Transcript: Episode 143
143. Guest: Pam Stavropoulos, PhD
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Interviewer: Bold Font
Interviewee: Standard Font
Very excited about what you have to offer, and what you’re going to share with us.
Oh, likewise. Very much admire your work, very excited to learn about the Plural Positivity conference earlier in the year, and your desire, and your group’s desire to narrow the gap between clinicians and lived experience. I think it’s a very exciting time. And, I know you’ve interviewed a number of ISSTD people on your podcast, like Richard Fitz, and Peter Barach. So, I think it’s a really fertile time to be connecting.
It’s amazing. That’s very gracious. Thank you for being with us.
Not at all.
To start with, go ahead and just introduce yourself a little bit.
Sure, well, my name’s Pam Stavropoulos. I’m the head of research with Blue Knot Foundation, in Sydney, Australia. Blue Knot Foundation is the peak, sort of body, for representing the interests of adult survivors of complex trauma in its many forms. We used to be called Adult Surviving Child Abuse - ASCA. And, the first set of guidelines that we produced in 2012 -- of course, now, they’re updated in 2019, which we’ll talk about -- but, the first set came out under the name of ASCA, whereas now we’ve had a name change, Blue Knot Foundation.
So, I’m head of research there, working on the research side, and I’m also a clinician. I have a small private practice with complex trauma clients.
How did you get involved with complex trauma?
You know, that’s a fascinating story, Emma. I connected with Blue Knot Foundation, which was then ASCA, I think was around 2010, and I was hired to do a research project, a small research project. And, to my surprise and shock, I realized there were not guidelines, at that time, for treating complex trauma, as distinct from single incident PTSD. So, I said to Kathy, you know, it’d be easier to do this if there was some guidelines in the area. And she said, well, why don’t we, you know, apply for a variation on the grants, and write some guidelines ourselves. So, that’s literally what happened.
And, of course, much of the research comes from your country. There’s been a hell of a lot on complex trauma over the years, but it hadn’t really been put together in guideline format, until relatively recently. And, of course, our first guidelines were 2012. That was also the same year that the expert [inaudible] guidelines for treatment of complex PTSD came out, of course. So, they were being released at the same time as our first set of guidelines.
But, yeah, the background to me being in this field, and the guidelines in Australia was literally at the time, quite recently, they put all -- the great research and clinical work in complex trauma had not been formalized into guidelines. So, we’ve come a long way since then.
It’s amazing. It is amazing, and I know that the community is super excited about it, and we’ve already had Kathy on, and talked to her, and shared a little bit about, sort of, her background, and how she got involved. And, so, I’m super excited that you’re going to share with us a little bit about the research and the guidelines themselves.
Sure.
Where do you even want to start with all that?
Well, look, maybe we can start with -- Kathy said, “Oh, maybe it’s time to update the guidelines.” And, I thought, Oh, is it time already? Because, we know already, all time is interesting in and of itself. It goes very quickly sometimes. But, six and a half, seven years since 2012, and a lot had changed. There’s a lot that stays the same too.
So, maybe the first step is to just sketch out what has seemed to have changed since 2012, why the layers look different, and what some of the main themes of the change are. Yeah, and then I can maybe fill in some of the detail and the research themes, and we can to and fro about that.
But, I guess some of the main changes since 2012 -- and this one’s very, very recent -- is that there actually is a formal diagnosis now of complex PTSD, C-PTSD. Now, diagnosis, of course, is not the be all and end all, it’s not the only means by many means to which to be complex trauma. But, it does represent a significant achievement of many people, including and not only, Judith Herman, who have tried over many years to get this diagnosis up. And, it now is. It will be in the -- it is the newer iteration of the ICD-11, the International Classification of Diseases, announced its release in June of 2018, I think it was. And, the diagnosis will come into being soon.
Unlike the DSM, of course, there’s no prestanding complex trauma, complex PTSD diagnosis in the DSM, but there is a dissociative subtype. And, I remember Christine Courtois at the time, that the diagnosis of PTSD is becoming more complex. So, there is a widespread recognition of the need to take account of the more extensive impacts of complex trauma, the distinctive features of complex trauma, and the treatment implications. So, yeah, complex -- I said it -- I mean, obviously it is the be all and end all.
Robin Shapiro said a long time ago, there’s more to trauma than PTSD. There’s also more to complex trauma than complex PTSD. So, one of the problematics of it is that…to make the criteria of C-PTSD, people still need to meet criteria for standard PTSD, you know, the familiar features that we know of - the hypervigilance and the intrusion and the numbing and so on. But, of course, many people with complex trauma actually don’t meet the criteria of standard PTSD. So, it’s going to leave some people out. So, there are problematics around it. But, I think it is important that it does exist.
And, you know, Judith Herman has talked about this. She talked about how the attempts to get that diagnosis up in the DSM [clears throat] -- excuse me -- into the DSM-IV, and it actually passed the field trials. And, there was great hope for DSM-IV even, that C-PTSD would become a diagnosis in its own right, but it did not happen. And, Judith Herman, when she talks about this in the forward to a book that came out in 2009, she said the message that came to them -- that came back -- was that complex trauma, or the proposed C-PTSD diagnosis, involves so many different criteria and impacts. You know, it could be schizo-affective, it could be depression, it could be anxiety. There’s just so much going on. And, Judith Herman’s point was that’s exactly the point. You know, we need a diagnosis that can represent the syndrome of impacts that complex trauma represents.
