowledge, when one is triggered by something that reminds the brain or nervous system of the memory, that information does not have the ability to readily connect with other information in the brain, which makes the nervous system believe the person is in danger.

When a traumatic event is experienced, certain structures of the brain go offline because traumas are intense and the brain goes into survival mode. As a result, the traumatic memory is not stored like a normal memory.

The nervous system then does its job very well, trying to alert the person to danger, even if there is none. Keep in mind this process in entirely unconscious. We can’t think ourselves out of the nervous system’s automatic response.

It is common, post-trauma, to see an over-linking between fear and danger because of the brain process described above: the person has frozen fragments of the trauma that are maladaptively stored in the brain, which means there are also maladaptive linkages. The brain does not know it is safe because parts of it are frozen in time. The over-coupling of fear and danger is even more severe when a person has experienced pervasive trauma throughout life.

Once people understand this process, it is usually relieving to know they are not “crazy” and their nervous systems are simply trying to promote survival. Understanding the dynamic that is happening in the body is the first step to uncoupling fear and danger. Some of the work in uncoupling is done with specific interventions such as EMDR (eye movement desensitization and reprocessing) therapy, somatic experiencing, and/or ego state therapy. However, between sessions a person can aid this process by simply paying attention to the moment. Paying attention to body sensations, emotions, reactions, and the environment is a big part of the work. Periodically checking the environment for safety can be especially helpful. Noticing what it’s like to be triggered, have fear, and still notice you are safe takes it to another level and can advance the uncoupling process.

Downcast girl sitting on fenceIf the title of this article threw you off a bit, it’s OK—I understand why it would. After all, forgiveness is quite the hot topic. Religious leaders, spiritual gurus, and even some mental health professionals emphasize the importance of forgiveness as a part of finding true happiness and freedom. I get where they are coming from. I can understand how forgiveness could be beneficial in some circumstances. For example, if a loved one says something uncharacteristically harsh in the heat of an argument, and you would like to keep that person in your life, it may be beneficial to understand that we all sometimes say things we don’t mean when we are upset and to forgive him or her in order to move forward in the relationship.

I work with people who have experienced horrific traumas at the hands of other people. These traumas include acts of sexual abuse, rape, exploitation, and physical and emotional abuse. Some of the perpetrators are relatives and some are not. Regardless, the degree of trauma in each of these cases is significant and has had a major impact on their lives and well-being.

The people I work with in the therapy room are resilient and courageous. They are able to work through their traumas, but many get caught up on one point: They believe they are supposed to forgive the perpetrator but can’t seem to get there.

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This is what I tell them: You don’t have to forgive in order to move on.

Understand that if a person comes in and finds that the word “forgiveness” resonates, I do not discourage it. We roll with it. But often people struggle with this word, and rightfully so. They do not want to imply what happened to them was in any way OK. They don’t want to excuse the perpetrator’s behavior. They feel the perpetrator is not deserving of forgiveness. The worst thing I can do as a therapist is to talk people out of the way they feel.

Emotions are important and automatic. When we can acknowledge and appreciate even the darkest, most negative-feeling emotions, they often soften and release. As soon as I say, “You don’t have to forgive,” the person usually breathes a sigh of relief.

Once we have determined that forgiveness is not necessary, we work on finding a word that will be more congruent for the person in his or her trauma work. I like the word unburdening.Once we have determined that forgiveness is not necessary, we work on finding a word that will be more congruent for the person in his or her trauma work. I like the word unburdening, which is something I first heard in Richard Schwartz’s book Internal Family Systems Therapy. I understand unburdening as a letting-go process. That is, letting go of the power the trauma has over a person, expressing and releasing anger and other strong emotions about what happened without criticism or expectation of what needs to come next. This includes allowing a person to have as much time as is needed to feel whatever he or she is feeling. This may include rage, hate, and resentment, among other emotions.

