 Hi, my name is Dragan, I'm a psychotherapist and the bulk of the work I do is in the field of complex trauma and gender diversity. I myself identify as a non-binary transgender man and today I'm going to be talking about a case of a transgender man from Brisbane with my colleague Pam. And I'm Pam and like Dragan I'm a psychotherapist who works near complex trauma and dissociation and I have a client in that area that I'm really looking forward to speaking to Dragan about and hearing about his client. Hey Pam, good to be here. Hey Dragan, good to catch up with you. Yeah, hey look I know you've got the case but I thought I'd just do a bit of a retap of what we're going to be talking about. Is that work for you? Yeah sure, just remind me that'd be helpful, thanks. Cool, okay so Dylan, he's a transgender man from Brisbane. He's 21 years old and his family are originally from India and he's been coming to therapy for about three months every week and he's fairly, he's sort of fairly agitated in his body, like he's quite fidgety, he tends to kind of push his glasses up his nose a lot and jiggle a bit in the chair and stuff but he's been working really well with the regulation concepts around the window of tolerance and noticing that kind of hyper arousal in his body, that's been working quite well for him. Right? Yeah, he's come to therapy because he's always been a meditator, he grew up meditating and he actually stopped it at one point a few years ago because he found that it was, he couldn't stop thinking about things that happened to him at school and stuff and they were really intruding and he wanted to get back into it and basically the same thing has happened, he's getting a lot of intrusions and a lot of sort of nightmares and flooding from when he was at school, he was 15 and he came out as trans and he got really bullied and physically bullied, psychologically trolling on social media, threatened in the hallways and even actually sexually threatened in the boys' bathroom so there's a lot of trauma around that time of his life, there's potentially other trauma as well that he's alluded to but what happened when he tried to meditate again was that that all came basically flooding back into his awareness so that he initially came to therapy to try and make that better for himself, he didn't understand what was going on, you know... Yeah, I've had a few clients like that and they've really kind of spooked because they've heard meditation is really good for them and they try to do it and all the stuff comes up so I hear what you're saying, yeah. Yeah, exactly, yeah. You know, it used to be a place that he could sort of find peace and he could escape and it's just not that anymore. He's actually brought up a lot more symptoms, if you like, for him around you know, feeling very startled and feeling, he gets a feeling, a tingling on the back of his neck that he feels like somebody's about to hit him and he'll just be walking down the road and start getting the sensation so it's brought up a lot of what I would say would be PTSD symptoms for him. And just remind me, Dragani, he's in quite a good situation in terms of support at the moment, you know, in a supportive community that he's got some concerns that his family, it's still quite difficult in terms of acceptance at that level, is that right? But he's got a lot of support in there here and now, outside of him. Yeah, absolutely. Look, he moved away from, he left school, he moved away from the family situation up to Brisbane, he was in Sydney and yeah, that's absolutely right, he's in a good community, he's feeling safe in that community, he's got a little dog that he absolutely loves called Milo and that's a real point of connection for him. And yeah, the main stuff that he is estranged from his father and his mother and sister are not allowed to talk to him. So he's only actually got an aunt who's connecting with him at all. Yeah, yeah, that's great that he's got support where he is now, that it's hard sometimes when the therapy relationship is the only one that's supported. Of course, it's possible when that's the case, but it's greatest is already good support outside of therapy, so he's in that situation and he's here and now kind of every day life by the sound of it. Absolutely, yeah. And look, he's been doing well with what I guess we would call more phase one work of, you know, safety and stabilisation, regulation, resources, he works well with that concept of the window of tolerance and where is he sitting right now. He's been doing well with that stuff and the reason we're talking about it today is that the last session, he basically brought up his uncle and he sort of hinted at the fact that there'd been violence there and possibly sexual violence there and then he completely shut down, stopped speaking and a lot of work had to be done to basically bring him back from that state. So he really moved into a different state. Yeah. Sure. Yeah. So the one of the questions that's been put that we can