So, yeah, I think on the one hand it’s a major achievement. On the other hand, it’s obviously not enough by any means. But, that’s probably the first change since 2012.
The second one for us in Australia, but also internationally -- implications are our Royal Commission into institutional responses to childhood sexual abuse. Now, that’s very interesting, because when I presented the 2012 guidelines of the ISSTD conference in Long Beach, in Los Angeles, in 2012 , Dr. Cathy Kezelman, who you know is the president of Blue Knot Foundation was unfortunately able to be there -- was unable to travel at that time. So, I just slid across and presented the guidelines. And, literally had up on a powerpoint, a slide, where is the impetus coming? Where is the next movement for complex trauma to be taken seriously?
Because, Judith Herman made the point long ago that for trauma -- is extremely confronting in all sorts of ways, and to get -- to really stay in the public consciousness, because it does slip in and out of awareness -- so, at the time, when a lot of this stuff isn’t new -- I mean, it’s validated in different ways now, with the new [inaudible] and so on, but people have known about complex trauma for a long time in the field. And, it does -- it has slipped from public view. So, this is Judith Herman’s point, that to be firmly lodged in public consciousness, it needs to be linked to a political movement, which is a fascinating point to make, isn’t it, Emma? Because, we often have this compartmentalization, you know, this isn’t politics, this is clinical work, this is, you know…but Bessel van der Kolk said a similar thing in his best selling book The Body Keeps the Score. He has people that will sometimes come up to him and say, “Why are you talking about politics when you’re talking about trauma?” And he says, “Because you have to.”
So, that was very powerful when I read Trauma and Recovery, you know, the landmark ticks of the early 90’s, by Judith Herman. You know, all this exciting material, even at the time, even before the neuroscience stuff was starting to break -- to read what she said. You know, don’t think just because all this information is available that it’s necessarily going to be taken up in advancement. It needs to lead to wider issues. So, that’s why when I was presenting the guidelines the first time, it’s like, surely we couldn’t lose all this amazing information, but if it does need to be linked to wider public consciousness, where is that going to come from. And, in fact, the Royal Commision in Australia, was announced a very short time, about a month and a half, after that. So, that’s our movement. That’s the vehicle through which public awareness has massively increased since 2012, which is fantastic.
Now, of course, whether the recommendations of the Royal Commission -- which went on for five years, which was comprehensive, which took enormous amounts of testimony and inquiry, into so many mainstream institutions of society -- not conspicuously, of course, of the institution of the families. We’re all very aware with just the main sort of context in which trauma frequently occurs - complex trauma. But, nevertheless, it’s alerted the public -- the Royal Commision -- to the fact that complex trauma is perpetrated in the heart of mainstream societal institutions that we’ve been encouraged to trust in. You know, the church, the local clubs, all sorts of various things throughout society -- sporting clubs, educational institutions. There’s really no institution in which -- which is, you know, immune from the possibility and actuality of complex trauma being [inaudible].
So, whatever people do with that information…it’s out there now, and that’s a major shift.
A third major shift -- again, I’ll sort of fill in the details later, if we have time -- is the changed treatment landscape. It’s now a very dynamic field, of course. There’s so many different approaches in therapy, broadly, not just trauma therapy, and that’s very challenging, that’s very exciting. How do we make sense of the diversity of approaches that are out there? Are they suitable for complex trauma treatment? If so, how do we integrate them? And, it’s challenging, of course, in terms of how to even represent them, because when we talk about traditional treatments, or alternative treatments, or mainstream treatments, that’s very contingent on where we’re coming from, and an approach which may be traditional in one area, might be, you know, not at all in another. So, yeah, the third theme has really been to try to make sense of the congestion of approaches that are out there, you know, the explosion of access to the internet. People are going online to, you know, find out all sorts of things. What challenges that poses to the complex trauma field.
And, the other main piece of it is the dissociation piece. It’s not really a piece, it’s prevalent. It’s huge and it’s unreal, but there’s much more in the updated version of the guidelines on dissociation, and a major need, you know, the great importance of every clinician knowing about dissociation, not just the most severe forms of it, which is often what people think about and think of. We don’t need to worry about other forms, but it does take many forms, and obviously we’re going to talk about this, and clinicians really need to be aware of that. So, that was another impetus for the guidelines.
And, I guess, one other change that’s not [inaudible] was that they announced just in time, before we went to print, was to be able to include was the Jeni Haynes legal case. Jeni Haynes, of course, experiences DID, and took her father to court, and her dissociative self states, her Alters, we can talk about the language, actually testified in court. That was part of the grounds on which her father was convicted of, you know, the mess, the abuse, that generated her DID, and received extremely lengthy prison sentence. So, to have a legal validation. Now again, we’re not saying that, you know, maybe can legal [inaudible]maybe are the only ones we take notice of. Not at all, but it’s been difficult enough to get, you know, sexual assault cases into the court at all, for all the reasons we know about.
So, to have that recognition of the DID diagnosis validated in that way, by a judge within the judicial system, and this is very groundbreaking stuff. So, in many ways, we are in quite different terrain.
It’s different than ever before.