It is equally important for others to refrain from pushing someone into forgiving a perpetrator. Even if the intention is coming from a good place, trying to get someone who has been violated to forgive can feel like being victimized all over again. Instead, it is more helpful to validate that the person is entitled to his or her feelings. Being a listening ear instead of trying to fix the issue is much more supportive and healing. The person needs to be able to have a voice and express what he or she is feeling and thinking without the fear of judgment.

The brain and body are so intelligent. It is important to allow the natural process of working through trauma to happen and to remove any barriers that may get in the way. This includes the belief we aren’t supposed to feel “negative” emotions or that we have to forgive. Once we remove that expectation, the natural process moves through. Even if someone doesn’t get to a place of forgiveness, he or she can still move on, unburden themselves, and thrive.

Couple hugging and holding handsAccording to the Centers for Disease Control and Prevention, in the United States 6.7 million women between the ages of 15 and 55 experience either problems getting pregnant or carrying a pregnancy to term. That is more than 10% of women in this age range. Chances are you or someone you know has experienced or will experience challenges related to fertility.

Infertility often has biological causes, but the emotional effects can be especially devastating for a couple trying to conceive. The National Infertility Association discusses these emotional effects, which may include:

In addition to these symptoms, I have noticed the people I work with in therapy experiencing the following:

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Infertility is traumatic. In addition to depression symptoms, it is quite common that couples experiencing infertility will experience anxiety in response to certain situations or triggers (such as seeing pregnant women, pregnancy tests, babies on TV or in person, etc.). They may experience intense emotion around certain times of the month, particularly the times near ovulation and when a period is due. Going in for fertility treatments may become very triggering and anxiety provoking, particularly if previous interventions failed. Sadness and grieving are common, particularly around holidays and other important life events.

When someone is experiencing infertility, negative beliefs about one’s inadequacy or defectiveness may come up. Both partners may question why their bodies are not functioning like seemingly everyone else’s, especially when those around them are having babies, apparently without any trouble.

If there has been past pregnancy loss, other triggers for anxiety, depression, and intense emotions may come up, including the date a baby was due or times of year associated with the loss. Triggers can seem unrelated or random but still have a profound effect on the emotional reaction of the people going through this difficult situation. For many, infertility feels like riding an emotional roller coaster of anticipation, worry, sadness, grief, and anger.

When someone is experiencing infertility, negative beliefs about one’s inadequacy or defectiveness may come up. Both partners may question why their bodies are not functioning like seemingly everyone else’s, especially when those around them are having babies, apparently without any trouble. People struggling with this issue may question their value and their self-worth can take a major hit, resulting in magnified depression and hopelessness.

The stress and trauma that result from infertility can also have a negative impact on a relationship. Because both partners experience their own challenges in infertility, they may be more prone to snapping at each other, taking things personally, or feeling disconnected.

There are steps people who are experiencing the emotional complications of infertility can take in order to cope and eventually thrive through this major life challenge.

1. Seek Professional Assistance

A mental health professional can help address the symptoms one is likely to encounter when experiencing difficulties related to infertility. Coping skills, trauma work, and couples counseling are just a few of the areas a therapist can help someone to work through to make this difficult path more bearable.

When working with people with infertility issues, I often utilize eye movement desensitization and reprocessing (EMDR) therapy to address negative beliefs about worth and defectiveness. EMDR has also been helpful in addressing and reducing disturbance related to fertility treatments, pregnancy loss, and worries about the future. When trying to get pregnant and while pregnant, stress management is essential in helping the body to be at its best to conceive and carry a baby.

2. Give Yourself a Break from Social Media

Social media can be wonderful, but they can be triggering for someone who is going through infertility. People love to make pregnancy and birth announcements through social media. Someone experiencing infertility may be much more sensitive to these announcements, as they can feel like a reminder of the pain that person is bearing.

If such announcements are triggering, give yourself a break and stay off social media for a while. Work with a therapist to decide when and how you will begin to engage in social media again. Working through some of the trauma and practicing coping skills regularly can help reduce the triggering effect of social media.

3. Acknowledge and Feel Your Feelings

Emotions are meant to be felt. One of the main jobs of an emotion is to alert us that we need to pay attention to something. Emotions can do what they are supposed to do only if we are willing to acknowledge and feel them.

