Transcript: Episode 132
132. Guest: Cathy Kezelman
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Our guest today is Dr. Cathy Kezelman. She’s a medical practitioner, mental health consumer advocate, president of Blue Knot Foundation, National Center of Excellence for Complex Trauma. She’s a current member of New South Wales Child Safety Standing Committee for Survivor and Faith Groups. She’s past director of the Mental Health Coordinating Council, past member of the Mental Health Community Advisory Council, and a foundational member of the National Trauma Informed Practice and Advisory Working Group, member of Independent Advisory Council on Address.
Cathy worked in medical practice for 20 years, mostly as a GP. Under her stewardship, Blue Knot Foundation has grown from a peer support organization to a national center of excellence, combining prominent consumer voices with data researchers, academics, and clinicians, advocating for socio-political trauma-informed changes, and informed responsiveness to complex trauma. She’s a prominent voice in the media and at conferences, as well as author of a memoir chronicling her journey of recovery form childhood sexual abuse, Innocence Revisited: A Tale in Parts. She’s co-author of multiple seminal Blue Knot Foundation documents, including the long awaited for, The 2019 Practice Guidelines for Clinical Treatment of Complex Trauma. This is what we’ve been waiting for and this is what we’ve been telling you about.
The Blue Knot Foundation is Australia's National Center of Excellence for Complex Trauma. It empowers recovery and builds resilience for the more than five million, one in four, adult Australians with a lived experience of complex trauma… this includes those experiencing repeated, ongoing interpersonal trauma and abuse, often from childhood as an adult, or both, as well as their family and communities.
Formed in 1995, Blue Knot Foundation is at the forefront of pioneering trauma informed policy, practice, training, and research. It provides direct services to survivors, specialist trauma phone counseling, and educational workshops for survivors and their family members, partners and loved ones, as well as an extensive professional training program for workers, professionals, and organizations from diverse sectors supported by supervision and consultancy services. It also has extensive resources, including fact sheets, videos, publications, and website information at www.blueknot.org.au.
It has launched the new 2019 updated Practice Guidelines for Clinical Treatment of Complex Trauma. These guidelines have been endorsed by us, as well as others from the ISSTD. The 2019 guidelines have also been extensively endorsed by leading academics, clinicians, and researchers in the complex trauma and dissociation field, prior to their release. They provide an integrative guide for diverse practitioners working with complex trauma and dissociative clients. In addition, a companion guide to the 2019 guidelines combine complimentary guidelines, which provide an overview of the differences between working with complex trauma clients and standard counseling approaches, as well as a guide to therapist competencies for working with complex trauma and dissociation have also been released.
Hard copies and free downloads of each publication are available from Blue Knot’s practice guidelines portal. These links will be provided on the blog.
What you need to know about this episode is that before we talk about the guidelines, which everyone has been waiting for, and is super excited about, that we promised were coming, Dr. Kezelman first shares her own personal story. She does this without trauma dumping or overly triggering, but it is a difficult story like the rest of ours, where it is not trauma-specific in the things she shares in this interview, but it is very vulnerable and raw in sharing the difficulties of the process of the healing and therapeutic journey. So, if this piece is too triggering for you, fast forward through half the episode. But there’s no specific trauma disclosed or discussed during the interview.
As part of sharing her story, she does reference the struggle with suicidal ideation. While this is not at all discussed in depth, I do want you to be aware of it as a trigger warning going into the episode. As always, keep yourself safe during and after listening to the podcast. Thank you.
After she shares her story, we speak more about the Blue Knot Foundation and the new guidelines, and why we think they’re so important. We will talk about the guidelines themselves, and the research behind them more specifically with another interview. But for now, we welcome Dr. Cathy Kezelman.
Yeah, so my name’s Cathy Kezelman. I’m a doctor by training. I also have my own lived experience of complex trauma and dissociation, and I’m president of the Australian national organization, Blue Knot Foundation.
Can you tell us a little bit about what Blue Knot is?
We’re the National Centre of Excellence for Complex Trauma. We’ve been around since 1995, and our focus is firstly advocacy around the needs of adults who have experienced different forms of trauma, usually repeated interpersonal trauma as a child, as an adult, or both. And we focus on empowering recovery and building resilience. We do that in a number of ways. We run a number of different helplines to support people where they can get short-term counseling, support, information, referrals. We run educational workshops for survivors and their loved ones. And we also have a very extensive professional development training program around the country, where we seek to build the trauma-informed literacy of workers, professionals, you know, diverse people, across multiple sectors. And around that we wrap supervision and consultancy. So, we’re really helping trying to drive trauma-informed changed processes through the community.
