 Hi, my name is Dhrigam. 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 with my colleague Pam. I'm Pam. I'm a psychotherapist as well. I'm also a Head of Research with Blue Knock Foundation. I work with complex trauma clients. I'm especially interested in dissociation and I have a client I'm really looking forward to discussing with Dhrigam and I know he's got a client he's going to talk about with me and I'm really looking forward to conversation we're going to have. So I hope you find our discussion useful. Hey Dhrigam. Hey Pam, how are you doing? Yeah, good. Oh, good. I'm so glad your relevant to, you know, have a quick chat. I've got a client I wanted to talk about with you. I think I kind of know what I'd like to do. It's just a first session kind of scenario but it's quite complex so great to have a chat if that's okay. Yeah, no, I enjoy that. Yeah, thanks. I know you know the brief details but just quickly recapping. It's Leanne. She's 28. She's with her husband who, she came with her husband actually. She's seen a lot of therapists and she said none of them were any good. So that's one of the presentations you're immediately on your mettle a bit. And I've got a letter from her GP which has information from the treating psychiatrist that she had a very violent background of fatherly when she was three. She lived with her mother but there was sexual abuse from the mother's boyfriends and she was thrown out of the house after her first overdose at the age of 16 and has lived on the street trading sex for food until she met Rob. And it seems to be quite a close good relationship with Rob but she's very up and down sometimes doing sex. She's very distressed and starts screaming. Rob doesn't know what to do. He's very concerned. She doesn't want to have sex anymore at all at the moment and she's having flashbacks of the sexual abuse and very depressed. And she's cut herself to stop voices in her head. I know from the letter from the treating psychiatrist that there's quite a lot of information that she's lost time. Sometimes apparently she's gone shopping and she's even bought clothes that she doesn't remember buying, doesn't identify with them as hers and has also been lost in different places without knowing how she got there. So I'm immediately thinking oh there's obviously some dissociative stuff happening here. The diagnosis is borderline personality disorder with suicidality. So I just want you to get your thoughts but my thoughts immediately because I think this is quite high stakes. None of the therapy is really good. She's very ambivalent about coming but of course she has come back to therapy and I imagine she's quite frightened or just think you know what's going on. I don't think it would be so scary wouldn't it? Absolutely, absolutely. And the borderline personality diagnosis which is often confused with DID you know now we don't know that it's DID. I certainly wouldn't be saying to her it could be DID but I've flagged you know the lost time not identifying with things that she's bought doesn't remember those hers and getting lost. It could well be. So it doesn't seem to me on the face of it that that may be an accurate diagnosis. I don't know yet but I just want to say. I agree yeah I agree and look it's you know I sort of harkened back to Bessel van der Kolk talking about if we can't get the diagnosis straight then how on earth can we provide an accurate treatment you know or an accurate plan for therapy going forward if we if we're not even being accurate about what's going on for her and I agree with you there's big big red flags for dissociation. Yeah and because therapists often aren't aware of dissociation as we know because we don't work in this field no wonder she's suspicious and uncomfortable if it is as we're saying likely dissociative and that hasn't actually been picked up and it's immediately been put in the BPD basket and obviously in the overlap of symptoms and mood swings and so on but of course there are differences with BPD and one of them is if it was DID but it'd be more likely to be the case that you know the client wouldn't be remembering and owning and recognising you know what have happened. My understanding is BPD people often can't identify with how they were in different states I might not be happy about it but it's kind of like me up and down you know when you can look at that but DID there's often a real you know discontinuity genuinely not knowing that part of themselves so if there's any of that there which it looks like it could be and that hasn't been picked up by previous therapists and she's been put in the BPD basket no wonder she's kind of you know a bit spooked a bit resentful a bit unhappy about therapy so I'd want to really I want to see what you think really you know move away from that diagnostic lens in what I say and very much assure her that I'm kind of client centered and that I'm not diagnosis driven and but I was wondering what you thought because at the same time I've got this information from the treating psychiatrist and I believe she knows that I've got the letter you know via the GP and although we always like to make up our own minds about people are not going what's been said before especially if we think it may be problematic I thought there's really valuable information in that letter that she probably would know I know for me to actually put out to her you know from what I hear you know you're experiencing this and experiencing that and you know this could be and kind of get into a general you know exploratory tentative alliance building conversation about making sense of what she's yeah would you would you flag that with her I mean it's very early days but would you even start making some you know because you're trying it's obviously very frightening and so would you be trying to give some information or share some information about it makes sense to me if this is happening for you because it's often something that does happen when people have experienced overwhelming things in the past or would you be making that well actually yeah yeah no I would with her and I do really good question thanks for I wouldn't necessarily make that link with everybody but in this case with Leanne I feel very I think it's quite high stakes she's very pissed off with previous therapist she's experiencing severe symptomatology that doesn't