Yes, absolutely. Absolutely it is, yeah. So, they have ballooned in size [laughs]. Maybe not everybody will be happy with it. But, we have 44 guidelines to take account of, you know, new themes, and more nuance. And, I won’t, obviously, go through all of the guidelines, but there’s half a dozen I want to quickly reference.
The first one, a new one in guidelines, is about the importance of every clinician knowing the core dissociative symptoms. Namely, you know, depersonalization, that sense of feeling disconnected from oneself, or distance between thinking and feeling. There’s different definitions of that. Derealization, you know, where the external environment we’re estranged from. Amnesia, identity confusion, and identity alteration. Now, of course, if all those five symptoms are present, then we’ll also talk about the problematics of the word “symptoms”, I’m sure, but if all those five are present, we’re in the land of DID.
But, of course, those symptoms can occur in varied combinations. There’s many different dissociative disorders, which clinicians need to know about, and mostly don’t, because dissociation still isn’t on the curriculum of most psychology and psychotherapy courses. And, there’s also, you know, what we call sub-clinical forms of dissociation, which don’t meet the criteria for disorder, but which nevertheless, you know, may impair people’s quality of life. So, if clinicians aren’t able to detect, or at least have it on their radar, the possibility of dissociation, there’s a great chance that, you know, it won’t be detected, and that’s going to really interfere with the appropriate treatment.
The other thing, of course, is that dissociation which is basically -- and again, there’s lots of different definitions and different views, and we can talk about that too -- but, you know, the very basic level is disconnection from the present moment. And, of course, if that occurs, that’s going to be severely inhibiting of therapeutic benefit. If a person consistently dissociating, or even, you know, intermittently dissociating at different points, and the clinician isn’t aware of that -- and, of course, the clients themselves may not be aware of it -- that’s going to really impede the therapy. So, it’s very important that we’re all aware of that possibility.
Daniel Siegel, of course, has famously talked about mind-sight, you know, the ability to focus and be present and so on. And, I think it’s Kathy Steele, who I think I'm correct in saying coined the phrase “mind-flight”, which is, of course, what dissociation is. So, you’re talking about different things here. Christine Forner’s written about this as well. So, it’s really important that we all know about dissociation, what to look for. And, of course, it’s harder to detect. We all know about hyperarousal, which is generally more visible, you know, and there’s often a change in the person’s demeanor and skin color, voice tone, and delighted people looking agitated. We can see that something’s happened for a person when they use that response.
But, dissociation, of course, and again it’s complicated when I say it’s the shut down response - there’s other forms, and it’s possible to be dissociated while being behaviorally active. But, in contrast to the general hyperarousal, hypoarousal is less visible. And, a person may just look as if they’ve hesitated, or had a moment, or were concentrating. And, we’re not saying everybody is [inaudible] an attention lapse is dissociative. But, it could also be indicative of an overt response, that’s regularly triggered, that the client is experiencing in their daily life, to be a detriment, and the therapist aren’t even looking out for. So, that’s just so important.
So, that’s guideline six. Then there’s guideline 19, which is attune to and integrate diverse approaches -- sorry, diverse interventions and treatment approaches within a phased model of treatment. And, again, I’ll fill in the details around that, because that’s a fascinating change, or maybe I’ll say something briefly on that. With the first guidelines in 2012, we could -- there weren’t many challenges to the phased treatment model, really. It was almost like two ships. I mean, complex trauma people are doing phased treatment, and many other people, in this sort of single instant, are doing exposure therapies, and there’s not much connection between the approaches.
But, more recently, there’s been a challenge to the phase treatment model, which we needed to take account of in the guidelines. And, the short answer is, I think, the challenge is very problematic. But, it did need to be taken account of. So, definitely, I’ll say something a little bit more about that in a moment.
So, phase treatment, I think we’re still endorsing in a nutshell, but that doesn’t mean that we don’t necessarily integrate. We responsibly can diverse approaches within a phased model, which may be able to safely accelerate. Anyway, we can come back to that. So, that’s guideline 19.
Guideline 20 is, in short, all treatment modalities are dissociation informed as well as trauma informed. So, as you can tell, the importance of dissociation. Many people would now say they were trauma informed in their modalities, and of course, there’s no one in complex trauma treatment, but it’s still possible for even otherwise good therapies to not be aware of, or take account of the dissociative response. So, in fact, EMDR is a very good example. All are very well evidenced and, you know, rightly respected and widely used modality. But, as Francine Shapiro said, in what of course would be her last contribution to the field -- she established, as she said in the recent iteration in her book on EMDR in 2018, that if clinicians aren’t well-versed in and experienced in and understand dissociative disorders, utilizing standard protocols can be very problematic. She specifically cautioned against that.
And, of course, there are varieties of EMDR now that do take care of complex trauma. This is, you know, the field is moving all the time. People like Anabel Gonzlåz, Sandra Pauslen, there’s many people now, Laura Pan - attachment-focused psychotherapy and EMDR therapy, which is specifically more around, you know, and rebuilding disrupted attachment and resource installation and so on. So, that’s an important point, I think, even within particular approaches that are otherwise very good. Not everybody within the field is dissociation-informed. So, that’s a key point to say -- to point out. Whatever approach we’re using, we need to make sure it’s dissociation informed as well, as well as generally trauma informed.
