The Complexity of DID

The Complexity of DID

Dissociative Identity Disorder (DID) is such a complex and highly controversial diagnosis in the field.  There are many in the medical community who deny its existence and even some in the field of mental health who are skeptical.  Despite the skepticism, it continues to find its way into the DSM and into our offices.  As a professional, I admit having a mostly healthy fascination with this disorder.  Early on in my career I began focusing most of my practice in trauma, and therefore have probably seen more than the average number of clients who would fit into the category of having DID.  Once you’ve seen this disorder play out, it’s hard to hold on to the skepticism and disbelief.  Believe me!

I find it so unfortunate that a lot of the individuals with DID who come to my office, have been through years of facilities, multiple diagnosis, and various therapies which has been in so many ways more harmful than helpful to them.  Clinicians who work with trauma, specifically complex trauma, are ethically bound to know the signs of DID.  This will allow for quick, accurate diagnosis that can then make smooth the decisions of treatment planning, treatment placement, and scope of practice.  Colin A. Ross, recently published an article in the Journal of EMDR Practice and Research, about how to notice the signs of DID and accurately diagnose.  Below are the early indicators Dr. Ross identifies for when to suspect DID.  For diagnosis, I have referenced the article below for further reading.

When to Suspect DID

1.       Trauma History  - A reported history of extensive, severe childhood trauma (which does not have to be corroborated).  This trauma does NOT have to include sexual abuse

2.       Borderline Personality Disorder – Prior diagnosis of BPD, criterion for BPD currently met or subthreshold.  It is common for depression and PTSD to be comorbid with  BPD.

3.       Voices- Auditory hallucinations which are usually chronic.  The voices may or may not have names and ages and often meets DSM-IV Criterion A for schizophrenia.

4.       Blank Spells- Discrete periods of missing time lasting anywhere from minutes to days (without use of drugs, alcohol, or medical condition).

5.       Switching- Sudden changes in behavioral state

6.       Prior Diagnoses – Extensive history with the mental health system, numerous prior diagnosis often including: BPD, bipolar disorder, schizophrenia, schizoaffective disorder, PTSD, substance abuse.

Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

As you continue in your practice, learn to see the signs that further assessment is needed for the possibility of DID.  Some helpful assessments include the Dissociative Experience Scale (DES),  Dissociative Disorders Interview Schedule (DDIS) , and for children/adolescents the Child Dissociative Checklist.

Accurately recognizing and diagnosing DID can be such a relieving experience for clients.  It also helps you, the clinician, make the best possible decisions for the client about treatment moving forward.  For more information on this article see Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

The ‘Stuck Place’

One of the most frustrating things that can happen in therapy for clients and clinicians alike is getting into a ‘stuck place’.  That place where the client is reporting no progress, the therapist is running out of ideas, and a camaraderie of hopelessness can be born.  The ‘stuck place’ can also be a petri dish for clinician and client shame (also known as transference and counter-transference).   The clinician may cycle into blaming self; ‘I’m not good enough’, or ‘I’m just too new at this’, or ‘I’m a failure and should change jobs’.  Alternatively the clinician may cycle into blaming the client ‘they are not trying hard enough’, or ‘they have a personality disorder and can never change’, or ‘they just don’t want it bad enough’.   The ‘stuck place’ is that place that everyone wants to avoid, but finds themselves on occasion throughout their career. 

I’ve found that when a client and I land in a ‘stuck place’, getting back to the basics in counseling help us get movement one way or another.  Below are some strategies to help you and your clients if you ever find yourself in the ‘stuck place’.

1.       Call it out!-  Meaning begin your next session with “I feel like we are in a stuck place, and I’m wondering if you have noticed the same thing?”.  Get the client’s thoughts and feelings about where they may be stuck and strategize together on getting movement. 

2.       Reassess Client Goals – I’ve learned that one of the fastest ways to move through the stuck place is to go back to the client’s original goals.  If I cannot clearly identify what the goals are, then the next session is spent working with the client on identifying specific measurable goals. 

3.       Evaluate therapeutic Alliance – Have a conversation with the client about how they feel about coming to therapy.  Ask if they feel like the current relationship is working for them or if they may desire something different.  Strategize with the client about other options that may be out there that have not been tried (e.g. medication, other treatment modalities, more intensive services if needed).