discuss is is that the therapist was wondering, is it time to move into phase two? Is it too soon to move into phase two? That was one of the questions that came up about the stuff we'll be talking about today. And that's a really always a difficult one because you're never quite sure, are you? Even when all the signs are good. But I like to be really transparent around that. Do you think that would work? Like really working with the client. So what Dylan thinks and, you know, if he finds he's not, what happens then is he got his grounding stuff. So it's kind of like a bit of a dance. And yeah, yeah, absolutely. And then it's not like suddenly we're going to do it and it's all full on. It's like knowing you can step out at any time and it's a little bit exploratory. And if you get the stress, we just stop and that kind of thing. Yeah, yeah, absolutely. Because it's not, I mean, you know, it's nice to have the phased approach. I think it's a good model, but it's not an exact model. It's not a nice, neat one, two, three kind of model. You know, we start with safety and stabilisation. We move into processing trauma. We integrate. Oh, it's all over. I mean, you know, it's not like that, of course. And I think absolutely. The information for me from from this is that, you know, yes, it probably is too soon to move into phase two. However, he did regulate back, you know, in that session, he did regulate back. They were able to come back to that place of safety and grounding. And I'd be, I guess I'd be curious about, yeah, like you say, testing it out. Like if he brought it, say, in the next session or another session and he wanted to talk about it, it would be OK, let's see how we go. We can, we can stop. We can come back to safety again. We can, there are lots of things we can do to make this a safe experience for you. Yeah. And is he on board with that, you know, the dissociative sort of stuff as protective and initial, like he's, if he's feeling overwhelmed, his body will give him, so he'll kind of tune out or get distressed. So he knows the function that that's serving and that it can be managed. If that comes up, you can manage it. Because I find a lot of my clients, they don't really like to spend a lot of time because people can freak it. What if I get upset? What if I get upset? Whereas if they kind of know? Exactly. We do get upset with distressing things, but we can manage it, you know, that kind of dynamic. Yeah, yeah. He's got a lot of knowledge now around, you know, the function of his nervous system and what's happening. He tends to go more towards the hyperarousal, like he tends to go more into the agitated state. Right. He's not as free as he tends to go more into that. I would call it an active freeze as opposed to the full shutdown collapsed freeze. Like he's not moving, but he's also not in that, you know, that collapsed state that's very, very dissociative and very sort of passive? Yeah, yeah, yeah. Yeah. He seems to be much more on the hyperalert state even if he's shut down. Yeah. That makes sense. Yeah, and it's so important, isn't it, that we as therapists recognise that somebody, you know, like you say, it's not necessarily a full shutdown, but people can still be overwhelmed even if they're not totally zoned out. They can stop and we might think, oh, they're just hesitating or taking a moment, but it could actually be a really distressed, semi kind of shutdown. So being really genuine as we're saying, reassuring around that, yeah. Yeah, yeah. One of the things that comes up for me, I think, with his case is that, yes, he's transgender and he does have the potential for, say, gender and congruence, I would call it gender and congruence, where he can experience a dissonance between his gender identity and how he's feeling in his body or how he's feeling even about his body. He does have the potential for that still. He can still feel quite uncomfortable in his body, but I feel like I work very much with what's in the room and I really feel like, you know, yes, his gender's in the room because he's in the room, he's a trans man, but his gender isn't an issue in the room at this time. I think that's a great point. Thank you for, because it's so easy for a therapist who doesn't work a lot with transgender clients to think, oh, everything's about the transgender issue, you know, if something comes up with something to do with a transgenderized gender, whereas you say, this is a human being in distress and that's the primary thing in working in the room. So thanks for just clarifying, reminding me about that, that's great, yeah. Yeah, look, I think, you know, for me, I would be, you know, yep, he's a trans guy, so I'd be aware of my language. I'd be keeping my language nice and open. I'd use gender-neutral language as much as possible. I'd use, you know, quite open concepts around, I wouldn't be describing behaviors or activities or even reactions using sort of masculine or feminine, like those sorts of concepts. I'd keep it much more open. And I'd