Cool study exploring expertise: confessions of a neuroatheist

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Todays obsession with the brain as a pseudoscientific tag line for all things drives me nuts. Yes, we have a brain. Do we really know how it is involved in our conscious, cognitive, behavioural and emotional selves. No.

Insert rant… more eloquently done by Ana Todorovic in her blog “Do psychologists need a brain

Would knowing more about the brain change anything? I’m not convinced. Just like understanding muscles might make some tiny difference to elite athletes but hasn’t helped in muscular dystrophies.

It seems fairly straight forward to me, that if I go to the gym and do arm curls my biceps will get bigger. And so it follows that if we recurrently practice something, the bit of our brain we are working with will get developed.

I went looking for a study I heard about in the ’80’s when I was at medical school. This study found that London taxi drivers had an overdeveloped part of their brain responsible for spatial awareness. As I embarked on this search I tried to recall if we even had CT scans in the 80’s and braced myself for some macabre post mortem study.

What I found was something much more recent, and my confession is that I found it interesting and thought provoking, raising useful questions for doing therapy.

The study:

Talent in the taxi: a model system for exploring expertise. Katherine Woollett et al 2009

They studied London taxi drivers and found that people of average IQ can develop expertise to an exceptional level, and this was associated with developing more grey matter in their posterior hippocampus, an area related to spatial awareness and navigation. The down side, as seen with autism where there can be exceptional abilities at the expense of social cognition and executive functions, and some expert musicians who suffer focal dystonia, the taxi drivers performed poorly on tests of spatial memory and delayed recall, as well as acquiring and retaining other types of new information. They also lost grey matter in their anterior hippocampus associated with worse anterograde associative memory.

Interestingly both the positive and negative grey matter changes began to revert after the drivers retired.

London bus drivers, in comparison, had no hippocampal changes, and this was explained by the different expertise required to follow prescribed bus routes versus being required to learn the layout of all 25,000 streets  and thousands of places of interest in London.

A follow up study in 2011: Acquiring “the Knowledge” of London’s Layout Drives Structural Brain Changes tracked individuals of average IQ over the time of their training and found that those who qualified demonstrated a structural increase in grey matter in their posterior hippocampus and concomitant changes to their memory profile, but there were no changes in those who failed the test, or those in the control group.

Some useful questions for working with clients:

One of the most reproducible findings for structural brain changes in PTSD is reduction in hippocampal volume. This has also been found in major depression, schizophrenia, and in bipolar where a correlation with verbal memory deficit has been shown.

Most people who are stressed or depressed report poor memory. I wonder if you practiced being stressed or depressed you could shrink your hippocampus.

What if reversing those changes were as simple as retiring from taxi driving?

Is it just a matter of use it or lose it?… or better still, lose it or use it…

What we practice we get good at. What are we practicing if we are depressed, anxious, obsessed, paranoid…

What could we practice instead?

What do you think?

Psychotherapy research: Playing the Game of Thrones

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I have been amusing myself thinking of all the players in mental health care as characters in the Game of Thrones. WARNING, if you haven’t been got by GoT you wont want to read this post.

Long ago, the first men, from Plato and Aristotle, to Mesmer, Pinel, Gall, Weber, Gage, Darwin, Broca, Galton, Wernicke,  explored the untamed lands of the human brain and mental processes. The children of the forest unwittingly created the first white walker (1878, Hall) by plunging a piece of dragon glass into his heart and declaring the brain and not the heart as the organ to study, and building a wall.

Was Freud the first Targarean? Their reign was strong, incestuous and peppered with occasional  madness. Until the rebellion.

So our story starts as it has always, with the field of psychology saying “winter is coming” The southerners (Psychiatry) mock this doomsday prophecy, but are themselves recovering from the era of the mad King.

Standing guard, the watchers on the wall, protecting the realm from Wildlings (aka counsellors, mental health workers, case workers). We discover they are actually people too with their own set of skills and resourcefulness. And they cope pretty well with the winter. But still, the common people are told stories that ignite fear perpetuated by the raiding parties as Wildlings fight for their survival. Despite their skill set they are thought of as lesser beings.

In the capital, the Crown is half a kingdom in debt to the Lannisters, so decisions get made, not for the good of the people, but to assuage the self interests of the investors. So too in psychotherapy research. If you think Prozac was made by the Lannisters you won’t be too far wrong. If you are going to spend their money you’d better make sure they look good.