We also run programs for clinicians as well around working clinically with complex trauma and also around mitigating vicarious trauma. Part of what we do is develop a lot of resources. So, our website is rich with fact sheets, and videos, and information, as well as a lot of publications.
That’s just incredible. Tell me about the publications.
Yeah, so looking into 2012, we published a set of practiced guidelines, nationally, internationally, called The Last Frontier: Practice Guidelines for the Treatment of Trauma and Trauma Informed Care in Service Delivery. And that now, has been downloaded over 25,000 times. And what they did was elaborate and recommend embedding the core components of effective complex trauma treatment across all different kinds of psychotherapeutic modalities. Since then, we’ve released an economic report around the cost of unresolved childhood trauma, specific publication for the legal fraternity, Trauma and the Law, and then a paper around memory, The Truth of Memory and the Memory of Truth, looking at the different types of memory and the significance of trauma.
Last year, we released a Talking About Trauma series, and that was talking about trauma both in the general public for services, and then for primary care practitioners. Because as we know, people are very reluctant to scratch the surface of conversations. But I suppose, you know, over the last several years since those first practiced guidelines in 2012, there’s really been virginging, I suppose, of neruoscience, and those clinical insights. And so we felt that it was time to update the 2012 guidelines, and so that’s what we’ve done recently. We’ve just released The 2019 Practice Guidelines for the Clinical Treatment of Complex Trauma, and they include substantial additions to the underpinning research that’s in a number of areas, you know, looking at the nature of complex trauma, much more about dissociation, and the related challenges in working with dissociation, looking at phased therapy, and current debates around phased therapy, new and many treatment approaches and issues with the respect to what is evidence and what is evidence-based treatment.
So, you know, that’s a very significant publication, and that’s just been launched. It’s already been endorsed, internationally, by a number of significant leaders of trauma and dissociation. And it’s also been launched with a set of combined complimentary guidelines, which look at the differences between working with complex trauma clients and standard counseling approaches, as well as what are the competencies for working safely with people who’ve experienced complex trauma.
And next year, not to slow down, we’re anticipating releasing a set of guidelines around trauma-related dissociation, and also for clinical supervisors - people supporting practitioners who work with complex trauma clients. So, you know, it’s a big program, but one we feel is much needed, because there remains a real lack of understanding around complex trauma, and it’s different from single incident trauma, and really an inability, because of a lack of training and cross-counseling colleges and universities, around dissociation - identifying and working with it. And so, you know, we’re very keen to, you know, contribute to filling that gap.
It’s beyond description, what you all have done. And the first set of guidelines, and now updating them -- it’s just powerful. The community has been asking and pleading for this. And people, since I’ve talked about, on the podcast, that I would be speaking with you -- I have gotten email after email after email of people just begging [laughing] to know more.
Oh, that’s very lovely.
Yes. They’re so excited, and so I know everyone’s going to be thrilled to hear about this. But before we jump into the guidelines a little bit… do you want to tell me more about your story, I mean, what you feel comfortable sharing, and how on earth you got from your story to all of this?
Yes, so look, I mean, my story is just part of obviously many, many stories. But obviously for me, it’s unique, and it’s a long story of recovery. So, let me just paint the scene a little bit. I was a medical practitioner. I mean, I still am. And I was working away in a busy group in general practice. I was also a wife and mother of four young children. And life was frenetic. And I used to -- manage with the parental duties -- but in retrospect, I had very little self-awareness. I really didn’t know how to acknowledge my needs, or be present in the moment. My life was very much about doing and not about being.
And I abhorred weakness, especially my own, and I really didn’t know how to ask for help. I was emotionally detached, and expected everyone, especially myself to just get on with it. I did my life by achievements, and was often intolerant, judgmental, and mocking. And I’d really perfected my own form of black humor, which some medicas is very good at. [Laughs] Other Medicas -- what they did was reinforce the barriers I had erected from preventing anyone from getting too close.
So, that’s not a great picture, but there are reasons for it. You know, despite that I was a successful doctor and being a doctor really gave me an identity, which I didn’t have otherwise in my personal life. And of course, you know, in my role, I’d referred people to psychiatrists and psychologists, but I perceived that as for being people with weakness and frailties, for which I couldn’t relate.
When I was in my 40’s, mid-40’s, my niece who I was very close to, died suddenly in a car accident. And her death paralleled another sudden death that I’d experienced as a child. And that was the trigger, which started my inner-world unraveling. And after Angela died, grief subsumed me, but it didn’t abate at all over time, and I was soon overwhelmed by, you know, what for me were uncharacteristically intense emotions. My practice, my home life suffered, and it took a near crisis in my medical practice for me to admit that I needed help. Doing that meant acknowledging the vulnerability I’d always denied.