Another one -- guideline -- is the importance of updating our own understanding of memory. Now, we’ve produced a quite separate publication [inaudible], very relevant, but we haven’t reproduced a lot of the material we’ve done on memory in these updated guidelines, but we’ve got the links for people to go to that publication. But, basically, it is very, very important, of course, that every clinician understands the distinction between explicit memory, which is largely conscious, largely verbalizable. It goes under lots of names, doesn’t it, you know, narrative, biographical, semantic, declarative. It can be very confusing, but basically explicit is verbalizable and conscious. And then there’s implicit memory, which is largely unconscious and not verbalized. These are -- there’s a distinction between that -- what is that? The [inaudible] -- was it John [inaudible] or someone, said the verbally accessible and situationally accessible. So, implicit memory, and there are many forms of that, and it’s a complex topic. But, basically this year -- well, there’s different types of procedural memory in the body, you know, remembering about how to ride a bicycle without necessarily having to consciously focus on that.
But, in terms of traumatic memory, traumatic memory is a particular form of implicit memory. And, it has particular features. So, clinicians need to know that there’s a lot of misinformation now still around memory. But, memories not unitary, it does take different forms. It is perfectly possible to forget deep trauma, and in fact, many do. That in itself is a survival mechanism. You know the whole discussion around recovered memory, which is -- people forget and recall often with situational triggers years later - traumatic events. That’s been shown and established with the Holocaust, with Veterans, not just with survivors of childhood sexual abuse, which is where the debates tend to be. You know, this is how the mind works often under extreme stress. So, that basic distinction between implicit and explicit memory is very important.
And, just the last couple I was going to particularly mention before we moved on to the research side - misconceptions about DID. Yeah, that’s very common, despite the very strong evidence base -- despite the fact that there are now neuropsychological studies that have compared the resting and activated brain states of people with DID and DID simulators. And, they’ve shown them to be different. You can distinguish between the different brain patterns if that’s the evidence people want to look at. DID is a legitimate diagnosis, and yet it’s still dogged by “controversy” by a lot of mistaking that it’s all iatrogenic, it’s made up, it’s all therapist implanted, it’s culturally specific to the United States. It’s the same as [inaudible], you know, [inaudible] that’s out there.
So, what myself was very glad to be involved in and Bethany Brand, and some of your key people in the field of trauma produced an article that we’ve provided a link for in the guidelines on -- it’s called Separating Fact from Fiction. And, we go through about half a dozen of these keys -- as clearly as we can -- myth one, and then show the evidence of why it is a myth. Myth two, myth three. So, that’s the key one, I guess. Not every clinician is going to read these guidelines, and won’t treat DID, but they do need to know that it’s a legitimate diagnosis, and yeah, and how to respond to the misinformation that’s still generating.
Yeah, and I suppose just one other one that I’ll mention before getting onto the research, is the differentiation between getting better and feeling better. I mean, that comes from Richard Kluft, who of course has done an enormous amount to contribute to the field, and has been, you know, very pioneering. If someone’s been dissociative, and starts to recover the capacity to feel, or if the dissociative barriers start to dissolve, it’s quite likely that the feelings are going to be very challenging, very unpleasant, maybe very scary. And, this is precisely the time when a client -- you know, when they’re starting to break down, or dissolve the dissociation. Panics…feels terrible, wants to stop therapy, thinks that it’s all gone wrong. And, the therapist doesn’t understand that distinction, and is open to work with it, and to reassure the client - this is not a regressive state. And, it’s certainly -- it can be managed clinically. But, people can panic when feeling starts to be recovered, rather than realizing that, yeah, getting better doesn't necessarily mean feeling better in the first instance.
Anyway, so we could maybe talk about that. So, there are half a dozen guidelines I just immediately point to that are perhaps a bit different than the previous ones. And, I’m certainly happy to go through them. Maybe I’ll just give you the chapter [inaudible].
The first part of the guidelines are the guidelines themselves, you know, one, two, three. I should also say we’ve produced two other sets of guidelines on competencies, like what do therapists need, what are the skills that therapists need to work in this area. And, they’re important. That’s a short separate set freely available on our website. We can talk about that.
But, what’s interesting is that a lot of otherwise diverse therapies don’t -- make a number of assumptions often about coherent continuous subjectivity, but isn’t applicable certainly with many forms of dissociation. And, this has very real treatment implications. For example, it’s standard in many counseling approaches to encourage a client to use “I” statements, quite quickly, you know, owning one’s experience. But, for a client, and even for many of us -- and we’ll talk about, probably in a minute, the model of the mind -- it may not be that we experience ourselves at all or in that moment as an integrated coherent being. So, we have to work differently in many ways, than standard “commonsensical” notions of what good therapy’s like. So, that’s a separate set of guidelines. Oh, we’ve got so many guidelines [laughs], but I can go on about that. But, we have two sets that are quite basic and short, that people may want to look at as well.
But, in the updated guidelines that we’re talking about today. So, the first section is the guidelines themselves, and the second section is research based, which is the same format as 2012. So, we’ve got five chapters. The first is understanding complex trauma and the implications for treatment. So, that looks at the C-PTSD diagnosis, also the limits of that, the extensive impacts on self-conception, relationships with others, you know, views about the world, ability to self-regulate, you know, complex trauma. You know, what it looks like.