Now the Starks were an honourable bunch, with great integrity, and so they didn’t last long. Ned stark, however, before his beheading inadvertently created the Brotherhood Without Banners, a rebel group sworn to protect the small folk from anyone preying on them.

Enter the activist for trustworthiness and transparency in science, calling out vested interests and conflict of interests in big Pharma and unfounded claims of miracle treatments. Yet sometimes their methods leave a lot to be desired.

John Snow, arguably the most loved character, who’s honour is only matched by his courage and creativity was willing to admit when he was wrong and change directions, including taking risks that were politically and personally dangerous. ( See Scott Miller, Bruce Wampold and their clan folk) Alas, killed as a traitor by his own men, though only mostly dead, he rose again, readying to reclaim territory stolen by the Boltons, aka CBT! (A bit harsh maybe, but it did invade Sweden and cause great suffering)

On a different note, Mance Rayder, the King beyond the wall United the Thenns, Hornfoots, WIldlings, Ice River Clans as none had done before. Probably learned this from Jeff Zeig bringing the field together at  the evolution of psychotherapy.

Milton Erickson of course inspired the three eyed Raven, and many might wish to be his disciple, but of course I’d say it was Rob McNeilly

In further speculation, was Jay Haley  Maester Aemon, and Michael Yapko  Jeor Mormont

G.R.R Martin created a brilliant story, but, despite the many fans of his books it was HBO TV that really brought it to the masses. So too attempts to bring science to the masses began in the media, but like the arming of the faith militant, things went terribly wrong. Someone, somewhere must have thought it was a good idea, but what followed was alarming. Using the power of persuasion, poor studies with low power, small sample sizes, undisclosed analytic flexibility, impossible to reproduce findings too weak to build theories on, were sold as tantalizing certainties based in science and so became armchair truths to the ordinary people.

As we wait for the next exciting installment, we know, that the best is yet to come.

Psychotherapy research is stuck in transit

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As a General Practitioner, working in mental health I try to keep abreast of all aspects of patient care. Looking at the evidence about best practice of psychotherapy has been an interesting and often frustrating pursuit, but some clarity is emerging, and to speed up the journey for those who come after I thought I’d write some travel tips.

If you’ve started on this journey as a non-psychologist, then like me, you are probably surprised by the academics who believe one model is best. It is surprising to an outsider because the data from decades of research can’t be clearer. All models perform the same.

Rarely do you find a more reproducible finding with so many supporting studies, often with studies that actually set out not to support it, but still supported it.

And yet, there are academics who actually believe with an almost religious fervor, that their model is best. They admit that the differences are very small, but they still claim they are statistically significant, and I think they actually believe that if we get clearer about categorizing mental health their hypothesis will be strongly supported as they discover which aspects of their model work on which bits of the disordered psyche. This is so strange to an outsider, because there is actually no evidence for that way of thinking, and yet it pervades the field and I think influences research in all domains in a detrimental way. I could go so far as to say this could be the reason why there have been no significant improvements in patient outcomes since clinical research began.

I have spent some time exploring their argument. It exists in psychologists more than any other group of professionals who work in mental health fields, so I suspect it’s roots are in their academic training. I suspect their beliefs are formed there, and I see some parallels with some of the beliefs that I picked up from my medical degree that were hard to shake even when they were found to be wrong.

There is an interesting phenomenon, that as a researcher your beliefs will influence your findings.

Recent controversies in Social Psychology have highlighted this phenomenon. Here is a nice article about the controversy about Amy Cuddy’s Power Pose research:

http://www.slate.com/articles/health_and_science/science/2016/01/amy_cuddy_s_power_pose_research_is_the_latest_example_of_scientific_overreach.html

The short version is that if you haven’t registered your study you are prone to let what you are looking for influence what you are seeing as the data emerges…. so of course your findings will be faulty and unreproducible…. but, in the case of The Power Pose study, they got some cool headlines and the most watched TED talk ever. Yikes.

The phenomenon is called p hacking, fishing, and the garden of forking paths. Andrew Gelman has written a very nice article about it:

http://www.stat.columbia.edu/~gelman/research/unpublished/p_hacking.pdf

It was by reading about this that I suddenly got it. This is the reason!