be aware of if I got that wrong for him, you know, I'd sort of have to be attuned to that or even ask questions if I wasn't sure. But other than that, that's, for me, that's just, you know, there's often diversity in the room and we're often trying to be as competent as we can with that around, okay, how do I meet this person relationally in a safe way for them? Yeah, yeah, yeah. Yeah, and would you articulate that too, Dylan, and welcome him specifically verbally? Say, look, please jump in. And I don't mean just around transgender and pronouns, but if there's anything at all that, you know, is uncomfortable or perhaps I've got something wrong and I obviously I didn't intend to, but feel free to kind of tell me, would you actually put it out to him like that? Yeah, definitely, definitely. I love, actually, I love, I know we get very languagey around our therapeutic approaches and stuff, but I actually love Pat Ogden's concept of contact statements. Like I, you know, I mean, it really resonates with me, that thing of what's there and that if something goes awry, then I have to make contact with that. Like, oh, that didn't go down so well. I'm sorry I did that wrong, you know, yeah. Yeah, yeah, absolutely, yeah. I'd rather pretend and going on as if nothing's happened if we sense discomfort in either of us, being able to somehow address that and acknowledge it verbally or not, rather than just going on as if it hasn't happened. Yeah, yeah, absolutely. Look, the only place I really, I think, I'd want to just keep an awareness around the gender stuff. I don't feel like it's in the room as an issue, but I, but it is in the room. And my awareness would be around working somatically and again, I'd just be attuned. I'd have to be attuned to if we're working somatically and we're working with the body, is that something that's easy for him or not easy for him? Can he come into his body or not come into his body? But that for me would be similar if you're working with someone with trauma around sexual abuse, for example, you might still come up against the same sort of issues around how easy is it for someone to access concepts around the body. Absolutely, yeah. So high sensitivity, but an issue for whatever, any client, that's an issue, isn't it? Attuning to the body and safe ways to draw attention to it that aren't going to freak the person out, so. Yeah, totally. And, you know, I do work in a way where I want people to be able to jump in. And I think initially that's quite a hard thing for particularly trauma survivors to be able to do that. But it's a great place you can get to therapeutically when someone can actually say, no, that's wrong for me. Because now we've really built some empowerment that someone's able to say to the apparent authority in the room as the therapist and they're able to actually disagree. Absolutely, yeah. And I think that's such a good point because obviously Vandekok talks about befriending sensations, you know, but it's so hard when the sensations are distressing, isn't it? So people, you know, if we're trying to take them quickly and talk about attunement to the body and the body can actually be very triggering, it can be the sight of the trauma, you know, especially around sexual trauma and probably with Dylan's dysmorphia, like you're saying. So you're attuning to sensations, but being very aware that that in itself is potentially really destabilising to someone. So the way in which we do it being just so important, yeah. And, I mean, you'd notice, wouldn't you? You'd see shifts in their posture, you'd see shifts in their regulation states. You'd be like, oh, this isn't really working for them. I have to be curious as to why it's not working. I mean, with someone like Dylan, probably before this point, when I would say well before this point, I would have figured out what language works for you around your body, you know, to get some of that information. Yeah, absolutely. And that's, I think where we're all stepping up, you know, we talking therapy people because the body's so important that most of us haven't had that body awareness in our trainings and we're listening to the words. But if we do notice, you know, someone kind of, you know, moving in the seat or looking at the side suddenly or fleetingly looking distressed, we don't just ignore, that's really important information for us, isn't it? Whereas if we just go on the words, we're leaving all that out, yeah. Yeah. I think, yeah, and I think for me, where he is right now, I'd be, so he's brought something up, it's been too much, it's shut him down. I would probably back off from it and be re-resourcing, but it wouldn't mean I wouldn't be, if he brought it, you know, I'm not gonna be, I'm gonna follow his lead around that, but I'd maybe be trying to find ways to, so instead of bringing it and him having to relive it, you could externalize it in some way. So if he wants to look at that, a way that it can be a little bit distant from him where he can start looking at it, not