And, I remember Christine Cortois saying it’s not only that the self is unregulated, it’s often unrecognized, which again gets back to the problematics of the “I” statements. So, looking at shame, which has been described as a core effect of complex trauma. Critiquing some common sense understandings of resilience. That’s become a bit of a buzzword. It’s very important, of course, to be celebrating strength, but it can mean that clinicians are insufficiently attuned to the difficulties of the subjective experience of a client. It’s perfectly possible, as we know if our field, to tick all the boxes of looking as if we’re functioning at all. But, the whole point about dissociation is the separation of different Parts, you know, the disconnections and the lack of consciousness. So, someone may be functioning very well in their work, you know, have relationships, you know, be earning money, and yet their subjective experience is deeply impaired. And, it’s very hard for people, of course, for all of us to present vulnerability.
So, if a therapist is just happily endorsing all positives, that, oh, you know, being a resilient person -- people can miss - clinicians can miss where a client’s really still struggling. So, yeah, a lot of stuff in chapter one on complex trauma.
Second chapter is squarely on dissociation, it’s called What is dissociation, and why do we need to know about it? And obviously, we could have whole seminars on that. I’m thinking one way of looking at it is Richard Fitz’s comment in his great 2015 book, Intensive Psychotherapy for Persistent Dissociative Disorders. I know you’ve interviewed him very recently. When he says think about…not about dissociative disorders, in the first instance. Dissociation is not mainly about that. It’s about how the mind copes with the unbearable. So, that is a good rule of thumb for us in the field, and it’s a very empathic one, to not immediately go into the notion of disorder. Dissociation as a response is highly protective in the first instance.
With complex trauma, of course, the difficulty is that if the mind becomes organized around dissociation as an almost default response, which is frequently, as we know, the product of severe childhood trauma experiences, it becomes problematic like all defense mechanisms. So, dissociation has a number of forms, many of us would say. The problem -- you know, if I’m going to say the “problem” -- is when the dissociative response is persistently activated for defensive purposes in childhood. So, it’s really very interesting that we know to attachment theory from many approaches now. The vital importance of a child connecting to a caregiver for survival.
John Bowlby talked about this. He talked about defensive exclusion. He didn’t use the term dissociation. And, that’s fascinating too. You know, Elizabeth Howell and Itzkowitz have recently released a book -- actually it’s one since then -- but I think it was 2016, on -- it’s called The Dissociative Mind in Psychoanalysis. And, they talk about -- yeah, well, a number of contributors to the book -- talk about, you know, a previous generation of clinicians and researchers in the field were really talking about dissociation in different terms. Winnicott would be another example.
But, the point being, whatever we’re talking about, is the need for the child to dissociate what threatens the attachment bond. So, it’s profoundly protective in the first instance. It’s an amazing, extraordinary capacity that we all have. Obviously not everybody’s going to -- depending on our circumstances in a lot of things -- develop a dissociative disorder. But, there’s a sense in which we all dissociate what threatens the attachment bond to our caregivers.
So, the broad rule of thumb, in this area, would be the more we have to dissociate to survive, and to maintain that bond, it will protect us in the first instance, but if the underlying reason for it over time is not resolved, it will impair our ability to function and to connect with others. So, it’s a very, you know, very challenging, intriguing, fascinating, important dynamic…dissociation…that we do need to understand.
And, I guess here, I just want to mention Frank Putnam’s book that came out in 2016, called The Way We Are. And, in it he puts forward what he calls a state theory of personality, which is really interesting, because he points out that, you know, it’s still not common among theories of personality. And, we know there’s many, many theories of personality, which he basically distinguishes between developmental and dimensional approaches, which are quite different. But, on the whole, he’s saying they still presume -- predicated on the basically stable, enduring conception of personality. You know, fixed, persistent, globally defining traits that pervade the person’s interactions with the world. Whereas by contrast, he advances the state model of personality, which I think is very interesting, and hopefully, you know, will start to really be taken up.
And, as he said, it better allows us a far wider range of desperate behaviors, [inaudible] of personality. And, it accounts for the fact -- because we’re all in different stages at different times. We all respond differently in different contexts. So, the idea of a continuous coherent self for anybody is problematic. He says we’re all multiple to some degree. Now, that’s not of course to at all minimize or diminish the situation for a person with lived experience who has very distinct self-states that aren’t co-conscious. So, certainly, if we’re talking about DID, it could sound a bit frivolous of just saying, “Oh, well you’re multiple.” But, the point Frank Putnam’s making is that, of course, and as we know, attachment theory is neuroscience, and is even common sense, when we think about it. We are very different according to context. We all do assume different roles in different contexts - there’s the work self, the home self.
And, so, what determines how functional we are, overall, is how readily we can segway between different self-states. And, of course, if somebody experiences childhood trauma, it’s going to be more difficult. There hasn’t been that good enough childhood experience to assist movement between the different states. The coherence is, you know, to the extent that we’re coherent, is a product of, you know, our experiences over time and develops over time. You know, we’re not born being coherent. So, probably getting into a lot of, you know, theories about the mind here, but I think that’s a really helpful way to see things.
And, how often do we say, “Oh, that person seemed to act out of character?” I mean, all sorts of ways. We’re challenged when people respond to things in ways that seem surprising on the basis that we know them. Yeah, it’s not like themselves. Whereas the state theory of personality can account for that. It recognizes that we’re often very different towards -- depending on the context that we’re in. And, I think this is something we can all identify why, and start to consider dissociation on a continuum. Not everybody accepts that model, but I think what Frank’s saying is really, really important.