seem to be any clear framework she's been given so I would without saying your DID when I don't know she is I definitely want to say to her look I notice you've got a BPD diagnosis I don't know you know let's talk about your experience but if anything on the basis of what I you know your doctors said I would suggest there was you know if there was any kind of disorder it'd be more dissociative I don't know if I'd use the word this sort of but I'd certainly introduce dissociation because that may be a totally alien concept to her and as she just said it could be very reassuring to make sense that she's not crazy yes it's scary yes we know we need to address it but it makes sense that you would be experiencing what you are if it is dissociative rather than you know another diagnosis yeah and you could check that stuff out with her you know so it says here that you've lost time tell me a bit about that and you know dissociation would cover that experience and if you link it to it's actually resilience actually that your amazing being has figured out a way to compartmentalize stuff that might have been too much absolutely I thought that was a gifted opportunity to talk about how privileged dissociation is like when it first emerges it's very protective it's this extraordinary capacity like you said you know I'm distressed yeah but as with all things if we have to use something decisively over a long period and we haven't been able to address the underlying stuff that becomes the issue so we're wanting to be reassuring her that this absolutely makes sense but also recognizing the impacts of having on her life and how we might start to so yeah do you what do you think I was thinking that would hopefully reassure her get some buy-in that she hasn't been put in a problematic basket and she's not going crazy but also yeah recognizing and that she hoping with head yeah yeah that she makes sense that's what you're talking to is that speaking to it she makes sense she's not some crazy person she's not just a diagnosis she's a being who makes sense yeah absolutely and given how we know that you know I noticed the suicidality that's in the in the treating to it later I mean it may be suicidality it may be self-harm without suicidality because we know that's often confused especially not recognized as dissociative as a coping strategy so it's a good opportunity I thought maybe to explore with her and I think I would want to explore what's going on with that you know because often we know that we know because we work in the field but self-harm is often about self-regulation and people actually do it to feel better not to necessarily you know try to genuinely kill themselves I'd want to explore what was what was motivating that there may be suicide but I you know it may well be self-regulatory and I think part of it do you think I'm thinking she would even be relieved at one level to have these out there and address absolutely you know and that it's not a it's not like you know this terrible thing oh my goodness you're self-harm and it's like okay look this is happening and there's often a reason that it happens and it often serves the function for people around regulation let's explore what it might be for you is it something that helps you feel relief is it something that takes the pressure off is it something that brings you back into your body because a lot of people who is associated use it to bring themselves back yeah yeah absolutely absolutely and again the information that's been provided that again I'm you know I'm pretty sure she knows that I know so I can you know draw on that and you know she does you know has had very early situations of abuse and sexual abuse so what we're saying before about you know the coping strategy the dissociative you know the way of part of the self-being protective and if things happen at a young age not being able to address them so it is absolutely protective and make sense that the child will kind of I'm not just really tentative about how far I get back into early life but wanting to what we're saying you know give a sense of how the coping strategies that are causing problems now were protective initially so she doesn't have a sense of herself as crazy and totally adequate to oh no this all makes sense we can address it does this seem like this is what your experience is I'm really hoping to do yeah client-centered and some gentle psychic around dissociative symptoms because I doubt she's had that so I'd probably want to do you know how we need to distinguish between mild moderate and severe dissociation because we all many of us see dissociation as a continuum and you know de-personalization and feeling a bit disconnected or those kind of things we all have that to a degree exactly it's very normal we all do it you know and yes of course the more that we're trying to compartmentalize or move away from something or avoid something then the more extreme it might get but we even do it in our daily life when we're feeling tired or overwhelmed we switch off we shut down it's a normal thing yeah absolutely yeah and I think you know now you go because it's you know the first session and it's very you know you're working to build that therapeutic alliance as you say would you do anything in the first session around regulation like how would you approach that with her I think my main thing thanks for helping me to you know workshop the ideas with you I I I may be able to you know gently kind of suggest some self-regulate but I think my main thing in the first session would be to normalize her symptoms in the context of a dissociative lens because it seems pretty clear in light of that information about lost time and not knowing where she is buying the clothes and not remembering and I feel like if she could come away from that session with a sense that I'm not going crazy and you know I'm there's a bit of understanding here and maybe this makes sense that she may actually commit to because this wouldn't be obviously a you know half of half a dozen sessions and given the long journey she's had of not having good experiences in therapy I feel like the buy-in would be the normalizing you know gentle kind of self I don't like you know so I get I used to sounds like a teachy kind of thing I think gentle information around association which she doesn't seem to have had before could be the