as something he's having to re-experience through telling about it, but through something he can start putting it over there, so just to start looking at it. Yeah, sure, yeah. And just getting back to what you said before about the meditation, something he's tried and can sometimes kind of be stabilizing, would you be kind of distinguishing between meditating and just noticing, rather than really trying to focus? Because mindfulness and meditation aren't the same, are they? A lot of people kind of link to it, but we're wanting people to notice, rather than kind of focus in a meditation type way, if they're not really like that. And I would say where he is at right now, the concept of noticing would be really useful for him, so even you could talk about the last session, so when that happened and what, if you look at it now, what happened for you and your body when that, what did it feel like when you stopped speaking and I saw your head go down and you were looking at the floor and so he can even start noticing that as a, it's like making it a story in a way, isn't it? I'm looking at it from here, it's me, but I'm looking at it from here, so I don't have to be overwhelmed by it. Yeah, yeah, yeah. And I always think of Janina Fisher and I like the curiosity. When something's painful or distressing that we notice about ourselves, that obviously that's usually not a good feeling, but if we can encourage people to be curious, you know, the body's always a source of information and if we can, you know, it's hard when the information it's giving is painful, but if we can keep up that care, it's interesting that my body's actually, like I said before with phase one and phase two, Dylan might be thinking he's ready for phase two and then he gets distressed and rather than kind of going into that, if he's able to, oh, that's interesting, my body's actually suggesting I'm perhaps not as ready as I thought or trying to see it as valuable information, even if it's, you know, distressing in the moment, it can take the edge off and if we can somehow try and keep that curiosity up and part of it is to do that. Yeah. And I mean, I do, you know, I do work a lot with the body, so I would use something like if he was wanting to explore that, I might be like, I'd be trying to find a way for him to put it out there to look at it. I mean, one thing I've done is, you know, you draw a little outline of the body and then you start talking about sensations and start floating out, particularly around his gender and congruence or his dysphoria. So if we coloured the body green, you know, areas that you feel really okay about and maybe we coloured, you know, red or whatever colour areas that you don't feel okay about, like you're starting to get to know that information and then you can, because you're trying to bring something from the external to the internal, so then it could be, okay, so if you put your hand on a part of your body where you've coloured it green, how is that to have your hand on that part of your body and you start exploring the inner and the outer? Yeah. Yeah, yeah, yeah. That's really, yeah, lots of ways of, a lot that visualising and the colour and that sort of externalising and a manageable way of addressing sensations that can be really confusing in the moment, but addressing it in that way can kind of make it a bit more user-friendly, I guess, bit encouraging to sort of get into that sort of way. And you're doing it, you know, bit by bit or using Peter Levine's idea of titration, you know, even if it's too much to put your hand on a part of your body where you've coloured it red, but you could put it near an area that you've coloured it red and you could explore what that was like and, you know, you move towards things, you move away from them. It really makes sense to me that whole rhythm of, you know, you move towards something that's stressful but you don't move too far so that you're overwhelmed, you come back to your place of resolve. Yes, absolutely. That air been floating over. And just on that, around the, you know, edging up to stuff, interphase to, and, you know, exposure, did you want to, that's always interesting to connect on, isn't it, because there are exposure therapies that often aren't as recommended for complex trauma people. There can be some confusion around that. And do we want to say something around that? I just want to get your sense of that. I think the titration you mentioned is a safe way. That's probably our guide. Like, exposure can often mean like confrontation or taking that straight into things. Whereas the titration fits with the phase model for complex trauma, it's gentle. It's moving towards, but it's not like a full-on exposure in the way that perhaps standard exposure therapies potentially can be. Yeah, it's interesting because it did come up in the training where somebody, I was describing the titration technique of moving, you know, towards and moving back to your place of resource. And somebody said, isn't that like