So, by p hacking, fishing, and the garden of forking paths, academics are perpetuating a defunct belief around model superiority, and continuing to instill it in their undergraduates and postgraduate students, leading to an enormous waste of resources.

Why is that important?

Well science is on hold. It is stuck in the transit lounge.

It’s strange to think that academia could actually become extinct, but the most interesting research is happening outside academia, in the clinical setting. Therapists who have managed to let go of this belief are free to explore how people get better. They are focusing on things other than models and working out how to improve.

In my work Ive been looking at the people who don’t get better and thinking that the one on one interaction of therapy is too limited for very isolated people and ventured out into our local community. Researching if anyone is doing any good work in this area I found there are grass roots initiatives cropping up everywhere that have given up on government policy and funding or non-government organisations and are looking for other ways.

That is just one area, and there are many other worthy areas of exploration, as the space to explore expands when once old, unworkable beliefs are given up.

 

 

 

Untangling the best treatment of mental ill health… a frayed knot!

 

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Find out why

I started this blog with enthusiasm, as a way of sharing my thoughts as I was exploring what we know about how people diagnosed with mental illness get better. I hoped that by getting clear I would find a focus and direction for developing and improving in my work, and that by sharing a summary, this clarity might also help other practitioners. This blog has been languishing while I have been lost in the metaphoric Amazon, but here’s an update.

Unlike many other areas of medicine, where such a pursuit is a relatively simple journey with well marked sign posts and a road well travelled, this journey has been a murky, muddy, poorly lit path with lots of scrub bashing required.

I have discovered that despite millions of dollars spent on research in the last 50 years, we are no better at treating mental illness now, than we were then.

Gene studies, Neuroscience and exploration about how the brain works has been fascinating, but it has made no difference to patient outcomes.

The promise of medications that work like antibiotics to cure a complaint, is a bubble that has well and truly burst, with placebo being the biggest winner. The strategy of throwing every new drug at every condition to see what happens has been pretty interesting, and probably been driven more by the practitioners desperation and anecdotal observations than any decent science. The result has arguably put the biggest dent in the rationale for diagnostic categories. If you say you can observe benefits of antipsychotics in depressed patients and vice versa… well isn’t that like saying antihypertensives have some effect in Influenza??? You’d have to wonder if we are trying to cobble some therapeutic effect from a side effect, rather than an explainable physiological biochemical intervention. As studies emerge with concerns for long term follow up, particularly of children who were exposed prenatally, we will likely see the pendulum swing in the benefit/risk debate about when to treat.

What has gone wrong? Where is the hard science? The indisputable ground on which to make decisions about patient care.

Well, as Deep Thought famously said: “I think the problem, to be quite honest with you, is that you’ve never actually known what the question is.”

I myself am just sitting with that one, and don’t claim to have had a bolt of lightening about the question. The experience I have in the face of this though, is like working with a family where all the logical attempted solutions to say a child’s behaviour have actually become part of the problem and there’s a big tangly mess of action and reaction, and the best thing to do is to down tools and start again, and a big part of this is to help the individuals give up their certainties about how and why the problem began.

In starting again, there are some things we can say about psychotherapy with certainty:

That the therapeutic alliance is of primary importance, but that the qualities the therapist brings to this alliance are vastly under researched.
That no one model is superior to another when put under scrutiny that controls for quality of study design, therapist allegiance to the model being tested, and comparison to a bona fide treatment.
That therapist allegiance has a robust influence on effective outcome, but is vastly under researched.
That most therapists do not improve with years of experience, implying that their education and continuing professional development, must not be currently focussed on what is responsible for effectiveness.

That feedback is a good starting point, but we need to know more about what to do with that feedback.

The difference between a good therapist and an average therapist is far greater than the perceived difference between models that has been exhaustively investigated, but we know very little about what the good therapist is doing that the average therapist isn’t.

Theres still a lot we don’t know about. We know almost nothing about people who get worse with treatment. The only things I’ve seen written about this phenomenon, generally follows a demeaning, paternalistic bent around the fact that these people are not psychologically minded or sufficiently cognitively sophisticated to be helped by therapy.