buy-in I feel like I need without minimizing how serious it is I'm not spooking her either but at her going away with a sense of okay maybe this kind of makes sense maybe I could start to you know address this rather than feeling that she's in the too hard basket or bounced around on the time yeah and also some hope like sending her off you know with some hope that there's that it makes sense and there's actually things that one can do and there's things that one can learn and there is there is a path forward absolutely yeah yeah yeah she needs I mean she does obviously need a lot of safety building which would be that would be a big piece of work wouldn't it like people often say you know oh well how long do you do phase one for with someone like Leanne there's a big piece of work to do around safety there's probably a lot of developmental trauma in there because she's had that since such a young age she's she's been in a really unstable environment a very frightening environment so you could be working with someone like her for a long time in phase one couldn't you look absolutely and if it is the idea which we you know not sure yet but if it is obviously the self-regulatory stuff is more complex because depending on what self state the person being a normal kind of soothing activity for one state may not be the case for another so I guess that's another reason why I'd be a bit reticent about suggesting strategies in the first I probably want to engage Rob a bit do you think to go I mean it's good that he's in the room and he could be kind of enlisted quote-unquote to be support he probably knows and notices things and it may be already doing things that are helpful or not helpful so I think maybe what do you reckon I'd be kind of wanting to draw him out and obviously she feels safe enough that you know he's with her in the session and really bringing him in as part of it in terms of what's going on outside of session and what could help in the meantime before our second session I'd probably want to set it up that I expect to see her again you know that kind of thing yeah and maybe Rob could be brought in as a support around that as well how would you work with something like because if he's there sometimes you know people she might like what if she brought up something like yeah we're not having sex because blah blah blah and it's right there like how do you work with containment because I think that's something people therapists and others really struggle with when there's disclosure or it's something's clopped in the room too early so to speak yeah around that yeah absolutely um and I notice that you know the information apparently she's not having said and Rob maybe you know upset about that or is there something wrong with me so I guess I'm hoping that kind of normalizing of the symptoms quote unquote and giving some kind of framework by which what they're going through as a couple would make sense you know so hopefully because it all makes and that it's not personally about Rob unless he say it's not about you but that makes sense in terms of coping with distress that there may be you know issues around that and there are things we can do like like you said there's ways of addressing this because it's very difficult for partners and I probably want to suggest that you know he gets some support from self or maybe not because he may think he's the problem and and there may be a dynamic in the relationship I don't know maybe there are problems it probably are but that's a really good point like if not having sex is an issue in itself and that comes up directly in session that would have to be addressed too because that may be the main concern yeah yeah and it might be you look there's you know that that's an issue between the two of you maybe that's relationship counseling but it's obvious there's a lot for if Leanne wants to continue therapeutically that's going to be very different you know that's a very different journey than their journey together mmm and I think you know you and I've talked about these things before and it's really people often over identify with you know they come in whether it was an immediate issue is and it's like all of us we often don't make a connection between a painful experience we're having in the here and now to what's gone before so I'm hoping it might be helpful for both Leanne and Rob to be able to if the section not having sex anymore is the issue in the room at the time or that comes up to be able to kind of get a sense of well you know that kind of is understandable that that that could be happening given you know and rather than it you know there's no realm of reason or the relationship's not working or there's something wrong with with either of them that that makes sense that it would you know there may be a protective aspect to feeling very exposed and triggered around it but again that that makes sense in context but these things that you know down the track that you know can be addressed so it's a really good point that about dealing with what's in the room because I've got all these ideas but maybe what comes up immediately is we're not having sex anymore and why I can't even know but I think that that that framework of under the dissociative lean if that hasn't been raised with either of them I suspect it hasn't hopefully that will immediately take down some of the temperature of what the hell yeah yeah I had a question as well I had a question Pam around because I work a lot with the parts approach like Jameena Fisher would approach it or yeah the internal family systems model and I had a question around with actual dissociation would you use that same kind of approach like to bring out say resources or resilience or the fact that there's yeah there's a part that might want to leave as in suicidality but there's also a part that comes therapy like would you use that approach anyway even when it is something like dissociation? Yeah I would and I think the beauty of the part stuff and you know on a van to people who work in complex trauma say this to the beauty of the part stuff is that we can use that framework with any client like we just said we've just segwayed haven't we like there's always the part of me that is the part of me that's I'm like this situation not in the other now obviously if it's the idea that the parts are more separated there's