exposure therapy? And I said, oh, that's a great question. And we talked about it as a group, you know, because it's not, of course, it's not the same as exposure therapy, but it is building your resilience to that sensation or to that event, or you are building resilience. Yeah, I think Christine Courts, why does she talk about approaching rather than avoiding? You know, it's like proximity, isn't it? And I think Lavigne talks about, as you said, indirectly. I think, doesn't he talk about that, you know, that Greek myth and, um... Is it who's here with the shield, Medusa? And he's advised that like the shield, you don't look directly into the heart of the trauma like looking at Medusa, you do it indirectly. So exposure is kind of that confrontation, immersion, full-on. Whereas we're saying, you know, you can edge up to something. Obviously, you can't avoid painful things all your life, but you can start to move towards it like you're saying safely with penjulation and titration rather than exposure, capital, full-on immersion. Yeah, absolutely. And there's so many, you know, we've got wonderful modality to be able to do that, you know, ways that you can, you know, edge up to it. Or you can do it symbolically or metaphorically or, you know, or even just, you know, through the body using sensation in the body. There's so many ways we can move towards. And as you move more into phase two, which I think is too far for Dylan right now, but as you moved on, you know, I imagine, you know, I like that concept of Pat Ogden's that you're working at the edges of the window of tolerance. You're, you know, you're extending resilience and it might be uncomfortable, but you learn to sit in discomfort. You learn to sit with a level of stress without becoming overwhelmed. Yeah, yeah. But I think that's really important because a lot of people who are struggling and, you know, with trauma, they kind of think, oh, you know, if I go and see a therapist, it's about talking about, it's about confronting. And we're very much, aren't we? With complex trauma, so it's not about that. It is gentle. It is being resourced before you go there. And if you do go there and you get unsettled, you go back to the resourcing. So that gentle kind of in and out, ebb and flow. It would be awful if people were thinking, oh, I can't see a therapist because we're going to be forced to talk about or forced to confront stuff. Whereas, as we're saying, complex trauma therapy, the phase to craft is not about that at all. Yeah, yeah. Look, another thing that came to mind, I wanted to see your take on this, I was really interested because he does, he does relate to sensations in his body like he describes the churning in the stomach. He describes this tingling on the back of his neck. And I was really curious about, because I also know that he has the potential for gendering congruence. I was wondering about a way to tease out the difference that the churning in his stomach and the tingling on the back of his neck, where he feels like he's going to be struck. Actually, he's put that all into the same boat of this is my gendering congruence, but I actually think those are PTSD symptoms. I don't think they're about as gender at all. I think they're about as trauma. Mm, mm. Wow. Yeah. Is that something you would draw, you know, have a conversation with him about or you feel he's not quite ready to make that distinction or it sounds like a... I think I'd explore it maybe at this. If he, yeah, again, if he brings it, you know, if he says, oh, my stomach's churning, I think I'd explore it because I think it's important to differentiate the difference, you know, with everything, isn't everything in the body isn't just about, for example, that I'm dysphoric. Yep, yep, absolutely. Yeah. But I mean, isn't that... Absolutely. Very good. Yeah, absolutely. No, I was just going to say, I think that's right. I can't remember which therapist it is, but never taking it face value, what a particular word is a description is. Someone might say, oh, I feel terrible or I have tingling or... And so, oh, you know, what's it like because that description could be very different for everybody and including for the person, the tingling in one context might be something somewhere else. So teasing out what that experience is actually like and like you say, in the course of that, he may well do, oh, it's actually, it's not what I thought initially or it can be different at different times and just give a bit more room to move because there's such a tendency to over-identify with a painful sensation. It's like it's all bad kind of thing, you know, or it's all about this, whereas if you break it down like that and, you know, explore those, what's it actually like, you can sometimes make helpful distinctions that people can help, you know, that can help them tolerate it better or get a different take on it or, yeah, it makes sense. Well, I think it's important, isn't it? Because people are often coming to us with a diagnosis or a variety