And there has treatment implications too. I mean, ego state therapy is very interesting in and of itself. I mean, there’s many diverse approaches of utilizing those states. You could say we all have ego-states. Also, here is very important is Richard Kluft’s point that, you know, when he’s talking about DID and structural dissociation -- which is this sort of personality divisions that are much more severe than sort of less chronic forms of dissociation, that there is, you know, many of us may slip in and out of without it being severe and disabling. But, Richard Kluft is saying all Alters or Ego-states, but most ego-states are Alters. So, again, we’re not saying that there’s more normal multiplicity model is putting everything in the same basket, and it’s all equal. Not at all. There’s certainly more severe, chronic forms.
But, we can potentially utilize treatment approaches, like ego-state therapy, when it’s informed by an understanding of dissociation and so on, to assist clients. So, although treatment of dissociative disorders may be regarded as very specialized, and it certainly can be, we also came to encourage people to think about how models that we may be familiar with, without thinking that they could be helpful with suitable supplements and adaptation, can actually really assist working with trauma and dissociation. So, that’s the second chapter.
The third chapter is phased treatment, or basically called revisiting phase treatment. So, very briefly on that, I think I mentioned before that in 2012, the expert consensus guidelines on treatment of complex PTSD -- so, of course, the term being used well before the diagnosis came out just recently -- and that was the 2012 guidelines, as I said, came out at the same time as our first guidelines. So, we hadn’t been able to read them at the time.
But, a number of imminent people in our field, very diverse people, you know, Bessel van der Kolk, Coltrane, Christine [inaudible], Julian Ford -- I mean, Bessel van der -- I mean, a range of sort of key people in the field, said -- I think it was 85% said they would use a phased treatment approach for complex trauma. That was very much the view, and that represents a continuation of treatment of trauma from the 19th century. You know, it’s basically a three-phased model. It’s referred to by different terms sometimes. But there’s stabilization and safety, which is about assisting the person in feeling okay in their body, being able to regulate affect, because it’s one of the major things, of course, trauma disrupts. The second stage is processing. And, of course the emphasis in the final phase treatment model is that you don’t go to processing until the person can stabilize and manage their effect. And, it’s not literally like a one, two, three. Of course, it doesn't roll out completely chronologically.
But, the whole rationale of phased treatment is that you don’t go to processing prior to being pretty sure that the person’s able to regulate the feeling that processing is going to throw up. And, the third phase is the integration. And, as I said, the terms are different. I think Judith Herman talks about remembrance and mourning. And James, too, talks about early, middle, and late phases.
But, basically that phased model has been around for a very long time. The [inaudible] model. And in 2012 it was endorsed very clearly, but since 2012 -- and this is why we needed to take account of it in the updated guidelines -- a number of therapists [clears throat] and researchers and clinicians, mainly from the exposure school have challenged the phase treatment model.
Now, what’s interesting about this, of course, in terms of research, and we’ll get onto evidence-based treatment in a minute, hopefully, is that it’s been difficult for a lot of reasons to have outcome studies around trauma, and certainly complex trauma. One of the reasons being the exclusion criteria has been very restrictive. So, the most severely impacted people, who we’re wanting to get more refined approaches to assist, have been excluded from outcome studies. So, that meant that we in the field could say quite rightly, “Well, you know, our cohort is not being looked at in outcome studies.” That’s starting to shift now.
And, Bethany Brand, of course, who the treatment of patients with dissociative disorders study -- it’s a fabulous international study around dissociative disorders. And, that’s in the process of being prepared for in our city. So, again, things are moving on.
But basically, a group of therapists have challenged the phase model, and these are the people who endorse the so-called evidence based approach, which sounds great. And, who would disagree with that at one level, but in fact usually relates to short term, exposure based -- you know, what are called first line trauma focus. There’s a few terms. It can be a bit confusing. When I first heard the trauma-focused, I thought Oh, that’s great, they’re focusing on trauma, but in fact, it’s a more particular approach. And, what the first line evidence based treatments have in common, generally, is taking issue with the phased approach, and thinking we don’t need a first phase stabilization, we can go straight to processing.
And, the rationale for that -- there is some rationale -- we’re not saying phased treatment is beyond criticism. I’ll get to that in a minute too. But, the approach -- the rationale for that is if we spend too much time or even if we’re at all doing stabilization, we’re withholding, you know, very helpful evidence based treatments that can assist people more effectively and efficiently and quickly and so on. So, that sounds very good on the face of it, but it fails to recognize what many of us would say the more distinctive stages of complex trauma is that people with complex trauma start in a very different position than people who, you know, that have anxiety, or even single incident trauma.
And, certainly, if a clinician isn’t savvy about -- around dissociation -- then they can miss signs of it. And, it’s possible for the client to be triggered by and even within the treatment itself. So, when we hear about prolonged exposure in particular -- that’s another one that’s, Oh, this is all great. Prolonged exposure is recommended. There’s a lot of approaches that will say there’s a lot of research there. But, we’re wanting to draw people’s attention. Well, there’s many of us in the field, too, who say, “Well, we’re not so sure about that.” And, there are studies around that too. So, we’ll put that in the guidelines.