I didn’t want to see a psychiatrist. They were for mad people, and that wasn’t for me, of course. So, I took a massive leave and made an appointment with a female clinical psychologist, who I’d referred to before. So, of course, you know, from my fiercely independent attitude, I thought it would be a few quick sessions, just to steady the -- to balance the season -- balancing my system -- the imbalance in my system. That was two decades ago.
So, within a couple of sessions -- and we’ll call the psychologist Kate -- she delineated the boundaries around sessions and contact and cancellations. I really resented being the patient. Most of all, I really hated being asked to talk about myself. The first session was excruciating, and the next few intensely uncomfortable. There were many lengthy embarrassing silences as I’d endeavored not to relieve a thing that was personal. Kate was empathic and warm and her office was comforting and containing, but I still felt like a lamb to the slaughter. In those early weeks, I continually fantasized about bolting, and tried to out-silence her by staring down so she’d be forced to speak rather than me. But she was a past master at sitting in silence, and all my attempts and asides and distractions started to fail miserably.
So, before long, without me really knowing how it happened, I was seeing my very own psychodynamic psychotherapist twice a week, for 50 minutes at a time. And you know, those sessions provided me with space for my feelings and thoughts and needs to be identified and listened to and heard for the very, very first time in my life. And a space which was safe, in which ultimately my trauma could be explored and processed.
So, I’d been in therapy for a few weeks when Kate asked innocuous questions about my childhood - about childhood friends, school teachers, classrooms, favorite foods, etc. I was shocked at how little information I could recall. And I blurted out what had become a very standard line for me, and that was, “I had a happy childhood. My mother told me so.” But I had nothing to back it up. But I’d always dismissed my poor memory, cringing when my friends would reminisce, and I simply couldn’t. So, over many months it became apparent that I had virtually no memory for 10 years of my childhood, and it really started to trouble me, because I was a doctor, I should have been reasonably smart. If I was smart, then why couldn’t I remember.
I didn’t, of course, know anything about traumatic amnesia back then, and Kate didn’t explain it. She let my story unfold in its own time. So, in those first few months I really struggled to trust Kate, and to feel safe, and my anxiety just grew. Then I had my first panic attack - the first of many. My medical training was useless. I thought I was going to die. Kate explained what they were, and before long, despite myself, I started to depend on her, but not without testing her arriving late to sessions and canceling appointments. She patiently assisted me in holding space and boundaries.
My approach and avoidant behaviors, of course, reflected my distrust and attachment issues, but she was consistent. And that availability started to address them. So, as time went on though, I became more depressed, withdrawn, and felt less safe overall. Yet, my relationship with Kate was evolving, and I did feel safe in her office, just nowhere else. And as soon as I walked out her door, I no longer felt held at all. I couldn’t internalize her caring, or know that she could keep me in mind, as this was an early experience for me.
But as Kate became the maternal thinking mind I needed, I tested her availability by calling her repeatedly. I didn’t want to talk to her. I just wanted to hear her voice. When she did answer, I’d hang up, as I didn’t know what to say. I didn’t know how to communicate my needs at all. You know, I was incredibly needy, and by now, extremely anxious and more agitated than not. Sometimes I’d leave a message on her answering machine, and then anxiously wait for her to call back. But when she didn’t call straight back, I knew that she didn’t really care about me, or so I thought.
So, my first flashback scared the living daylights out of me, and again, my medical training didn’t help. My mind kidnapped me and my body adopted a life of its own. I experienced it outside of therapy, in the safety of my husband's arms, and it terrified us both. As I arrived in pain, terror, and confusion, I thought I was losing my mind. I didn’t know about flashbacks, or that these fragments of dissociated experiences in the past couldn’t hurt me. As they intensified and became more frequent, I told Kate about them, but was too ashamed to reveal their content. She understood. Maybe I wasn’t mad afterall.
She suggested that I should write about them, and I did that, and brought the writing to therapy. At first I couldn’t read what I’d written, so with everything was my shame. I’d hand the material to her, and she’d read it. Eventually I could speak some of it out loud, and we explored it together. In terror, the sensations, the intense emotions, the body contortions -- but there was little to no context, and that made it hard to interpret.
And what was incredible was it just seemed to be outside of my realm of experience, and yet here it was. As my flashbacks intensified, my depression deepened, and I considered suicide. My life became my memories, and my past subsumed the present with my everyday life, all but disappearing. Kate had worked hard to ground and orient me back into the world in the present. After each session, she would scrutinize my plans. By now I was profoundly depressed and barely functioning. And I was forced to render myself and my identity as a doctor, which of course, kept me further adrift.