of diagnoses and that becomes a blanket thing. Oh, I'm disparate. I have gender incongruence. I have borderline or I am a borderline, you know, personality, disordered person or, you know, people claim that as my identity and part of our work is like, well, actually, yeah, let's tease this out. You know, what is this actually about? What if it's a trauma response? What if it's actually your body reacting to something that's happened in the past? What if it's that? What if it's not what you've been told it is? Absolutely, absolutely, yeah. So some gentle kind of psychic aid around that too, not in a kind of teaching way. But a lot of people, you know, these are the responses when we're dismisses how the body works, how the brain under stress. It's like, oh, it's not just me or I'm not, you know, I'm not my disorder or whatever. These are responses that human beings have to distress on. Yeah, I find that works really well often as well, yeah. Yeah. Would you, where are you thinking he's sitting for yourself? Like just before we sort of wrap up how is it working for you as far as what you think you'd be doing with somebody like him? Sure, yeah, well, I guess I'd be, like you were saying, a little bit unsure. And when I feel like that, which is quite a lot, like if someone's ready for the next day and they're not ready, I think we never know that for sure. I'd probably be tempted to really have a conversation with him, you know, can we take stock, Dylan? You know, we've met for a while and I know you're kind of thinking at times you want to address stuff and other stuff. And you're not sure if you're ready and can we have a conversation about that and really kind of enlisted as a partnership? Because I don't think we ever are quite sure about that. And putting it out there and trying to have a collegial conversation and then, okay, you know, maybe we'll try it, maybe we won't, what do you think? And if we do and if there's distress, what will we do? So it becomes a kind of, you know, potential consolidation of the resourcing and what the format will be and that kind of thing rather than, yeah, you can kind of see people around and, yeah. It's a co-journey then, isn't it? Like it's a collaboration together, like if this should become too much, what are you going to do? What are we going to do? I don't know all the answers, teasing out their own answers, you know, for him to say that was too much last time. You know, for him to be able to identify, yeah, my body's shut down. Okay, that tells me it was too much. So how do we work with that going forward? Yeah, and back to your point about the stages aren't rigid. It's, you know, a lot of people think, oh, that's phase one out of the way. Oh, now I'm into phase two, but it's often with phase two, no matter how resource the person is. I mean, this is trauma often with clients, isn't it? No matter how resourceful you are, you're potentially going to be quite distressed. So it's not a matter of just barreling on. Like if the distress comes up, we stop, we go back to the phase one resourcing. And I think, you know, that often really reassures people, doesn't it, but it's not this sudden, okay, we're ready for phase two, white knuckling, getting through it. Yeah. It's like, okay, maybe we can start it in an exploratory, can we get this, I can go back and do such and such. And it becomes a bit more manageable rather than this big spooky transition. Yeah, and it is a flow, isn't it? Like we are organic beings, it is a flow. And sometimes we think we're well down now, therapeutic path, and then something else comes up and we're like, oh, I need to go back to that early stuff that I did, I need to get back to that place of solidity in myself. Yeah, yeah, yeah, absolutely. So hopefully it sounds like you've got a good therapeutic rapport with him and you can have that kind of conversation. And he's, you know, so we're not the experts in that way. We've got some resourcing, some ideas and we're going to assist, but we're really interested in what he feels himself and how best to support him. And if he gets the stress, we can go back to all that kind of thing. So it's very conversational and exploratory other than suddenly we're into what kind of thing. Yeah, yeah. Totally. Well, look, I've got to get off, but thank you so much. It's been great having a chat about it and sharing ideas. Oh, great for me too. Yeah, likewise. We have to catch up more often. Jogun, yeah, thanks. Yeah, it's nice. I feel like, you know, we're going to approach things in our own ways, but we have a really sort of similar, we're on the same page around these these are the best practice approaches to working with complex trauma so that we don't overwhelm people and so that we are working from a place of strength and resilience and not working from a place of deficit and people getting so overwhelmed and flooded. Absolutely. It's really good to touch base on that, all that. Thanks, Jogun. Till next time, it was great. Thanks. I'll see you later. Bye. Bye.