often less co-consciousness you know it's a different degree of separation of parts but the model of parts itself I agree is incredibly helpful and I would probably absolutely get into that quite early so it would hopefully be a bit reassuring for both Leanne and Rob that can be very different at different times potentially I would want to you know normalise we are all different in different situations and sometimes if you know there's been very distressing situations in the past that can be more you know that the shifts can be perhaps more rapid or more extreme or it makes sense that there may be forgetfulness so I think it segways really well from the part that we all have to getting into the parts of the idea which are more rigid and and more separate but he's a kind of normalising way of talking because we can talk like that to all our clients exactly yeah yeah I agree and you know it's there's a part that's freaking out during sex you know it's not that Leanne the whole of Leanne you know it's finding ways to okay yep this is happening and there's probably a reason that's happening that makes a lot of sense and maybe we don't need to get to that reason yet or even approach that yet but it's enough to know that it makes sense yeah and you mentioned Janina Fisher and that's really helpful if you've reminded me I'm Janina Fisher is really strong on this isn't she she wants to move away from the language of I with to encourage the client and ourselves to start using parts language so getting back to your point you know thanks it's really helping to clarify as I speak with you rather than you know her going with strategies which I don't think would work very well if she can lead that first session in starting to think about parts you know if she finds herself doing something or role-play it's the part of me that oh part of me this rather than this assumption of a coherent self and I which with severe dissociative stuff people just don't experience that so the language is not helping so I definitely be using parts language in that way and hopefully that would be a bit reassuring that Leanne has a sense that that's understood that a lot's going on inside that she doesn't make sense of and that she doesn't identify with all the time either because there's various parts in different directions yeah and even and then introducing that concept that sometimes a part can actually take over to the degree that we don't remember where we were yep yep absolutely and there may be parts that jump up that actually are very functioning as well like when I don't know yet enough about her life but a part that takes over to get her through situations that kept really well so like we say we don't want to pathologize the part you know some of them are probably stepping up and doing really good and it's only the ones that are causing difficulties that are you know that she's focusing on so all of the parts she has a purpose and yeah yep and she has a very strong or survival part or part that have got her through which is extraordinary you know she had a part that was able to get away and actually survive on the streets and found ways to do that I mean there's a lot of resilience in that story yeah that's great yeah I think I definitely want to validate that too do you find dragon it's always a dance between strengths based and recognizing what people are still up against so I'd want to actually validate what how she survived and how it's really good but also indicating that you know it is a struggle it is difficult as well and saying it's the parts you the parts that are really getting on with life that you know and doing well and extra cutting from difficult to really validate in that because she's probably down in herself for what's not going well but also empathize with the bits that are still difficult but that you know makes sense in light of dissociative stuff which as we saying she probably hasn't had any discussion or connection around so yeah yeah I think it's an important point too isn't it because we tend to get these catchphrases like strengths based in in our service provision and yes it's great we because we know we want to bring out there's going to be a resilience narrative in there as well but we can't diminish the very real struggles in people's lives you know we don't want to just focus on them yeah yeah I feel really strongly about that there's a lot of people who look to be and are in many ways resilient but according to external criteria are you in a job you know relationships should be data and people can young people can jump out of it's really strength but can completely miss what is the subjective quality of life of the person and because I see a lot of dissociative costs I really try to clue the surface presentation can be immaculate you know we see that often that we would dissociative clients and it's not safe often to present differently so if we just say oh you're doing really a resilience and you're in your job but what's it actually like to be you know what's the experience of being oneself so celebrating the strengths but also recognizing the challenges yeah yeah yeah yeah well that's really helpful thanks Drogon yeah look very interesting is that yeah sounds like you you know you've got good ground work set good places to connect with her and it's all it's all going to be around that connection isn't it because she's had not very good experiences of therapists before so it's going to be you know getting getting that connection and probably very very transparent not being the expert she'd probably react to that I suppose if she's had a lot of that before so really forming the alliance where we're doing this together yes I've got stuff to offer but so does she she's going to know more about her experience than we could ever know yeah no no no but Leah like you said if it's often you've got time to segue into the relational connection but I feel that needs to be there from the get-go we've had so many bad experiences and trying to kind of yeah in power sense that it makes sense and we can work on this yeah rather than taking a long time into it it's really important that and then yes if she's seen as a client in a person and her experience rather than the labels and so on so yeah so thanks for that dragon that's brilliant no worries thanks okay go well yeah all righty thanks okay okay bye bye