But, the reality was that I could barely get out of bed and I struggled to attend to my home and to my children’s needs, as I flipped repeatedly between my daily life as a middle-aged mother to being a four, sixteen year old terrified and agonized child. My husband picked up the pieces of the home and family.
Kate made herself more available, and remained reliable, and predictable - rarely running late for a session or being interrupted during my -- seeing her became my lifeline. I would start the countdown to our next session as soon as I left her office. I longed to feel safe, if only for 50 minutes a day, three or four times a week. I still regularly tested her in our relationship, but she held firm when she needed to be. But she was always patient, empathic, and validating.
By now I’d withdrawn into my familiar isolated childhood space, initially withdrawing from the rest of my friends and from my family as well, and of course that put me at enormous risk. Kate worked hard to keep me connected. She told me to walk into my children’s bedrooms when they weren’t home, to look through photo albums, and keep family photos in the world and in the car. I needed to be drawn out of my isolation repeatedly. She urged me to get out of the house, to join a gym and get some exercise, and to take the dog for a walk. I tried, but you know, sometimes those suggestions were totally absurd, when I was at my lowest I ever was. I couldn’t do that. I couldn’t at all.
Despite seeing Kate three, four, sometimes five, times a week with phone calls in between, my mood plummeted further. A psychiatrist prescribed antidepressants, which I took begrudgingly. I still didn’t want to admit that I was unwell, or worse, still needy. At first, the medication took the edge off my mood, but as suicidal thoughts filled my days, trips to the gap, a local cliff face became a daily occurrence. I didn’t tell Kate about this for weeks, but when I did, Kate was calm, and urged me to call her whenever I needed to. That battle with suicide raged on and off for years. I really didn’t want to die. I just wanted to end my pain, which is excruciating.
On several occasions, Kate and I talked about a hospitalization, but we ruled it out as my relationship with her was fundamental to my survival. On a few occasions, Kate urged me to sign a contract, which I did. I don’t know how or why, or if I really resented it, being coerced to do it, but I always replied.
As time progressed, I learned to keep Kate’s presence in my mind, outside of sessions, yet with the slightest perceived inconsistency, I would doubt her all over again. Meanwhile, the flashbacks continued with a vengeance, and I became overtly dissociative in my everyday life, but especially around and during my therapy. I covered it with my kids, pretending that I was kidding around. But for the first time, I realized that I had undoubtedly been dissociative from early childhood, and now more often than not. I would dissociate more as each appointment approached, and arrive for the session completely spaced out. And when Kate asked me in, I couldn’t get up. She’d find me in the waiting room unable to move, and sometimes had to lead me by the hand into her consulting room.
By now, my memories were returning thick and fast, no longer with my husband, but from my dissociated state in the safety of Kate’s office. And so Kate patiently observed the outpouring of horror I relived in her presence, and sat with me, holding the feelings, and the experience in the room. In these sessions, I would be completely subsumed in the past, writhing and contorting in terror, in my chair, in her room. Twenty minutes before the end of each session, she would offer me a glass of water. I often couldn’t find the cup in her hand, she’d have to guide my fingers to hold it, but as the water trickled down the throat. The sensory input usually pulled me back through the dissociative cloud to the present. And from there, we could reflect on some of what we’d re-lived together.
The material was terrifying and emerged in dis-articulated fragments without chronology or context, but Kate would sit with me as I struggled to accept what had played out. Together we would question, examine, reflect, and process. At the end of each session, I would be finished, immobilized, and struggle to move. I sometimes couldn’t believe that she could throw me out in that state, when my trauma was so raw and my suffering so acute. But my session had finished and the next patient was waiting. I’d occasionally have to stay in another room before I was safe to be able to leave, or I’d work to find my feet and place them on the floor, one foot in front of another, to walk out her drive to my car. I’d struggle into the car, tip the seat back and pass out.
When I came to, I’d drive home and rejoin my life in the present. I experienced a range of dissociative phenomena, strange out of body experiences where parts of myself disappeared, my mind not feeling like my own, and myself, or the world around me, feeling unreal. The most terrifying and confusing of all was the day in which one of my Parts spoke out aloud for the first time. Overtime, different child Parts came to therapy, some only fragments, others holding a single horror, others more formed, but all playing a pivotal role in my survival. And each of them would find their voice and speak, while the adult Part of me and Kate would listen in disbelief.
I’d typically begin our sessions dissociated as in previous years, slip further away, and then speak in a child’s voice, and the child would use children’s language and context. Sometimes different Parts spoke, and they would converse with one another, with Kate, or with my adult self. My mouth would switch between different voices. I never knew what to expect until words came out. I didn’t know it then, but to come with my trauma, I’d compartmentalized and created different Parts or Self-states, many of them children. Kate engaged with each of the Parts in an age-appropriate way, helping them each to feel safe and begin to trust her.
