[7] Metaphorical hand-holding helps the frightened child who keeps reliving the trauma, helping them to process it in small digestible doses.
Treating PTSD involves metaphorically holding the hand of an injured and terrified child. It is comforting them so as to enable them to process the impact of the trauma in a way that protects them from being overwhelmed or re-traumatized. It is to enable them to process the trauma in small dose that are digestible and not overwhelming to the individual.
The therapist must resist the urge to learn the details of the abuse unless and until the patient wants to reveal details. And then, no follow-up interrogation of the patient. Avoid asking questions when they are based primarily on the curiosity of the therapist. All historical events of trauma must be seen as private to the patient. We only find out as much or as little as is required to get the patient over the distress. Remember we are not police detectives writing up police report. The details of the trauma is of limited therapeutic relevance except to the extent that an alter needs to express it. The need to express, and to protect from re-traumatization, is of therapeutic relevance – not the details that are expressed.
[8] “The body keeps the score” so help the patient connect with their body.
The memory of the trauma is kept in the body. Therefore, a physical approach rather than an intellectual approach is at times more relevant in therapy. Teach “grounding” techniques. Spend time to teach how awareness of the breath can impart calmness as can physical exercise and movement. Patients can use that awareness to ground and so neutralize the panicky feelings.
Flask-backs are best understood as a combined physical and psychological event rather than simply a psychological event. Some alters have severe PTSD features in the form of flashbacks. In a flashback, the alter is essentially reacting bodily to the memory of the past trauma. In other words, the past trauma is intruding into the patient’s present. He/she is in fact re-living a segment of the original trauma. The body is reacting/behaving as if it is actually facing that same trauma. Imagine if you had once been attacked by a man-eating tiger. The next time you see that kind of carnivorous animal, your body would no doubt flood itself with adrenaline. You might run as fast as possible in the opposite direction when you hear the roar – even if this time you see that the animal roaring is caged in the zoo.
The individual is frightened and confused during a flashback because they are experiencing a massively hyperactive sympathetic branch of the autonomic nervous system that is not in accord with their actual perceptions. The affected individual is not in control of his/her hyper-reactive physical state. Even though their sense perceptions are giving them the same information we interpret as no big deal, their nervous system is screaming danger. In other words, PTSD is basically a disorder where an individual experiences flashbacks of trauma that take away control of the body. The body goes into panic mode when encountering a trigger, like encountering a sudden storm when you are traveling in a calm sea. For those not triggered, it seems like the individual is completely panicking at the drop of a hat.
Treatment is essentially teaching the individual to take back the control of his/her own body. When flashbacks happen in therapy, if the therapist remains calm, there is a powerful transmission of that calmness to the patient. Simply teaching the patient that attending to the one’s breath in the present moment can be an effective way of giving them the skills to handle the flash back. Self-induced calmness means empowerment. It means that one has found a way to overcome this distress though one’s own effort. A self-generated sense of calmness is a skill that can be regained by the patient, the result of which is vastly superior to a tranquilized sensation induced by a pill.
Drug induced calmness, even as it works, maintains the patients in a dis-empowered helpless role. He/she is being trained to rely on the availability of the medication when the next panic attack or next symptom appears. This avoids addressing the real issue, which is the past trauma taking over the present experience. In other words, with medication, one remains in a helpless posture. Further, it is common to find the body needing a higher dose of medication, the next time panic or agitation arises. Exclusively administering drugs to treat PTSD symptoms is doomed to failure and runs the substantial risk of chemical dependency.
Treating DID is teaching an individual how handle the result, the consequences, of having had tremendous overwhelming and repeated exposure to early trauma. The mind is fractured. What is left behind is a system of split and conflicting parts forced to live together in one body. Prior to appropriate DID therapy, each part likley has only varying degrees of awareness of the split. Each part has its own agenda.
How to bring about a fragmented selves to function in a cooperative way is the task of the therapist. How to deal with flashbacks is the key skill to teach through communication, cooperation, and compromise. In the wider world, we need to learn to live with our neighbours. Within their systems, those with DID need to learn to live with the divided parts to learn how to control impulses and delay gratification when necessary. Both the path and result of healing is that we have to do it ourselves, not through use of an external agent, like a pharmaceutical.
[9] EMDR or CBT (cognitive behavior therapy), are only tools to use in the treatment of symptoms in PTSD.
If they are helpful to any particular patient, that is great. But, they are not exclusive tools for treatment. Therapists must know how to apply these tools, like surgeons knows how to excise a malignant tumour. But, just as surgeons know that there are often other options for treatment than surgery, therapists must be familiar with other options as well. Tools can be used but their limitations must be recognized.
Using an antidepressant for someone with DID is like using a cough medicine in someone who has chest infection. There are cases where a patient may have a true brain disease that has a fair chance of responding to pharmaceutical intervention. But, so far there is no laboratory method to diagnose these cases, to separate them from depression that requires predominantly a psychological approach for its healing. We rely on subjectively identifying a group of symptoms to fit into a diagnostic label.
In PTSD, whether the result of early childhood, wartime or other trauma, the brain is set to a hyperactivity mode, like a thermostat that is set a few notches off the scale. So far, purely using a mechanistic approach, like chemical or physical methods, has failed miserably. Witness the poor track record of treating veterans with PTSD, returning from the Gulf war and from Afghanistan. The result have been very disappointing when pharmaceutical methods are used exclusively.
It is unlikely that there will be a magic pharmaceutical agent that can exclusively used to heal the damage of early childhood trauma that results in DID. We must come to our senses to recognize that to fix the cause of a car accident, we cannot just focus on the mechanical parts of the car. We need to understand the whole car, driver, weather, and road conditions to actually understand what really happened. In that same way, we must look at the entire patient beyond a simple mechanistic view.
With empathy, compassion and a willingness to engage the alters, by both the therapist and the patient, healing is possible.