The human body and brain are very good at working through difficult material when we stop avoiding emotions and allow ourselves to feel fully. A therapist can help with learning to tolerate and regulate emotions.

4. Celebrate and Enjoy the Little Things

Infertility can consume your life. From your thoughts to your time to your emotions and your relationship, it seems that there is not an area that infertility does not impact.

With your partner, find reasons to celebrate life. Engage in fun activities that you wouldn’t or won’t be able to do while pregnant or with a newborn. Try to soak up the moments of joy, calm, and fun as they come up. Seek out new hobbies or activities you have wanted to try. It is important to find joy and meaning in life, even when you are going through a difficult time.

References:

  1. Centers for Disease Control and Prevention (2006-2010). FastStats: Infertility. Retrieved from http://www.cdc.gov/nchs/fastats/fertile.htm
  2. Dunkel-Schetter, C., & Lobel, M. (1991). Psychological reactions to infertility. In A. L. Stanton and C. A. Dunkel-Schetter (Eds.), Infertility: Perspectives from stress and coping research (pp. 29-57). New York: Plenum.
  3. The National Infertility Association (2014). Emotional aspects of infertility. Retrieved from http://www.resolve.org/support/Managing-Infertility-Stress/emotional-aspects.html

GoodTherapy | The Brain in Defense Mode: How Dissociation Helps Us SurviveAccording to Ross and Halpern (2011), there are several definitions of dissociation. One of them (referred to as “the general systems meaning of dissociation”) is “the opposite of association” or the disconnection of two or more things that were once associated with each other. Another definition, presented by Steinberg and Schnall (2001), defines dissociation as “an adaptive defense in response to high stress or trauma characterized by memory loss and a sense of disconnection from oneself or one’s surroundings.”

Dissociation occurs when someone disconnects from some part of himself or herself or the environment. It can occur in a number of different ways, including disconnection from one’s emotions, body sensations, memories, senses, etc. A normal and common phenomenon, dissociation can happen in mild forms even when there is not imminent danger or stress. Think of a time you drove somewhere, arrived, and then couldn’t remember the drive because your mind was wandering; an instance when you lost track of time because you were engrossed in a riveting television show; or when you disconnected from body sensations to avoid going to the bathroom when you were on a tight deadline at work.

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Dissociation is something we all do, and it is a vital part of our ingrained survival system. It is a part of the system that helps us to cope with stressful situations, which may otherwise feel overwhelming (Steinberg and Schnall, 2001). It is built in and is not pathological (Ross and Halpern, 2011). However, when a trauma occurs, sometimes this built-in system disconnects to a greater degree in an effort to protect the individual from traumatic material, body sensations, emotions, or memories that may be overwhelming.

Dissociation related to trauma occurs in varying degrees. On the lower end of the dissociation spectrum, for example, let’s say someone was in a car accident. A few days after the accident, the person finds that he or she cannot recall parts of the accident, even though reports of others were that he or she was conscious and responsive during those times he or she cannot recall. On the other end of the spectrum, someone who was severely abused throughout life can dissociate to the point that he or she has more than one personality, all of whom display and contain their own characteristics and who hold different memories associated with the trauma.

The goal in therapy is not to eliminate dissociation completely, but rather to help the brain and body to update to the current circumstances. Specifically, this would include helping a person to integrate current information about the present circumstances in which they live.

For the traumatized individual, dissociation may help him or her to survive circumstances that may have otherwise been intolerable. Dissociation can help a person feel as if situations, his or her body sensations, emotions that would have been overwhelming, etc., are muted and distorted so he or she can then go into “autopilot” mode and survive extreme situations and circumstances. When trauma is ongoing, dissociation can become “fixed and automatic” (Steinberg and Schnall, 2001). When this is the case, integration of memories becomes difficult for the brain, and the brain also continues to send of signals of danger, even when the traumatic situation is over (Steinberg and Schnall, 2001). This can continue for years after a traumatic situation has ended.

