Transcript: Episode 219
219. Guest: John O’Neil, MD, FRPC
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[Short piano piece is played, lasting about 20 seconds]
Several months ago, in EMDR training with the ISSTD class, there was a quote that we discussed at length about the subjective phenomenological model of dissociation. And as we discussed the authors I realized that I knew them from consultation group with Peter. And so I asked John O'Neil to come on the podcast and talk with us about the quote.
Dr. John O'Neil is a psychiatrist and psychoanalyst in Montreal, Quebec. He was Assistant Professor of Psychiatry at McGill University and staff psychiatrist at St. Mary's Hospital until his retirement to private practice in June 2018. Dr. O'Neil joined the ISSMP&D in 1991, and has attended every conference since then and now as it is called the ISSTD. His private practice has progressively narrowed to the diagnosis and treatment of dissociative disorders. Over the years, Dr. O'Neil became a fellow of the ISSTD, co-taught ISSTD’s day long introductory workshop for eight years, hosted the town hall meetings for six years, became an ASCH approved consultant, has taught in the ISSTD’s professional training program at all adult levels except the master class, in Montreal and in Burlington, Vermont, and online. In 2009, the 46 chapter book Dissociation and the Dissociative Disorders: DSM-5 and Beyond was published, co-edited by Paul Dell and O'Neil, for which O'Neil received ISSTD’s Piere Janet writing award. He is currently an assistant editor of the planned second edition of the book, now being co-edited by past presidents Martin Dorahy and Steve Gold. You will hear him in the interview referenced this book as The Brick, because it has 1000 pages and it's a very large book.
And it's from this book that the quote we discussed in class originated and why I wanted to talk to him about it. I had not realized until this day in class, that my friend John O'Neil from consultation group was the same John O'Neil as the author of this book. So it was fun to put that piece together. And we are glad today to welcome John O'Neil to the podcast. Welcome, Dr. O'Neil.
*Interview begins*
[Note: Interviewer in bold. Interviewee in standard font]
You're going to be raising whatever topic you wish to raise with me.
Yes, there's only, I only have the one specific thing about the quote from you and Paul Dell. But, um, just very simply about how you got into working with dissociation, and how you define it, and just very, it's very, very easy.
Okay. So, hi, everyone. Yeah, so I'm Dr. O'Neill, John O'Neil. And I've been involved in the diagnosis and treatment of dissociative disorders for I guess about three decades now. And I'm also a psychoanalyst and a certified consultant with being American Society of Clinical hypnosis. I have EMDR certification. Oh, and I co-edited the fat book that some people call The Brick because it's 1000 pages long, and with Paul Dell in 2009. Currently, it's in its second edition, but this time being co-edited by Martin Dorahy and Steve Gold with a bit of input from Paul and for me.
How did you first get involved with dissociation or first start learning about dissociation?
My wife, who's also a therapist, was working at a Céjap, it’s a junior college in Montreal. And she was referred to patient by a colleague of hers who said, “I think this one has multiple personality disorder.” And my wife thought, “Yeah, right. As if that's ever gonna show up here.” Anyway, she saw her, thought she had multiple personality disorders, so she referred her to me. And I saw her and I thought she had multiple personality disorder, and this was a surprise to us. I, in fact, had seen my first case in 1978 when I was a first year resident at the Jewish General Hospital in Montreal. And I thought it was the only one I would see in my career, because at the time the idea was that they were one in a million. And well, 6 million people in the province of Quebec and I'm seeing one of them. What are the chances? Anyway, so she made a certain impression on me in ‘78, but not enough for me to really catch on to what to look for. And so then in the early ‘90s, there was this case that my wife had that I saw, and that sort of revived my interest in the possibility of the diagnosis. And and then we ran through the usual thing of thinking back over previous cases we had seen before that in retrospect we thought probably had multiple personality disorder, which is what DID was called in those days. And join the ISSTD, which at that time was called the ISSMP&D, International Society for the Study of Multiple Personality Disorder and Dissociation. And then we went on from there.
So that's how it began. And so in the ‘90s, we learned from the, I guess you could say, the the masters of the time. The top gurus of the time. And I guess since then, oddly enough, while I've, I've been in it long enough now that I'm considered one of the one of the guru's, especially since co-editing that book with Paul Dell.
The book with Paul Dell was quoted in a recent EMDR class that I took from the ISSTD EMDR class that they're giving. And when it was talking about dissociation, and introducing dissociation specifically. How, before we talk about the quote from the book, how do you usually explain dissociation? When you're doing a training or seeing a client, how do you explain dissociation?