We don’t know much about people with severe mental illness who do actually get better. The people who are literally “cured”. It is usually said that they can’t really have had that severe diagnosis in the first place. Then they are dismissed.

I think that we need to think differently about the whole issue, and to start asking different questions…. but what? What do you think?

 

 

Time for the Emperor to buy new clothes from Kmart

I have been preparing my talk for The Brief Therapy Conference in San Diego in December and I’ve just discovered an awfully big problem.

Responding to feedback from my last presentation… People want evidence.

So I looked for evidence for the major points I want to make and I can find it. Some of the studies I could use to support what I am saying are even pretty well designed, but here’s the thing. After my exploration this year, I now know that they are meaningless. You can actually find anything you are looking for in the social sciences and psychology research.

Most of the time researchers are honestly passionate about what they are exploring and don’t see the biases and allegiances they bring, and some of the time affiliations to industry, pharma, or just getting published and keeping your job or earning a crust let the rot creep in.

Even if you find a good study with seemingly none of this, it won’t be reproducible, because none of them are, and for a finding to have any scientific rigor it has to be reproducible.

And there’s another funny thing which I discovered when speaking to my brother who is a scientist. Chemistry is his thing. I could barely understand the title of his PHD, let alone what it was about.. He has embodied the science machine and chemistry has behaved itself appropriately. Being analytical has worked well for him, and I value his clarity and experience.

He is, however, also an athletics coach,  most recently an official Olympic coach. Pretty amazing achievement to manage in his spare time. Inspiring. I have spoken to him about doing the landmark forum, as I think the distinctions and experiential learning would open a whole new world for him in his coaching. He is reluctant, and would expect to walk out not being able to manage the hoopla. But here’s the thing, feedback from 2.5 million participants of the forum show that 95% get a major life altering transformation. This is way better than any therapy or coaching process. Then my brother started telling me how impressed he is with neurofeedback for coaching. Ho hum. We know that Neurofeedback, CBT, or any of the other hundreds of models are all the same. But there’s the thing… Neurofeedback is very palatable for the scientific mind and The Landmark forum is not.

And I think that’s it. We put these studies up on a slide to make what we are saying palatable to our audience. If you really see that, most presentations are like persuasive writing. We are more like journalists than serious contributors to our field.

It’s actually quite funny when you think of all the criticism Erickson got from his Ocean Monarch Lecture, when people discovered he was speaking to generate an experience so that learning could actually happen, and some people felt manipulated. If only people would get offended by the attempted manipulation anytime someone used research to make their point.

Holy toledo! What now?

 

Communing with communities

All my working life I have worked with vulnerable individuals to heal them, primarily physically, as a doctor, but as a General Practitioner or “family doctor” I couldn’t ignore their emotional or relational worlds as a source of their good health. Many times, helping someone to connect to a community that let them thrive was the greatest medicine of all. So often though, for the most vulnerable and isolated, that was the hardest thing to do.

Recently I have seen how absurdly unworkable that was. Like my life’s work was about carrying individual raindrops in an attempt to make a waterfall. Duh! There are plenty of spectacular waterfalls in the world, with plenty of tributaries that actually suck reluctant raindrops into the mainstream just by their very nature. Why try and make a new one from a mass of reluctant raindrops?
Another thing hit me earlier this year when I joined “The School of Health and Care Radicals” and was asked the question: Have you ever noticed that when you are at a conference listening to an invited speaker, there is actually more knowledge and expertise in the audience than on the stage, no matter how expertly specialized the speaker is? It follows for me, that any community has more resources than its leaders.

My interest in individuals turned to families about 16 years ago, and with my husband Rob McNeilly we developed a very simple yet effective Solution Oriented approach to working with families, so that an individual with a perceived problem, did not become the black sheep. With the resources of the whole family, and the ubiquitous love that all families have underneath their gripes, a family in strife could flourish as a strong flock. If you’ve ever seen the first Ice Age movie, where the Mamoth saves the Sabertooth tiger, and the tiger is confused, not understanding why his potential enemy would do such a thing. The Mamoth simply replies, “We’re a herd. That’s what you do in herds” the sloth then says “Funniest looking herd I’ve ever seen” Human beings are herd animals. We know that in our bones, but we also feel the isolation of modern life, which I guess is why that line is so funny. Similarly, at a presentation I went to, I think at a Brief Therapy Conference in the U.S, a presenter was talking about “Blended Families” but thought they should more accurately be described as “lumpy familes”

So, just as I got that it’s easier to work at a family level with an individual problem, because there are so many more resources to work with, I finally got the power of of working with a community so that no person is left behind, isolated, marginalised, brutalised, radicalised, but rather, the potential of all is realised. And it’s done from within, not imposed by some outside expert.