Over the many months, all of them introduced themselves, some were suspicious, others were very angry, and very hurt. It took a long time for them to accept one another, and for me to accept them all. The process was fraught with resentments and abject terror. I particularly struggled to accept the Parts which had told the worst of the abuse, those of which I was most ashamed, at which the other Parts blamed. Those Parts felt bad and dirty to the others, and to me. I rejected them harshly and cruelly, but Kate modeled acceptance in her understanding of them and their roles.
I endeavored time and again to get rid of the bad Parts, and the feelings of shame pushed me to the gap again and again. Kate encouraged me to put my arms around the hurt, scared, and shameful Parts, which I initially abhorred and resisted, but over time, I started to accept the different Parts of me, and over time, the fragmented turbulent we, became a more peaceful resolving me. I can never reflect on my struggle to reach that point. During that time, I really was a we, and often experienced a marketplace in my head. It was exhausting, and often came with descending eye pain and headaches. During this time, I had now, in retrospect, made loads of conversations with Kate. For example, I’d tell her to keep the dirty parts over the weekend, especially a Part called Growly, despite this being a part of me. Growly had done the most terrible things of all, and I had hated him. The internal battle to accept Growly raged for months. Accepting Growly meant accepting a part of me, which had perpetrated despicable acts, and it made absorbing the pain and guilt of being Growly, dissociating Growly, and the other Parts had allowed me to externalize those needed feelings and behaviors, but in doing so, it lost so many Parts of myself - and not only my memory for bad things, but my capacity for joy too.
Kate did never draw any conclusions before I reached them myself. She remained open to whoever and whatever I brought to therapy, and I took my cues from her, but I was hypersensitive to every nuance of her words, and by now, even when I was deeply dissociated, I remained aware of her appearance and demeanor. She listened and she heard, most importantly, she acknowledged and validated my experiences. But any small attempt to hurry me along, and any perceived impatience would send me into a deeper dissociative state. I and the material needed to set the pace of therapy, not Kate. Not to say that Kate didn’t ever challenge me. Some of my thinking absolutely needed challenging. Thinking like my assertion that my suicide would only make my children a little sad, that I could throw one Part of me, Growly, over the gap, and the rest of us would live on, that as a young, terrified child, I could have stopped a group of adults from abusing me. Drawing logic to my thought process that helped me manage my emotions better. And eventually the highs and lows became less turbulent, and my battle with suicide and depression subsided.
I think my shame was a very, very big obstacle, and dealing with it took a long time. I blamed myself harshly for my abuse, and judged the child me for being abused. Kate challenged me to think of my own children, especially my two youngest daughters, and whether they could have stopped the powerful adults abusing me. Or look at young children, at the age at which I was abused, that I should stop judging myself with my adult mind and show compassion for my child self, to forgive myself and believe that I wasn’t to blame, that I wasn’t worth listening to and wasn’t bad afterall.
My history’s very complex, and I had a driving need to know. That meant exploring it repeatedly from many angles, but ultimately I had to accept that I would never know and understand certain aspects of it, or make sense of them, and never really be able to explain why. But, you know, I’m glad to say that I have reached a place in which I can sit back from my story, and see it as part of my life’s journey, not all of it, but also part of a much larger collective.
I was lucky, in a way, I found a way to therapy to feel safe, to build a strong relationship with trust, and find a voice which was respected. I spoke in therapy, and I also wrote. Writing started as a private purge, as a way of getting the trauma out of and onto the page. Later, I chronicled my history, and eventually wrote a book. This was a process of integration for myself, alongside weaving it into a semi-digestible narrative. Of course the voices grew stronger and moved from therapy into social settings and now for my book, interviews and I work in the public domain.
And, I think, like many survivors, I’ve sought to find meaning in what happened to me, and to become an advocate, which is one of my key roles with Blue Knot Foundation.
That was amazing.
Thank you.
I don’t just mean well presented, or amazing as in a good job of telling a story, but it was just so touching -- the pieces that you shared, not just of your own story, struggling with the process of dissociation and healing and coping, but even the vulnerable pieces of how hard it is just to get into therapy, and how hard it is to stay in therapy, much less actually engage in the process.
Yes, and of course, you know, I do feel privileged, because I was able to find a therapist who was skilled, and although, you know, sometimes in the process, I had a sense that, you know, she was struggling, but she was obviously always able to go to supervision and find what she needed to really hold me in that space. And I just know that so many people are unable to do that. And of course, therapy’s not the path for everyone either. There are many, many ways to healing, but you know, I was privileged in that I could do that, and I could stay in it for a the long haul and have someone, who despite all my challenges, and challenging her so often, was able to just hold that, and be there, and walk alongside me.