I don't use the DSM definition because it's too show up gun. If you like. It's it has too many, too many bits of shot and puts them all together. I, I make of fairly strict distinction between kinds of dissociation. And one kind is depersonalization/derealization.
Another kind is dissociation of specific mental faculties or functions from central consciousness. So that includes memory, motor functioning, sensation, things like that, sometimes affect. We can think, in about other words a particular body part that may be dissociated and so you have anesthesia and that body part; so that would be like dissociation of sensation. You might also have dissociation of motor control, so that an arm might be paralyzed or something like that. So you can have bodily symptoms.
And you can also have psychic symptoms like dissociation of memory, if you have amnesia, or dissociation of affect if you have total blunting of effect or whatever. You can certainly have other kinds of dissociation, like dissociation of impulse if you suddenly have no drive or initiative to to eat or to relate or whatever. So you can have various kinds of dissociation of mental functions.
And then finally, you can have dissociation of identity, or what is really multiplicity of centers of consciousness, where there's more than one conscious agent. And that really is restricted to DID, and OSDD-1, or other specified dissociative disorder example one, which is basically sub threshold DID.
And those three meanings are really quite distinct from each other. Even though, if you have multiplicity, as in DID or OSDD-1, then you or any one of your others, or alters, or other self-states, or whatever language you prefer to use, may individually or as a group have symptoms from the other kinds of dissociations such as the depersonalization, derealization, or dissociation of sensation or motor function, or whatever.
So, I don't know if that's more confusing than clarifying that, put it simply depersonalization/derealization to some extent stand apart. And then dissociation of mental functions includes amnesia, and it includes what normally would be called conversion disorders. And then there's multiplicity itself, which is sort of something else again.
This was interesting to me in class. And the reason it got my attention is because it's the first time that I saw them in an educational setting distinctly grouped like that. Even though this work is a classic work, anytime that I've had just in public education a presentation about, or a lecture about, or textbook about dissociation, it only presented it, in my experience, it was only presented as almost like a continuum. But you're explaining that these are different distinct things.
Each one is its own continuum. So you can have considerable dramatic multiplicity, for example. But it may be that depersonalization and derealization is not present in the symptom. And, and dissociation of faculties and functions is, that will always all almost always be there. But it's, whenever you have it, you wonder what it's about. Because they're all presenting symptoms that aren't, well, it's never something in its own right. So if you have if you have an anesthesia of a body part, you need to find out what it's about before you really know anything about it. Or if you have paralysis of a body part, or if you have a flashback from post-traumatic flashback, then you again need to figure out what it's about before you really know where to put it. So some of these things are presenting symptoms that require further investigation to find out what they're really about. And others are, well sort of, if they're there, they're there. And that's, that's all there is to it. If multiplicity is there, then it's simply there and that's all there is to it. With regard to the other symptoms, they can come and go and need to be further interpreted.
You also mentioned EMDR. What is EMDR like in treatment in dissociative disorders?
I use it very selectively when there's a specific trauma that comes up in the course of therapy, which is sort of subjectively, continues to be subjectively a bit overwhelming to the person concerned. And it is one of the ways that one of those traumas can be worked on or worked through. It's not the only way. But depending on the patient, some patients respond better to EMDR, some respond better to hypnosis. So it's really a clinical judgment call that I make together with the patient as to how best to tackle and give them fairly acute and focused symptom.
What is, what about hypnosis? You mentioned hypnosis as well. What is that like when treating dissociative disorders?
Dissociated disorders are auto hypnotic. So anyone here has a dissociative disorder is engaged in self-hypnosis to some degree. So in treating anyone with a dissociative disorder, there's two ways to go about it. One way is simply to employ or facilitate the patient’s own self-hypnotic abilities or whatever. Sort, you sort of, it’s almost like directing traffic, you know, suggesting, “oh, why don't you go this way?” “Oh, okay. I will go that way.” And then patients who were perhaps less spontaneously auto-hypnotic, to use what we call hetero-hypnosis, which is where you induce a hypnotic state to facilitate further work. So from my point of view, working hypnotically, I'm doing therapy with someone that has DID, for example, or OSDD-1, well, it just comes with the territory. It's automatic.
How, how have you seen treatment of dissociative disorders change or evolve from the beginning to now?