4.       Consult – Our profession can be a lonely profession.  Having a small community of professionals whom you can meet with regularly and staff the ‘stuck places’ with, not only helps you professionally, it benefits your clients tremendously.  We are never so seasoned that another perspective can’t be helpful.

So the ‘stuck place’ doesn’t have to be a scary place, or a petri dish.  The ‘stuck place’ is actually an opportunity for growth clinically and personally as it challenges us to get back to the basics of good ole fashioned therapy.  The ‘stuck place’ creates space to slow it down and reevaluate.  So remember the next time you find yourself there, return to the basics 1) Call it out, 2) reassess client goals, 3) evaluate therapeutic alliance, and 4) consult. 

Binge Resting

As I consult and supervise with clinicians across the country a theme that regularly comes up is that of fatigue.  Some call this fatigue all the classic signs of burnout; dread going into the office, tired of doing what your doing, frustrated with clients, frustrated with self, and just plain weary.  Approaching this topic as most supervisors would, I look for a personal balance for the clinician around self care.  What I have found is a pattern of what I coin Binge Resting.   When rest is explored a little more I hear things like “I’m just holding on till summer vacation”, or “I have a weekend planned in the mountains”, or “If I can just make it till….”  The pattern appears to be work, work, work till exhaustion, binge rest, work, work work till exhaustion, binge rest, etc.  The end result is never feeling rested.  It has become quite the phenomenon however, and one that if we look at it clinically, is just as unhealthy as all the other things that can be ‘binged’ on. 

So we have to challenge ourselves to think about it in a clinical way.  If you ate the way you rested, what would that look like?  If you drank the way you rested, what would that look like?  If you shopped the way you rested, what would that look like? And so on and so on….  You may find alarmingly that your rest life fits into one of the following categories: anorexic resting, binge resting, balanced resting. 

What is healthy rest?  Other cultures do this well.  In some cultures there is a mid day ‘siesta’ or ‘rest time’.  In other cultures one day a week is devoted to rest.   Individual rest life can be personalized.   Below are some things to consider when examining your ‘rest life.’

1   

--       * Examine your priorities: What are your priorities in life?  Does your current work life, play life, social life, rest life fit nicely with those priorities?  Or are they in conflict?

2    

      * Get a clear picture of balanced rest. How would a balanced rest life look in YOUR life?  If it were possible to imagine having a balanced rest life, how would you know it was happening?  What would be different? How would you see yourself being with others? What would be present if stress and anxiety were not there anymore? How would I know by looking at you that you were a rested person?

3      

      * Set small goals: Start daily.  What is one thing you can do each day that would be restful?  A space of time where you are not DOING anything (including watching t.v. or reading books).

4       

      * Consider starting a daily mindfulness or Prayer practice for at least 30 min.:  Research supports the use of mindfulness and prayer in the reduction of stress, anxiety, and burnout.  There are many user friendly apps, books, and videos on how to do mindfulness exercises with guided options for first time attempters.  There are also books and videos on centering prayers which act in the same way as mindfulness exercises. 

Our goal driven, product driven culture lends itself to setting anorexic and binge resting as the norm.  As a profession that works to help promote health and balance, I challenge us to set a new standard of balanced rest.  Begin by 1) examining your priorities, 2) get a clear picture of what balanced rest would look like for you, 3) set small goals, and finally 4) consider starting a daily mindfulness/prayer practice.  

Compassion Fatigue

“How do you listen to those stories all day long then go home to your family?” 

“How do you separate work and home?”

These are questions I get asked all the time by clinicians and non-clinicians alike.  The answer isn’t an easy one.  It’s actually more of a journey.  I have spent more than 12 years working in some capacity with trauma victims.  The terms ‘compassion fatigue’, ‘secondary trauma syndrome’, ‘burnout’ have all been thrown around, trained on, and warned about throughout my entire career.  I learned early on what this was when I would go to dinner with my husband and space out thinking back on a client’s session I’d had that week.  Or when I would jump when someone would hug me, preparing for them to attack me.  Then there were the times that I would wake up from a nightmare in which I experienced my client’s ‘story’ as they had told it to me.   Quickly I learned that something had to change about what I was doing in order for me to keep helping in the field I loved.  I was so fortunate to have great mentors who spoke into me early on in my career and whom I felt safe enough to ask for help.  What I learned from them are 5 ways to help prevent compassion fatigue. 