That’s so beautiful. It’s beautiful. And I appreciate the inclusivity of it as well, that it is a privilege when we’re able to find a good therapist and have the resources to be able to continue going, and all of those layers that are so hard --
Yeah.
-- for so many. And then also, acknowledging that there are so many different aspects to healing.
Yeah, that’s right. And we’re all, you know, we’re all unique, so there’s many paths to healing, as there are human beings.
What else do we need to know -- do listeners, both survivors and clinicians -- need to know about Blue Knot?
Blue Knot is a small charity in Australia, and we’ve really struggled to claim a space around complex trauma, because we realized that there’s such a misunderstanding about what trauma really is. And when people think of trauma, they usually think of a single incident - a flood, a fire, you know, and with a lot of bush fires lately -- not to minimize the impact of that -- or an accident, or an assault as an adult, and you know the equivalence with PTSD, and again, profound impacts often. But there’s a real lack of understanding about the difference between that and complex trauma, and how complex trauma affects the very core sense of yourself, your identity, your ability to have relationships with yourself, which of course, is the most critical relationship of all, with others, and with the world, and you know, how you struggle with strong emotions, and just an understanding also of the differences in the levels of arousal. People struggle with the physiological responses, which just make so much sense, but which are not understood, and are judged, and the behaviors that are generated by them are really often judged and responded to so punitively.
So, a lot of what we do is to really try to educate and invert understanding everywhere, where people engage with human beings. We’re not saying that everyone has experienced trauma, but we all have experienced different life experiences along the way, and they all impact the way we respond, or react, or don’t engage with services, or do engage with services. And so it’s about understanding -- it’s a human lens that we’re trying to invoke. I mean, the word “trauma-informed” has become a bit of a buzzword, and buzzwords tend to lose their meaning over time. But, what we have tried to do, along with other partner organizations, is explain that, you know, being trauma-informed is about putting the humanity back into services, and service responses, and treating people as we all want to be treated - with respect, with human dignity. We all want to feel safe, we all want to be able to trust, but understanding that with complex trauma, many people have never felt safe, and that’s such an alien experience, and it can take so long. So not to take people’s reactions personally, but to understand that what has happened to them, a long life’s journey, has meant that for them, it is really, really hard to trust. They have been betrayed, often repeatedly, they haven’t had a safe space, they often haven’t had any choices in their life, and they’ve often being repeatedly disempowered.
I was really quite shocked myself, in my mid-forties, when you know, still in therapy, I was asked what I liked. You know, what were my choices? And I really struggled, because I don’t think I’d ever known that I was allowed to make my own choices. And I really struggled to identify what my real feelings were, because again, they hadn’t been validated, or mirrored, reflected back to me. And that’s a real struggle for so many people that have experienced repeated interpersonal trauma. So, you know, we have a long way to go in our society, certainly, with an understanding of this.
What we have had in Australia, quite recently, is a number of Royal Commissions, and you know, Royal Commissions can come and go, but these appear to have not only been very meaningful, but to have really started to change the conversation in this country. So, we’ve had a child abuse Royal Commission wanting to -- the age sector, and now one to disability, as well as a number of inquiries to domestic and family violence. And what it is doing is creating more understanding, and a healthier conversation around, you know, what violence, and abuse, and neglect, at different times in people’s life’s journey, can impact, and why some adults, you know, just struggle to get to first base. It’s about understanding why some people can’t get a job, can’t get to the shops to buy the groceries they need, they may not have the money or the capacity to manage the small welfare payment that is received. You know, we’re very quick to judge as human beings - this is about tolerance and understanding.
I don’t even have words. I love so much what you are doing, and what Blue Knot is doing, and the new guidelines -- which we’ll talk about in a minute -- but it’s one of the reasons I wanted to have you on the podcast, because I so want people to see and know what you’re doing, and help support what you are doing, and spread word about what you’re doing. Because, I think, it’s not just significant work that you’re doing, but you’re doing it so differently, and so beautifully, and with such compassion, and attunement to the person, as a person, and to people as people, not just a diagnosis.
Yeah, I mean, recently -- I mean, a couple of times this year -- we’ve had a few clinicians over from Britain who have developed a framework called, The Power of Frameworks -- I don’t know if you’ve heard of it. Which is a framework which offers an alternative to the diagnostic model of distress. And what it does is bring together a whole lot of research, which, you know, builds on the trauma-informed paradigm, and just looks at, you know, what we all need in our lives, in terms of the ability to create a narrative of what’s happened to us, to help us make sense of mental distress, and to de-pathologize the medical model, and find other ways of reflecting on people’s difficulties. It’s really quite -- yeah, it’s really quite an inspiring, powerful framework. It was developed by people with lived experience, as well as clinicians under the auspice of the British Psychological Society. It’s really worth taking a look at.