In the early ‘90s, the stress was really on what we would now call stage two. And that meant confronting and working through traumas. And doing a lot of that work. And that led, I think to quite a few casualties, therapeutic casualties. Which is what led to the development really of a staged approach. Where with stage one you work very hard on containing and maximizing normal functioning, maximizing emotional stability, maximizing sleep, regularity, and good diet, and good self-care, and all the sorts of things that someone really ought to pay attention to before you go diving into working through the specific life events that lead to the condition in the first place. So the major development that I've seen since I got involved has been the the staged approach, and the much more careful and gradual approach to treatment than we saw in the early ‘90s. Just the major difference.
What would you want someone who's just being diagnosed with a dissociative disorder to know? What would you want them to know?
That would depend on which dissociative disorder they were diagnosed with. There are cases of-. See what you said, never heard about the three being separated out that way. But way back in DSM-II [sounds cuts out] relation was not part [sounds cuts out] creation. And so it stood alone. And the other two kinds were called hysteria, dissociated type and conversion type. And then in DSM-III, those two were separated out; so conversion went over to the somatoform disorders, and this well MPD was with the dissociative disorders. And thrown in there was depersonalization disorder and amnesia and fugue. But amnesia and fugue could have gone over to the somatoforms, except that it's more in the head than in the body. So the divisions that you said were novel to you have very clear representatives in the history of how to classify dissociation.
And so when faced with a client today, it depends on whether they have pure depersonalization/derealization disorder. Or if they have relatively pure dissociative amnesia with or without fugue. Or relatively pure somatic form dissociation, because that's the other word that's given to it. Or, most commonly some form of multiplicity that has some blend of those other symptoms mixed in. So it depends a lot on on the diagnosis. Keeping in mind at the same time, of course, that any of the symptomatic displays of what we call dissociative symptoms, such as depersonalization/derealization, or sensory motor conversion, or pseudoneurological symptoms, can all be surfaced presentations of underlying multiplicity, but they aren't all necessarily that.
So diagnosis is important. And it's often a work in progress. It can sometimes take weeks or months to really pin down exactly what the underlying condition is. And certainly I've had patients whose multiplicity didn't show up for a couple of years. Then it was not dramatic, but it still did show up and made a major difference in treatment once we could address it.
Pure depersonalization/derealization disorder remains a bit of a statistical outlier, or the odd member of the group. It's less well understood. The cause is less well understood The treatment is less well understood. Despite the fact that it's perhaps, or seems to be, less severely symptomatic, fairly narrow, it can be quite severe and may need to be treated in a way that's quite different from some of the other dissociative disorders. So it depends very much on on the patient and how they present. And figure out, what you and the patient together figure out what it is that needs to be dealt with.
Why do you think that these pieces are not taught? Like, why is so much left out? I feel like if I had not found ISSTD and received such incredible training through the classes and webinars and conferences and trainings, that there's so much I never would have known because it was not taught at all. And when I work in hospitals, the doctors and physicians and emergency room people, like they have no idea. They really, they, it's not just that they're stereotyped against it or because of stigma. Like there's really a gap in knowledge. Why, why does that happen?
Well, it happens because most people wish that it didn't exist, especially multiplicity. And even within the DSM-5, and it's been true ever since the DSM-III, and even in the DSM-5, if you don't specifically go to the section on dissociative disorders, you don't read about it anywhere in the rest of the DSM-5. So if you're reading the section and dissociative disorders in the DSM-5, then when it comes to differential diagnosis, you will be referred to schizophrenia, you'll be referred to ADHD, to bipolar disorder, to anxiety disorders, to PTSD, to personality disorders, the substance use disorders, as you read through the, you know different things that often go through your mind when seeing a patient that you think may have a dissociative disorder. But when you go to any of those other sections, dissociative disorders are never mentioned. So that's an internal contradiction within the DSM-5, for which there is no good excuse. If you go to schizophrenia, it will not mention as a possibility of dissociative disorder. If you go to affective disorders or bipolar it won’t mention DID is a possibility. Most egregiously, I guess, if you go to borderline personality disorder, even though one of the criteria says transient stress induced paranoid or dissociative symptoms, it won't list dissociative disorder in the differential diagnosis of borderline personality disorder. These are basically, anyone who doesn't specifically look at the dissociative disorders will read the rest of the DSM and conclude that dissociative disorders don't exist. You’re never prompted to think about them. And so if you have a gross deficit like that in a document as important as the DSM, it's not surprising that you'll find it as well in other approaches to mental functioning.