According to Steinberg and Schnall (2001), the five central symptoms of dissociation are:

For someone who is concerned that he or she is experiencing a more-than-normal incidence of dissociative symptoms, help is available. Several accurate tests are available through therapists and psychologists who have been specially trained in diagnosing and treating dissociation and trauma.

The goal in therapy is not to eliminate dissociation completely, but rather to help the brain and body to update to the current circumstances. Specifically, this would include helping a person to integrate current information about the present circumstances in which they live. If no danger currently exists, helping the brain and body to learn how to be safe would be one part of treatment. Working toward being able to maintain awareness of the present moment, body sensations, emotions, surroundings, etc.—also known as mindfulness—is one way to start to address dissociation, especially prior to any trauma work that needs to be addressed.

As a therapist, I appreciate dissociation as a valuable gift our brains are able to give us when we endure trauma. I emphasize to the people I work with in therapy that dissociation has helped them to survive, and we can acknowledge that this is a defense that has perhaps worked for longer than it was intended. It is important to remember that experiencing more than a regular level or type of dissociation as a result of trauma does not make a person defective. Rather, it shows that he or she has been able to live through and survive extraordinary circumstances that no one would be able to endure without the brain’s ability to dissociate.

References:

  1. Ross, C., and Halpern, N. (2009). Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity. Richardson, Texas: Manitou Communications.
  2. Steinberg, M., and Schnall M. (2001). The Stranger in the Mirror. New York, New York: Harper.

GoodTherapy | Between Therapy Sessions: 3 Handy Coping Skills for TraumaWhile it’s true that working with a good trauma therapist enhances healing, not all trauma work happens in the therapy room. Even when a person regularly sees a therapist, the trauma work does not stop because a therapy session has ended. On the contrary, the brain keeps working and sorting through traumatic material in an effort to heal and move forward.

The brain is incredible in its resiliency and natural tendency toward healing. The brain wants to heal, but in doing so, sometimes distress happens. For example, when the brain has nightmares or flashbacks after experiencing a traumatic event, it is in fact attempting to heal by trying to bring forth information related to the trauma. But the distress and anxiety from experiencing these intrusions and related trauma symptoms can cause a person to want to (understandably) push away the memories and other intrusive symptoms related to the trauma.

It is not uncommon for intrusive symptoms to sometimes increase at the beginning of trauma therapy. As much as trauma therapy helps, it can also cause discomfort and intense emotions as a person faces and works through the traumatic memories. Therefore, having effective coping skills to use between therapy sessions is imperative. Below are three skills that can be used in or out of therapy sessions.

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1. Body Scan

The body often tenses as it prepares to fight, flee, or freeze due to continued trauma symptoms, even long after the traumatic event has ended. The body holds onto trauma, which can cause it stay on “high alert” status. This is exhausting and can take a toll on your health. Body scan is an exercise during which you pay attention to parts of your body without changing anything you notice. The objective of this exercise is not to relax. It is simply to be aware of what is happening in a particular moment.

Why doesn’t the body scan encourage relaxing the tension or pain you find? Because sometimes just noticing the tension you find is enough. Also, releasing any expectation of what is supposed to happen during the exercise can relieve anxiety about the exercise itself and make it more effective. If you have the expectation that you are supposed to feel relaxed during the exercise and that is not what you experience, negative thoughts about “not doing it right” may come up, which can cause distress.

During this exercise, you can start at the head, feet, or any other part of the body, and then pay attention to each part or section of the body at a time, noticing any sensations that come up. You may notice tension, itching, discomfort, or no sensation at all. The key is to just pay attention and to be aware. If you get distracted, simply notice that you got distracted without criticizing yourself, and gently redirect your attention back to the part of your body you were focused on.

2. Containment

Containment is one of the skills I was taught early in my EMDR training and it has become one of the stabilization skills I teach most frequently. This exercise is effective in utilizing the brain’s natural ability to contain material. It involves imagery of a container of some type that can hold onto material that is distressing or disturbing, until the time you feel better able and prepared to deal with it.