I think that’s a powerful thing. And that’s another thing that survivors, as a community, have been asking for, is to be involved and have a voice in what’s being done to them.
Yeah, exactly.
In the name of treatment.
Yeah, exactly. Well, absolutely, you know [laughs], I mean, it’s just so ludicrous to think that the person who’s, you know, lived the experience, and is struggling with its impacts, doesn’t have a say in what happens to them. It just doesn’t -- it makes no sense at all.
Right, right.
Yeah.
How do you, from your perspective, or Blue Knot, how do you all explain dissociation, when you’re educating and advocating?
Look, I mean, dissociation is a very complex area, and it’s one in which we’re going to release a new publication in the new year, but, you know, there’s a lot to say that dissociation is probably much more of a factor in a whole lot of mental health diagnoses, than just things that are called dissociative disorders. And you know, certainly, for me in my experience, I really struggled with the fact that people don’t understand this is a defense mechanism, that is really so ingenious, that when you have a child who’s experiencing the sorts of repeated traumas and horrors that no child should ever experience, that the mind brilliantly divides that trauma up into bite-size chunks, and keeps them all separate, so they won’t overwhelm the mind, and cause, you know, psychic breakdowns. It actually just -- it’s ingenious, and it deserves to be celebrated, rather than questioned.
And so, look, in the new publication, in the new year, and believe you’re going to be talking to Pam Stavropoulous down the track in the head of research. And she, you know, can really talk to the research around this, but you know, from my perspective, it’s about, you know, understanding that dissociation is a normal phenomenon. And in the presence of trauma, of course, it’s seen as pathological, but I certainly see it as an incredible coping strategy, and a way of surviving. And for me, you know, it actually helped to protect me, to enable me to study medicine, and be successful in that very contained compartmentalized way, while there was this wealth of traumatic material, that was sectioned off, until really I was in a safe space, where I could begin to examine it. And it was able to be revealed over time, and processed, and understood.
A trauma team that I worked with in Israel, actually, freezed, and obviously in Israel in that area of the world, knows trauma in their own way --
Oh yeah.
-- but they said they would use the phrase about how it’s such a normal response to abnormal situations.
Yeah, exactly, exactly. It’s about normalizing it. Exactly.
So, what makes the Blue Knot guidelines -- what makes them different?
So, in the 2019 guidelines, you know, really look at the last seven years of research, and then look at practice-based research, and you know, new evidence, and there’ve been quite a few developments. You know, further into the discussion about dissociation…in this country, there was a pivotal legal case, earlier this year, in which a woman called Jenny Haynes took her father to court, on the basis of a number of her Self-States, providing testimony in court. And so that was the very first time someone with dissociative identity disorder, and her Parts, actually made the perpetrator receive a conviction, I think it was 45 years. So, it shows that change is afoot, and to actually think that’d happen in a mainstream court, in the state of New South Wales, in Australia, was really quite incredible. So, you know, that’s certainly one of the things that has changed.
Well, and the other thing that is -- that I’d like to think that has changed -- is the ICD-11, has announced that there will be a formal diagnosis of complex PTSD for the first time. And that makes recognition, and appropriate treatment of complex trauma much more likely. And that’s going to come into effect in January 2022.
As I said before, there are lots of inquiries that are really changing the societal perception here, of complex trauma, and what it means, and just more tolerance about the emotional impacts it has. And of course, we know it’s a changing with treatment landscape, and one that’s much needed. You know, with studies, it’s found that current treatments are ineffective for between 25% to 50% of people in trials, and most of those trials are for people with single incident PTSD, and that’s because people with comorbidities, which often by definition of people with complex trauma, are excluded, and what that does is really limit the service system, in terms of the number of sessions, the type of therapies, and to focus really on believing symptoms, rather than looking at the whole person, and a real depth of feeling.
And also, of course, what’s changed is a much greater focus on, and understanding of the body, and the importance of working with the body, and physiological responses, and needing to calm what is an overactive nervous system, before you can really start to look at processing. You know, the whole idea of working from a CBT approach, with thoughts, and reflections, when the prefrontal cortex is offline, just isn’t very logical. And of course, there’s much greater understanding, as I said, about dissociation and its complications.