As another example, if you look over the criteria for general personality disorder in DSM-5, you find that general personality disorders skims and requires that there be only one pattern of functioning. One pattern of personality expression, and so on. That immediately means that anyone that has any form of multiplicity can't have a personality disorder, and isn't being talked about in that entire section. Despite the fact that most people that have internal others, other self-states, altars, others, wherever you want to call them, the personality differences within a given person may be really quite dramatic at times, even exaggerating. So that’s another example. Virtually all personality theorists assume that there's only one personality that one can have.
And so if you were to ask the majority of psychiatrists and the majority of academic psychologists, what do you think of dissociative disorders? The accurate answer would be, “We don't think of them at all.”
What would you tell either new clinicians or clinicians who are new to treating trauma or dissociative disorders? Where can they start to learn?
Oh, they can start to learn by by, you can point them to the dissociative disorders section of DSM-5. That's kind of the baseline rudimentary entry level sort of thing. Because it's short and sweet. But more important, it's official. It's something really simple. The population of greater Montreal is about 3 million. And so if you live in an urban setting that's around 3 million, the official prevalence of DID is supposed to be 1.5%. And 1.5% means that there's there's 45,000 45,000 cases of the DID in Greater Montreal. That by the way, is a huge number. It's more than the number of schizophrenics. It's way more than the number of illnesses that are readily identifiable like rheumatoid arthritis or things like that. Most illnesses are numbered by prevalence in number of cases per 100,000. But when you have 1.5 cases per 100, then you're dealing with a huge prevalence. Which, despite the fact, well, in general aren't identified. I think there's a good reason for that, which is that the range of symptom expression of people let's say with DID is enormously wide. And I think it's kind of obvious given the numbers that the huge majority of people with the DID fly under the radar, don't become symptomatic enough to be brought to the attention of clinicians, and live their lives and then die without ever being identified. So anyone with DID who’s identified as having it at any point in their lives are at least in the medium range, or if not the severe or extreme range of symptom expression for DID. So yeah, so that's why certainly in the earlier days, they typically showed up with diagnoses of atypical schizophrenia, or atypical bipolar disorder, or borderline personality disorder, or atypical anxiety disorder, or complex PTSD, or whatever. But rarely ended up actually getting the the correct diagnosis of of DID, or MPD in the old days.
Well, there's one issue that we haven't brought up, which is the reason you decided to invite me to talk at all, which had to do with the phenomenological definition of dissociation.
Oh, that's right. That's right. So in the EMDR class, in the training manual, it's on page 39. I don't know if you have a copy of the manual, but it's on page 39. It says “the subjective phenomenological model of dissociation by Paul Dell and John O'Neil have suggested that dissociation has two distinct sets of phenomena whose relationship remains uncertain and which commonly co-occur: faculty dissociation and multiplicity.”
Oh, okay. Yeah. And there, I guess the depersonalization/derealization are folded into faculty, although they really do stand apart. The subjective phenomenological model of DD is, it's more Paul Dell’s approach. And it has to do with what symptoms are most typically-. By the way phenomenological means what is it that the patient experiences? That's what phenomenological means. And what is it that the patient experiences that they can describe to you and then you can put a name to. That would be the phenomenology of dissociation. So what are those symptoms? And they include things like depersonalization, derealization, intrusions, such as hearing a voice, or getting an image, or feeling something in the body, or finding your one part or your body parts doing something that you didn't do on purpose with a hand or gesture or something, or saying something that you didn't intend to say but the words just come out there it is. So very much the intrusions. The amnesia of course. And so on. So the phenomenology is anything that you kind of attribute to any symptom that a patient may have, which indicates to you that there was some dissociation going on in the patient. And so the the range of symptoms is really very very high. Now in the case of DID or OSDD-1, the most glaring of these would be these sort of subjective intrusions into your own consciousness. So that's the phenomenological model that Paul prefers.
We had lots of debates about it, though, because if you see dissociation as that which keeps things apart, then every time you have an intrusion that's not being kept apart very well. If it were being kept apart really well, then it wouldn't be intruding on you.
So those are, again, two different ways of using the word dissociation. Even though someone with rather strict severe DID, for example, whose host personality experiences absolutely nothing except lost time or amnestic episodes. And there may be evidence from other people and from everything else about what they were like and what they did, and all that sort of thing during the amnestic episode. And they may have no consciousness of that at all. So in that case, the only symptom is amnesia. On the other hand, if they also experience intrusions, and copresence, and sort of unintended acts, and symptoms in the body, then this, from one point of view can say, “Oh, that's all dissociation.” You can also say, “Yeah, but it also means that the dissociation is starting to weaken, because you're getting all these leakages in a sense and intrusions from the others.” So they aren't as dissociated as they used to be. They're now a little closer, a little less dissociated. So-.