To utilize this exercise, imagine a container of some type: a box, safe, vault, trunk, etc. Whatever the container is, it should have a door or lid that you can open and close as you please. The container needs to be big enough and strong enough to hold anything that is causing distress. When something distressing comes up and it is not possible or optimal to address whatever is coming up in that moment, imagine letting the traumatic material go into the container temporarily, until it can be addressed at a later time.

The objective of this exercise is not to disregard or ignore the important information that the brain is trying to communicate. Rather, it is meant to allow the brain to set aside distressing information for the time that it is optimal to address the material. This helps to prevent becoming too overwhelmed by trauma symptoms, which often include intrusive thoughts, images, and memories. It is beneficial to discuss with your therapist the thoughts/images/memories/etc. you contain between sessions so that he or she can help you sort through the material in the container, a little at a time.

3. Body Movement

Sometimes the body is our most underutilized resource. Recent research by Bessel van der Kolk, et al. (2013) found that a yoga practice as a supplementary treatment for posttraumatic stress (PTSD) dramatically decreased symptoms of PTSD in participants. The researchers in this study theorize that yoga practice may help individuals with trauma to learn to more effectively tolerate and cope with body and sensory sensations, in addition to helping them to learn to tolerate intense emotion.

It is my belief and experience that, whether it is yoga or some other form of exercise, moving the body has major benefits and enhances trauma healing. The exercise or body movement you choose does not have to take a great deal of time or money. Some people report that simply walking and stretching has positive benefits on their ability to cope between sessions. People often report that engaging in some form of exercise or body movement also is helpful in gaining self-appreciation and the ability to self-soothe and nurture.

I have found with the people I work with in therapy that, when used consistently, the above skills help to move trauma work forward as they begin to feel more confident in their ability to tolerate intense emotion and distress. Contact a qualified trauma therapist if you think you might benefit from some guidance.

Reference:

Van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., and Spinazzola, J. (2013). Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trail. Journal of Clinical Psychiatry, 75, e1-e7. Retreived from http://www.traumacenter.org/products/pdf_files/Yoga_Adjunctive_Treatment_PTSD_V0001.pdf

Runner athlete legsWhen people think of eye movement desensitization and reprocessing (EMDR) therapy, they generally think about a treatment for trauma, which is partially accurate. Treating trauma is what EMDR therapy was developed for and continues to do. But since its development and introduction over 25 years ago, it has become more than an intervention and is now a comprehensive psychotherapy, one that is exceptionally effective in addressing multiple issues and challenges.

A common misconception is that a person has to be struggling with mental health or major life challenges to benefit from EMDR. On the contrary, one of the most interesting and innovative uses of EMDR has been in performance enhancement in addition to its ability to decrease fear, stress, or anxiety related to performance.

How EMDR Works

In short, EMDR therapy accesses and links the multiple facets of memory (image, cognition, emotion, and sensation) and uses bilateral stimulation/dual-attention stimulus (eye movements or tactile or auditory stimulation) in order to decrease disturbance associated with specific incidents in a person’s life. It taps into the brain’s natural ability to heal and helps it file away memory appropriately so that when the memory is recalled, there is no disturbance associated with the memory.

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Other Ways EMDR Can Help

EMDR has several wonderful applications. In addition to decreasing disturbance associated with trauma, it is effective in decreasing anxiety and targeting irrational or negative thinking, both of which may get in the way of performance. In addition, it can help a person to gain confidence in his or her ability to perform a task or reach a goal. EMDR works to achieve this by installing positive beliefs, and by having a person imagine doing the thing he or she is nervous to do or wants to improve in while doing bilateral stimulation. This has the effect of simultaneously decreasing the fear, anxiety, or stress associated with the task and boosting confidence.

It seems that EMDR helps the brain to think in a healthier, more adaptive way by removing blocks (such as negative self-beliefs) and helping the person to tap into his or her strengths.

An Example of EMDR in Practice

Sometimes EMDR is hard to conceptualize without a specific example. Here is a hypothetical one.