And you know, the people really dissociate to protect against the challenges of interpersonal contact, where previously they’ve been harmed. It just makes so much sense, but many therapists are just not trained to detect it, and to understand it, and often don’t acknowledge it, in everyday presentations, let alone in complex trauma and structural dissociation. And I suppose the other major change, also, is -- and I don’t know if this is happening in the States -- I mean, it came originally from the States as the whole sort of trauma-informed change process -- and certainly we’re seeing that trauma-informed care is being taken up in this country, still sporadically, but you know, governments are also starting to introduce it through medical health units and ED’s. it was a big part of the report for the Royal Commission into institutional responses to child sexual abuse.
So, there is much greater trauma awareness, still not so much complex trauma awareness, but we are seeing shifts. And I suppose we just -- we wanted to reflect those shifts, just really reexamine the new research into neuroscience and the neurobiology of attachment, into working with the right brain sensorimotor approaches. New treatments -- I mean, there’s just so much. And we just felt the time was here to do that.
When I read through the document -- I read through it to see if I wanted to endorse it or not -- and as I read through it, I was just in awe of what a completely different document it felt like, than the old guidelines that are used so often, because it’s still there. And so to have the honor of endorsing that, and to be able to share your story, and what Blue Knot is doing, and these new guidelines, has just been such a powerful experience to be a part of, and I’m so grateful, because we have, as a community, asked and asked and asked for this, and you all put this into a document, and just handed it out so beautifully. I’m just amazed.
Look, you know, a lot of credit has to go to Pam who, you know, has done, you know, she worked for 18 months on the research bases, and she has an incredible ability to filter and distill and to articulate and, you know, obviously fantastic for me to be able to work with her, and to, you know, form them into the guidelines that you read. I really appreciate your time, and thank you for your feedback -- it's very generous -- and you know, for doing what you’re doing. I mean, it’s amazing, so very much appreciated.
I absolutely mean it authentically. We started this year -- at the ISSTD conference -- began an online counter-conference, with the survivor community -- not against the ISSTD. I want to be very clear about that.
Yeah.
Not that kind of counter, but at the same time, a simultaneous conference by survivors, for survivors, on the same topics.
Yeah, fantastic, yeah.
And it was so amazing, but as part of that conference, I did a keynote that was a history of DID, so to speak, sort of a timeline, and at the end was this section of -- I have -- did this survey, and got almost 10,000 responses. And the things that people were concerned about, and the things people wanted to ask for change, and what they wanted things to do better -- almost every single piece of that is in these new guidelines --
Oh wow.
-- that Blue Knot is doing.
Wow.
So, I absolutely -- that is not at all false praise. I absolutely, from my heart, am so grateful for the work that Blue Knot is doing, and that you and Pam have contributed, and that so many have worked for. And I think -- I don’t want to speak for Jenny Haynes at all -- I have talked to her, and invited her to be on the podcast -- her team has not permitted it yet, because of the ongoing legal issues.
Yup.
But without at all minimizing her courage to do what she has done -- what they have done -- I think it is also evidence that she was successful, is evidence of these kinds of conversations, and these kinds of changes, and these kinds of shifts that you’re talking about, because it wouldn’t have been possible without that.
Absolutely. I think they all go hand in hand, and I think there is a lot of change, and hopefully with this wave, it will make a real difference to practice, and ultimately, of course, to people’s healing journey’s, and opportunities to actually find some of what -- some of the life that they -- everyone deserves.
Yes, yes. Thank you so much. We will be talking to Pam about the research and the guidelines more specifically. Is there anything else you wanted to share yourself?
Just, you know, congratulations on what you’re doing, and thank you again for your time. I really, really appreciate it.
Oh, that’s so kind. I’m so grateful. Thank you for being on and talking with us today.
Pleasure. Well, what a commitment, but it’s so well-respected. And, you know, when I look through who you’ve had on here, it’s very impressive.
I’ve learned so much, and I had no idea it was going to turn into this, but I’m grateful it’s been helpful to people.
Such a substantial contribution. Yeah.
Well, this is my very favorite part -- are these connections that we’re starting to make, and younger people learning the history of these famous people, and why they’re famous, and what they’ve contributed for, or just normal conversations of what it’s like to hear another survivor’s story in a healthy, healthy, healthy way, and not just trauma dumping or drama. You know?
Yeah.
It’s a healthy expression.
Yeah, not healthy, not at all helpful. Yeah. Absolutely. Yeah.
It’s an amazing thing, and I think it adds to our resilience when we connect to each other.
Yeah, of course, absolutely. Absolutely. And, you know, just that need to have hope, because for so long, hope doesn’t exist, and to know that there is possibility - very important.
Thank you so much. I very much enjoyed speaking with you today.
And likewise, Emma. Thanks! Thanks so much.
You can find out more about Australia’s Blue Knot Foundation at www.blueknot.org.au. A direct link to the 2019 Practice Guidelines will be included on the blog. We are very excited to be sharing them.
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