Sorry to interrupt you. Is that why it can feel worse before it feels better?
Oh, yeah, absolutely. Yes. Exactly. Cuz, yeah. If you have complete like airtight dissociation, then all you know is yourself and amnesia. But if you start to have leakage of dissociative barriers, and then experience all these intrusions, and copresences, and all that sort of thing. It may be from a subjective point of view, highly uncomfortable, although from a strictly degree of pathology point of view, if you want to put it that way, that’s because you're becoming slightly less dissociative. And some of the divisions between you and your others are starting to weaken. And you're starting to have more consciousness, more copresence, more symptom sharing, and so on. And so, yeah. So exactly what you just said is is quite true indeed. Does that make sense?
It does. Thank you.
Is there anything else you'd like me to comment on? Or that you want my opinion on?
Um, there's just, like you said, it's just so big and there's so many pieces. And this specific quote was what I was curious about, but you explain that. It lists, on the paper it lists them two separately, the faculty dissociation and multiplicity. But you are separating out a third one as well to put depersonalization and derealization in a third group. Is that right?
It's not really that I'm separating it out. I'm declining to put it together. [Laughter] Let's remember it started out separate. It started separate in ICD ICD-9 DSM-II, and then it was put together by DSM-III. So it's only been considered dissociative since 1980. And ICD-10 declined to put them together. ICD-11 is finally putting them together. But depersonalization/derealization remains kind of the oddball in all of this. Which basically means that it's really difficult to figure out exactly what it's about, and what causes it, and how to treat it, and how to rise to everything else.
For example, for faculty or functional dissociation or multiplicity, the origins in trauma and neglect are much clearer than for depersonalization/derealization. And depersonalization/derealization seem to be more like related to disordered attachment. Now, I know you've had Peter Barach on, and he's talked about detachment, or a rather disordered attachment, as key to all dissociative disorders. And I think he's right in that regard. Like you almost always get trauma as well in in those other things. Whereas in depersonalization/derealization disorder, you often can't get a real history of of trauma or overt neglect. But you may get basically, these bad screwy inappropriate mother-child attachment patterns. But not necessarily more than that. That doesn't mean that that's what it is. But that's that's what, that’s what tends to show up.
That goes back to Simone's research in the spring with the MRI scans about relational trauma being more damaging neurologically.
Yes. And that's been true for quite a while. And it's interesting that on the one hand, it's always easier to notice, to put your finger on, point to a trauma—because it's a specific event—that it is to point to something that's missing. It's always easier to identify bad things that happened that shouldn't have happened, than it is to notice or identify good things that didn't happen that should have happened. And at the same time, though, all of the research that points to basically attachment and neglect on the one hand versus over trauma on the other. It's the attachment and neglect that are better predictors of multiplicity and other kinds of pathology, than the trauma itself. So like I say, the trauma is easier to notice, and to deal with, and to confront, and to identify, and everything else. But it's not as important, either from a cause point of view or from a treatment point. It's not as easy. It's, it's harder to notice and harder to treat. Let's put it that way.
Thank you so much.
You're welcome. That'll do for today.
No, you were brave and good. Thank you. I'm sorry to have bothered you. I just, I didn't even know. I don't know. I hadn't connected the dots even that I knew the name and the book, but I didn't realize that was you. And we were in class and he was talking about you. And I was like, “Wait, wait, I know this guy.” [Laughter] So I just wanted to hear from you. Yeah, sure. It was interesting, because I, I don't know, you know, what was blocking that there. But I had not literally not connected you to the book. And so when I heard you in class, I thought, “Oh, I know who that is. I need to ask him. I could just ask him.”
Well, I think you've seen Paul as well, right? Yes, yes, in our group. In our group. Yeah. But well there he is. And just to underscore that he and I don't disagree about anything really substantive. In fact, from a substance point of view, we agree on pretty well everything. It's just with regard to what slant, or what interpretation, or what use you want to put the word dissociation to; and he puts it to one use, and I put it to another. So that's the main difference.
I love that though. The capacity to have different perspectives on the same pieces and put them to use different ways. That's very different than what's happening in America right now with politics. [Laughter] Isn't it though? Okay, Emily. So that was fun.
Thank you so much. I appreciate it.
And good luck with the podcast.
Thank you.
Take care.
[Break]
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