1.      Set Boundaries – With clients and with your friends and family.  You should not be the only one your client relies on.  Use community resources and hotlines, create safety plans that involve other numbers and people to call other than you.  Set boundaries with your friends and family by not going to gatherings if you need the rest and self care time.  Find other resources to help your friends and family so that you are not the main provider for them as well as your clients.

2.      Set a ritual to leave it at the office- For me I bow my head and offer up each of my clients I’ve seen for the day in prayer.  I give them to the Great big God that I serve who can help them a lot better than I can outside of the office.   I then get up and literally leave it there in God’s hands.  As I leave my office I turn my mind over to what needs to be done when I get home and call my husband to switch gears into home life.   Setting some kind of ritual for yourself that you do every time you leave your office as a way of ‘Leaving it there’ can greatly increase your separation from it when you leave.

3.      Create your own container- In EMDR Therapy we use a resource called a container where we use guided imagery to create a container of any shape and size needed to contain disturbing materials for clients.  I have my own container for the hard stuff I hear.  When I can’t seem to stop thinking about it, I close my eyes and send it to my container in my office to be pulled out and examined when I have time and space set aside on a work day.

4.      Practice Mindfulness living – Learn the art of gently bringing yourself back to the present moment.  When you catch yourself recalling a session with a client, gently let it fade out of consciousness and pull your focus back to the present moment focusing on the 5 senses of sight, smell, taste, touch, hearing.  Continue to do this whenever you catch yourself and let yourself truly feel the moment you are living in.

5.      Seek your own therapy if needed- One of the greatest forms of self care is realizing that you may need some help getting past either your own story or a client’s story.  Finding your own therapist to process with and learn some additional tools to help separate it can be very beneficial to both you and your clients.

As you continue to listen to the hard stories and struggle with figuring out ‘can I keep doing this?’ know that it is possible to do this work and stay separated.  Know that there are strategies available for helping make that easier.  And know that it is a journey.  A journey that can begin by implementing the 5 prevention steps mentioned above 1)boundaries, 2) setting a ritual, 3) creating your own container, 4) practicing mindfulness living, and 5) seeking your own therapy.

If you are wondering if you may be struggling with compassion fatigue or secondary trauma, Click Here for a helpful assessment resource that you can take, score, and then help guide you as you begin your journey to self care.

Addressing Sexual Behavior in Children

“I caught my 7 year old child hiding in the closet with our neighbor’s child.  Their clothes were off and they looked guilty.  I told them to get dressed and sent the neighbor child home.  I don’t know what to do now.  I’m tore up inside and do not want my child suffer the rest of their life because of this”.

The call came from a desperate mom just hours after this event took place.  It really is one of a parent’s worst nightmares.  After the initial shock, the questions  set in, “will this affect them for the rest of their life?”  “What do I do?”  “Does my child need help?” “Do I call the police?”

While this is one of the worst moments a parent can find themselves in, there is a step by step structured approach you can help them take in the moment of discovery and post discovery.  If you are a professional who gets this phone call, consider walking that parent through the following steps. 

Instructions to Parents---

If you catch them in the act:

1.       The most important thing is stay calm.  Take a deep breath and ask the children to either dress, or stop engaging in the behavior they are engaging in.

2.       Separate the children and ask what was going on- After the children have dressed ask one to stay in one room and another in the other room.  Calmly talk to each child to get the story of what they were doing, what made them decide to do it, and how often have they done it.  (avoid shaming the child by telling them what they did was dirty, disgusting, or bad)

3.       Bring the children back together and talk about Sexual Behavior Rules:  Say it’s ok to be curious about body parts however it is not okay to do the following with that curiosity:

School Age

1.       It is not ok to touch other people’s private parts.

2.       It is not ok to show private parts

3.       It is not ok for other people to touch your private parts

4.       It is ok to touch your private parts in private

5.       It’s not ok to make other’s feel uncomfortable with your sexual language or behavior

Preschool Age

1.       No touching other people’s private parts

2.       No other people touching your private parts

3.       No showing private parts to other people

4.       No touching your own private parts when others are there

5.       Touching your own private parts when you are alone is ok

Begin enforcing these Sexual Behavior rules in your home from here forward.