Alice wants to implement healthy habits into her life, so she has set a goal of exercising three times per week. However, she is self-conscious when she thinks of going to the gym. She worries about other gym members and trainers judging her.

She visits an EMDR therapist to help her reduce her anxiety and to boost her confidence in going to the gym. The therapist completes a thorough history and teaches her stabilization and calming skills to utilize between sessions and (if needed) during the desensitization phase. Once fully prepared for the next phase of EMDR therapy, Alice and her therapist assess and desensitize any past experiences that feel related to the current experience.

Once there is no longer any disturbance associated with past experiences, they then assess and target the current situations that are triggering for Alice. Specifically, Alice targets the image of the gym, the belief “I am not safe,” emotions (fear and insecurity), and body sensations associated with this target. They use bilateral stimulation and work through the target until no disturbance remains, Alice is able to fully believe the thought “I can keep myself safe,” and she no longer has any negative body sensations associated with the target.

Alice and her therapist then move to the next phase of EMDR therapy, during which future situations are targeted. During this phase, Alice plays a movie in her head, imagining herself packing her gym bag, getting in her car, driving to the gym, going into the gym, completing her workout successfully, and leaving the gym feeling a sense of accomplishment. Alice finds that when thinking about this scenario, she has some anxiety and another negative belief: “I am going to fail.”

Alice plays the movie through several times, all while the therapist provides bilateral stimulation. If Alice finds she gets stuck, she lets the therapist know and the therapist helps her to work through the sticking points. She finds that each time she plays the movie in her mind, she is less anxious and more confident in her ability to go through the actions she is imagining. She eventually finds that she no longer believes she will fail and, while playing the movie the last few times, instead holds the belief “I am strong and capable.”

The next time Alice goes through the actions of preparing for and going to the gym, she has far less anxiety and much more confidence.

Of course, every case and person is different, but this is a simple example of how EMDR may be helpful in not only addressing past and present issues related to performance, but also in enhancing future performance and decreasing anxiety related to potentially triggering situations. The number of sessions will vary from person to person, but it has been my experience as a therapist that EMDR is both efficient and effective. Contact a therapist trained in EMDR if you think it might be beneficial for you.

Caring FriendVictims of domestic violence will sometimes display specific behaviors or attitudes that make loved ones unsure about how they can help. Please keep in mind that victims of domestic violence are very capable and strong. Their reactions to their experiences are normal, human reactions in the face of abuse and complex emotions, including issues with children, finances, and love and attachment to the abuser, among many other complexities that accompany this type of situation.

Below are five common reactions that victims of domestic violence may exhibit and how you can respond and help.

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1. Denial

In this scenario, the victim is in denial that the abuse is happening. Even though his or her loved ones are noticing abusive behaviors, he/she pretends everything is great.

2. Defensiveness

In this scenario, the victim comes to the defense of the abuser and is not open to discussing the abuse or leaving the situation.

3. Wishy-Washiness

This is a situation in which the person goes from one extreme to the other. The victim will ask for help and either leave the relationship or express a strong desire to leave. A short time later, he or she justifies the abuser’s behavior and returns to the relationship. This can be very frustrating for loved ones; sometimes, loved ones may feel like giving up on the person.

4. Withdrawal

It is not uncommon for victims of domestic violence to become completely withdrawn and hard for loved ones to access. This could partially be due to the abuser isolating the victim to gain more control over him/her and could be compounded by depression and negative self-views, which is common in victims of domestic violence.

5. Fear

In this scenario, the victim expresses he or she wants to leave, but has fears about leaving. These fears are valid, and major barriers to leaving a violent relationship do exist. Common barriers are threats by the abuser of killing the victim and/or children if he or she leaves, harming pets or children, and financial concerns and constraints, to name only a few.

Of course, it is important to keep in mind that every situation and person is going to be different. It is not uncommon to see a combination of the above reactions. Keep in mind that these are complex situations that don’t always have simple solutions. If you suspect that someone you love is in an abusive relationship, connect with the National Domestic Violence Hotline, your local domestic violence coalition, or click here for additional suggestions and support.

Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.