Judith Herman said, I think it was in 2009, very explicitly, what one does not do in the early phases of therapy for complex trauma is any form of exposure therapy, and the emphasis is on any. And Peter Levine, he’s a very different clinician and researcher in some ways -- but he too, in his fantastic book Trauma and Memory has been quite critical of exposure therapies, and certainly prolonged exposure therapies for trauma in general, much less complex trauma. And, he makes use of that wonderful, you know, the image of the great myth of Perseus and fighting the Medusa, when the Goddess Athena advises Perseus not to look directly into the eyes of Medusa, because you’ll be turned to stone. And Medusa, the sort of gorgon, with all the tentacles coming out of her head. And, she advises him to use a shield. So, when Perseus fights the Gorgon Medusa, he’s reflecting the face in the shield, rather than looking directly at her. I think that’s a lovely way of conveying the concern that many of us have about exposure therapies, which is about going straight in, you know, looking at the eye of the storm.
And, there’s also questions about what we’re even exposing people to. I mean, complex trauma’s about interpersonal violation, betrayal of it. It’s not about spiders and simple phobias. It’s another point Peter Levine has made, that exposure therapy goes back to the 50’s, isn’t it, with Joseph Wolpe? Very simple specific phobias. So, extrapolating from that to more current variants and prolonged exposure, as if that’s the same thing as complex forms of trauma, is a whole other animal.
So, yeah, it is a case of complex trauma people now being included in more studies, but many people are -- exposure therapists are just saying, “Oh, well that just shows that it’s just as good - exposure therapy and first line treatments and evidence based.” You know, childhood trauma history doesn’t preclude you from benefiting from exposure, or many of us would have doubts about that. So, we’re looking at that in chapter three.
Now, having said that, that’s not to say that phase treatment is beyond refining, or we don’t need to revisit it in any way. Basically we are still endorsing it, absolutely, and it has to be some kind of phased approach. You know, if you look at some of the critics of phased treatment -- when you look at what they’re actually saying, they’re implicitly adhering to a notion of phases anyway. They might not call it that, but it’s hard to see how the range of impacts of complex trauma in particular, cannot be addressed in some kind of attempted sequence way, because somebody can’t self-regulate is in a different position than somebody who can.
So, another important distinction is unpleasant and unbearable. I mean, what people are exposed to, obviously, if someone is severely anxious, that’s very unpleasant, but it’s not quite in the ballpark of overwhelm, and, you know, complex related dissociation, where the dissociation occurred in the first place because it was overwhelming. So, we do risk endorsing evidence-based treatment with people who go, “Oh, it’s great for all sorts of forms of” -- is putting in the same basket, where they’re actually qualitatively different things, arguably.
So, that leads to the next thing, well, how do we go -- where do we go from here then? And, that is this whole kind of notion of “new” treatments. Is it possible to integrate some of the insights and interventions and approaches of very different -- and sometimes short term. That’s what’s interesting, because -- into the different phases of phased treatment.
So, that leads into the next chapter called, “New” Emerging Treatments. And, the ones we specifically look at are energy psychology; EMDR; brainspotting, which is a fascinating, more recent therapy; clinical hypnosis; MDMA assisted psychotherapy, which, of course, is really taking off, and I understand will be quite readily available for psychotherapy purchases in your country. So, there’s a lot of diverse approaches that are challenging the way we think about what effective treatment looks like.
So, we’re sort of looking at how do all these interesting approaches, many of which do have an evidence base, so we’re making a distinction between evidence based in the sort of standard, short term, exposure based, trauma-focused, so on, and approaches for which there is an evidence base, but not necessarily one that’s recognized by formal trials, or are in a position to offer formal trials within that structure. And, there are problems within formal research methods too, which we’ll get to in a minute. But, that’s basically what chapter four is about, looking at all these different approaches, and how might we utilize, draw on, to assist people with complex trauma, and do they take into account dissociation, and can we assist more effectively, stabilizing safety processing. So, it’s possible to say that an intervention of energy psychology -- say -- I’m just saying -- I’m just pulling that out of the air out of the million things out there -- but energy psychology’s quite well evidenced in its own terms. I don’t practice it myself, but I’ve known people who do. It’s possible that an intervention from that field, potentially, could assist somebody in phase one, you know, whereas many of us who haven’t taken in account some of these so called newer therapies -- which, of course, they’re not new, but depending where we’re coming from -- so, we’re really missing out, and perhaps I’m wittingly shortchanging our clients by not recognizing just what is out there to address challenges, especially around physiological relaxation, which is very challenging, of course, for dysregulation and complex trauma clients.
So, we all know now, that phrase, you know, bottom up, rather than top down, or bottom up as well as top down. A lot of our therapies are still top down. This is a point that Schwartz and Corrigan have made, that many therapies for trauma are still protocolized, which would be the evidence based stuff, and affect phobic. You know? So, there’s still quite a lot of privileging cognition often, and not working with the body.
Now, that’s to some extent, that’s challenging. We’re all aware of the importance of somatic stuff now, physiological, soothing -- that -- what that really means is quite major and a challenge, to some extent, to talk in therapy. We need to be able to find ways to integrate interventions that can assist people physiologically, because many would say, and of course polyvagal theory, very important. And, that’s now been developed into clinical application. There’s now clinical polyvagal therapies.