4.       When trying to decide if you need to call your local authorities, you may find the following link for TN related sexual behaviors and reporting helpful.  Click Here  (Be aware that the laws are different in each state, so check out your own state Gov. website to be sure).

5.       Allow your child to come talk to you about what they did or experienced as they need too.  If they have questions you do not know how to answer, let them know you would like to talk with them further but would like to set a specific time and place to do that.  Then you can find some helpful resources to help prepare you for that conversation by contacting an area professional or even your local pediatrician.

Lastly as you worry about if this will have a lasting impact on your child, consider watching for the following signs.  If they are present, your child may need to see a professional about what happened.  If they are not present you may just continue monitoring your child, allow space for them to talk to you more and trust that they have processed what happened in a way that will not make a lasting impact.

Signs you may need to consult a mental health professional:

a.       Extreme change in their behavior (they go from outgoing to isolated or vise versa)

b.      They become fearful of people or places

c.       They begin wetting the bed

d.      They begin having regular nightmares

e.       They play with their toys in a sexual nature

f.        They become aggressive

g.       They complain of their tummy or head hurting

To summarize for them remind them they are being a great parent by being concerned.  Moving forward  they need to 1) Address rules about touch  2) allow space for their child to talk about it  3) monitor their child for signs they may need additional help. 

Checking Out

The ‘checking out’ phenomenon, otherwise known as dissociation, is one of the most feared symptoms experienced in our profession (next to suicidality and psychosis of course).  Specifically, those clinicians who have decided to dedicate their career to focusing on trauma, addictions, eating disorders or personality disorders are starting their path with an understanding that dissociation may show up somewhere along the journey.  Other clinicians hold the blissful denial that they will never have to deal with it.  Reality is, dissociation shows up in all of our offices at some point, and it is advantageous to know when it does.  Then of course is the logical next step, what to do.

In the context of experience, dissociation is a natural phenomenon in all human beings. Consider a time you took a regular route in your vehicle and you remember getting into your vehicle, starting it, backing out, then starting on your way.  Then sometime later you realize you are pulling into your destination with little memory of actually how you got there.  A phenomenon we can all relate too.  This is the most basic of dissociation levels.  Bruce Perry, M.D., Ph.D. postulates “Dissociation is the most primitive of reactions: earliest life forms, infants, and the very young rarely escape dire situations of their own accord. For infants and young children, dissociative response to extreme stressors is common. If it’s prolonged it is connected with increase in PTSD symptoms.”  Under this explanation we understand that trauma in the developmental timeframe of childhood, commonly results in dissociation.  Continual trauma in childhood results in the regular occurrence of dissociation which can eventually become habitual. 

What does it look like in your office? On the simple end of the spectrum it can be experienced as a client stating they feel foggy, floaty, or numb.  On the more complex end the client may describe feeling robotic, disconnected from the present moment, or even shift before your eyes into someone quite different than what you have experienced in your client before.  A lot of times clients do not really know they are dissociating.  Those who do it often do not know that it is something unusual, and frankly if they do they are embarrassed to let others know.  In my experience they do not come out and tell you this is something they do regularly, because they think it makes them ‘crazy’ (their word not mine). 

I’ve learned to ask in my intake process about childhood experiences, this can be done in a psychosocial, genogram, timeline, or family history assessment.  When trauma’s are mentioned by the client, I make it a point to add in an element of psychoeducation on trauma, it’s impact on the brain and common reactions/symptoms of trauma.  Part of that psychoeducation includes explanation of dissociation.

That is the beginning process of how to notice it and then what to do.  As the clinician the next step is teaching the client ‘present living’.  Present Living is part of many treatment models today, including many marital/relationship models, family models, and solution oriented models.  These models are about helping the client live in the moment and out of reactivity.  This is exactly what the objective with clients who dissociate is as well.  For those clinicians who practice ‘present living’ models, just add one additional step of teaching a client who regularly dissociates how to ground.  Simply put, it’s teaching the client to be mindful or aware of when dissociation is happening and then giving them the tools to stop the dissociative process and return to the present moment. 

Watch the following video to get an example of an effective therapeutic tool to use to help ground clients who are dissociating. 

Or click on the following link to watch a demonstration of the “Senses Bag” a technique I use to teach clients how to ground.

Dissociation doesn’t have to be scary.  At the simplest explanation it’s a symptom.  Now you the clinician have some resources that can help address and eliminate this symptom for a client.

****Dislcaimer- Complex forms of dissociation should only be addressed by clinicians trained to address the complexity of those symptoms (e.g. DID, dissociative fugue, and depersonalization disorder). However basic forms of dissociation can be addressed by all clinicians.  If the symptom persists or gets worse, seek consultation. ****

Preventing Drop Out

Preventing Drop Out

In a previous post “Helping People”, we looked at variables that can impact client retention within the therapist.   As we continue to study ‘client drop off’ with the intent of preventing it, we must consider the question “is there anything I can do to prevent client’s from dropping out of therapy”.  

This question may be uncomfortable for many of us.  I mean we have spent so much time as a profession making ourselves less responsible for client’s change and empowering them to take that responsibility for themselves.  What if both can happen… what if we can take responsibility and they can take responsibility for that change.  Whew…I can feel anxiety rising from here.  But before you stop reading consider a better question… where does my responsibility end and theirs begin?

I recently attended a webinar with Scott Miller around outcomes based treatment approaches.  I have heard this concept over the past few years and have allowed the concept to percolate in my mind.  But it wasn’t until recently, during this, webinar that I feel like I truly grasped the concept to it’s fullest in terms of my responsibility and the client’s responsibility. So bear with me as I try to put into words my ‘light bulb’ experience. 

Clients are coming to therapy for something to change.  Either a loved one has encouraged (or forced) them to come in the hopes of change, or they themselves have come in again with the hopes of change.  So if that is the product….change, then I have a responsibility to that client to: 1) understand the change they want 2) Identify if I’m the best person to help them get to that change 3) Know who are other people in the community that could help get them that change if I can’t.

The client has a responsibility to 1) Tell me the type of change they are wanting 2) Tell me if and/or when that change is occurring 3) Provide feedback on the customer service they are receiving through the change process.

So you may say ‘how does this prevent drop out?’  Well imagine with me what could happen differently if you were to add 3 simple things to what you are already doing…just three. What if you added a brief assessment of the change the client is desiring into every session. This gives them the responsibility of looking for their change and reporting that it is or isn’t happening.  Second, what if you had a way of getting feedback on your customer service, again giving client the responsibility of telling you what is/isn’t working for them.  Finally, what if you had a structured protocol to follow when change isn’t happening, giving you the responsibility to direct client to where change may better happen. The only thing that will happen differently when you add these three things is catching potential drop out clients early, before drop out.  With the prevention of drop out, clients get the opportunity to share what is not working for them, and can collaborate with you on what may work better.

When considering these three additions, here are some helpful tools:

1.     *  Change Assessment – Outcome Rating Scale (ORS)

Trauma Recovery Scale (part III) TRS- 

Outcome Questionaire (OQ-45)

Partners for Change Out5come Management Systems (PCOMS)

2.   
*  Customer Feedback Assessment (Therapeutic Alliance) -  Session Rating Scale (SRS) 

3.      

*          *  Structured Protocol –

·       If after 3 visits no change – staff case with colleague/supervisors

·       If after 5 visits no change – Start looking for other places/referrals and begin talking to client about that option. (Referral may include medication management, psychological assessments etc.)

·       If after 8 visits no change- Recommend referring

Based on research that if change has not occurred by the 12 week of treatment a decline or drop out most likely will occur.

Resources: http://www.scottdmiller.com/wp-content/uploads/2014/06/The-Outcome-of-Psychotherapy-2013.pdf

http://counsellingresource.com/lib/what-works/

http://scottdmiller.com/wp-content/uploads/documents/BeyondIntegration.pdf