And, Stephen Porges is an enormously important person. And, really interestingly, a key experiment of energy psychology has said that it’s often been regarded as a strange, weird treatment. But, you know, it’s probably the case of Stephen Proges’ classic polyvagal’s theory providing the evidence base that we didn’t know existed before. So, one of Steven’s major contributions is this notion of neuroception, which is, you know, detection of threats prior to awareness. So, neuroception precedes perception. Story follows state. You know, what we tell ourselves about our experience -- the meaning we make of our experience is actually, you know, actually follows our physiological response. So, that’s hugely significant. And, in fact, he uses the phrase hues of safety are the treatment. So, when we’re able to recognize that, and to integrate approaches and interventions, it can assist people to soothe and stabilize physiologically. There’ll be major psychological benefits.
And, this is very challenging to think about story preceding -- sorry, story following state, rather than preceding. They’re quite challenging to talk therapies.
And, that also leads to, I guess, the final chapter, which is Evidence Based and the Challenge of and for Complex Trauma. So, I’ve already mentioned the distinction we’re making between evidence based and an evidence base. But, the model of evidence based has been criticized. It is considered, even by its most furtive inheritance, is that it does not work for many, many people. It’s one thing to have an evidence based treatment, but translating that clinically is a whole other ball game. There’s many people who are missing out, in terms of effective treatment, if we were to hold, you know, the only standard to use the evidence based treatment. I think that’s an obvious point for many of us, but perhaps not obvious for others who are working from different perspectives.
And, Stephen Porges has talked about a top down bias in medical research, which is a fascinating point. That’s not just -- you know, we therapists who were saying this towards -- the bias towards sort of measurement of motor fibers at the expense of sensory fibers -- and he -- you know, obviously his work is around the vagus nerve, which he says approximately is 80% of sensory fibers. And yet, a lot of the emphasis is in the laboratory, in terms of formal studies and vagal research is -- does in fact contain a bias towards the emphasis on motor fibers, rather than at the expense of sensory fibers.
So, this raised a whole interesting issue, Emma, of what we’re even talking about with evidence for psychological therapies. The more we take account of the body, and the importance of somatic approaches, the more we take seriously, top down -- sorry, bottom up -- as well as top down approaches, the whole issue of what effective psychological research even is, is raised.
And, this is a point Bruce Ecker’s made that David Grands made -- talk about phenomenological rigor, that clinicians and clients have access to, in terms of real world fluctuating changes and states within the therapy room, rather than something abstractly measured, you know, in a top down way, that’s biased in the ways that Stephen Porges describes.
So, it’s very interesting. It’s very dynamic - the field. And, yeah, we’re basically just wanting to distill -- I mean, a lot of it’s basically summary, but it is research -- there’s a lot of references. And, we’re hoping it will encourage people to, yeah, become aware of dissociation, and you know, some of the variety of approaches that are out there, and how they might be responsibly utilized within treatment of complex trauma.
And, I guess that’s the next phase that we’re looking at, is how to do that. You know, how can we draw from approaches that are perhaps very alien to us, but which perhaps do accord with the principles of polyvagal theory, you know, the neurophysiological foundations of affect, and how we integrate those into a phased model to, yeah, to safely, potentially safely accelerate treatment, but not in the sort of short term, traditional way. If that makes sense.
That’s amazing. Thank you so much for sharing that with us.
It’s very exciting, isn’t it? It’s a very exciting time, I think, for our field. Yeah.
It’s a huge thing.
Absolutely, yeah.
Can you tell people where the link is that they could find it?
Sorry, the link to the guidelines?
Yes, ma’am.
Oh, okay, so it will be www.blueknot.org.au - that’s the general link to Blue Knot Foundation, but pretty quickly you’ll find a link to the guidelines, which are downloadable free of charge, or also available in hard copy for a small charge. So, we do want this information to be readily available and accessible, and I’m sure you’d agree, Emma. And, you know, it’s just so important that we’re aware of this complexity, but also there’s ways of making sense of it, and ways of making -- or working with it more effectively than we’ve known how to do before.
Thank you so much.
Not at all, very most welcome. And, thank you for your work. I always listen to your podcast and very much enjoy them, and they’re fantastic, yeah. Thank you, Emma.
Thank you for your time. I very much appreciate it!
Not at all, hope to talk to you again.
Oh, thank you. You were amazing. You provided such a great overview of all of it, and gave such information, and the research behind it, and helping people connect the dots between what you’re presenting, and the theories, and where it all comes from, and the need for it. And, it’s interesting, because I feel like, in a way, in that neuroception kind of way that the community has felt a need for it, and now it’s sort of been almost in that attachment repair kind of way -- it’s almost validated that need when the research comes into place and says, “No, this is this, and this is this, and why we are pulling it all together.”
That’s a great way to put it, Emma. It’s bringing together. There’s so many insights and there’s so much more available, and we need to make those links, and draw on what we can use to really help and assist. Absolutely, yeah.
Yeah, and there’s layers and layers of how powerful it is in the different ways that it’s powerful. It’s such rich content, it’s such important history, and the research being all pulled together in that way, and then it’s just powerful in how it’s applied. There’s just so many layers to it.
Absolutely. Yup, yup, yup. Thank you. Yeah.
Thank you so much for your time. I appreciate it.
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