I have also discovered that the “how” of doing this is showing up in my actions and conversations with other people, not so much in my conversations with myself, so if you feel similarly inspired I would love to speak with you. We can talk by phone, email, or zoom. I am cooking up an online conversation with a group. Let me know if you are interested to join. Email me at gabrielle@cet.net.au or add a comment.

 

 

Mental health, toasters and social transition.

Like many Australians, I have been very stirred up by the events of the week. A man asks a question on Q and A that thousands if not millions of Australians have asked themselves. Then a well intended fellow does what many of us thought was a nice thing, without questioning his right to put this man at centre stage. The paternalism and missionary zeal at rescuing the poor savage is so transparently present in our present from our ancestors DNA that many good people forget to question such a pull to action. Indeed they felt it themselves and then found relief in giving to this cause that spoke to them.

I had a moment where I thought we might actually get some real debate, from real Australians not filtered through media self interests. And then the tribalism began. “The he said, she said” The trial by fire. The guilty until proven innocent. Another primal aspect of our humanity fanned into flame. Fanned into flame, in this case by the media self interests. And the tall poppy falls.

All human endeavors through history that fight for human rights have not been without casualties. The suffragettes were blamed and demonized and many saw that only violence was a language that could be understood. The oppressed, violently pushed down, often violently retaliated. And some didn’t. Gandhi grew the power of non-violent non cooperation, but even he couldn’t stop the Civil war that slaughtered innocents even when their victory was at hand.

In Australia, women have had the vote since 1908, though not yet equal pay. Indigenous people did not get the same voting rights as other Australians until 1965, but still have inequality in all Western standards of health and wellbeing. Nelson Mandella got the right to vote for the first time in 1994 in the election that made him president. Imagine that! Yet still, if an indigenous man had asked this same question in Q&A would anyone have wanted to buy him a toaster? What if a woman had asked?

Under all of this lies the last frontier. The child who lives in poverty. Third or fourth generation of poverty and concomitant mental ill health. We all see them. We watch them grow their own mental ill health. From beautiful baby to harried toddler. It’s such a complex story that it’s hard to know how to speak it. For me, as a young GP, more than 2 decades ago, I saw these babies and their young parents as the great Aussie battlers. Against all odds. Blamed more than they were helped. I have worked in General Practices that would refuse to see, even mothers and toddlers because they had missed appointments, with no understanding  that they were punishing them for a symptom of the problem for which they so needed help. After  attending a talk by our human rights commissioner I now have the tools to advocate for such a person, but to have to advocate to doctors for basic human rights is not something I ever envisaged. So often when seeing such patients I found myself thinking that if I had had to endure what they had had to endure I would not have been doing so well.

25 years on and nothing has changed for this minority, and again we see a lonely voice shredded. And where are the Gandhi’s, Mandellas, Martin Luther King Jr’s, who know how to make visible the inconvenient and generate a mood of public debate that grows solutions and change?

“History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people.” Martin Luther King, Jr.

If you feel moved to speak, please leave a comment.

Rethinking childhood trauma on Anzac Day

I have been attending some monthly meetings held by the Commissioner for Children, and this month Narelle Whatley A PhD Candidate At the School of Social Science UTAS, presented some of her thesis on “Young people’s experience of family violence” The thing I have been left with the most is that  most people who suffered childhood abuse or trauma, didn’t seek counselling, even as adults. I’m sure I’d heard this before, but somehow it hit me differently.

I had been immersed in reading and listening to world experts on trauma treatments over the last while and suddenly I was hit by the image of these experts with all their knowledge, worlds apart from the child who pretty soon works out no one can help so keeps quiet. I got a sense of their world through the voices presented. I hadn’t noticed that part of the reason they don’t find a trusted adult early on is that they moved houses and schools so often. I revisited my own emotional experience of early school life and imagined adding a new house, school, teacher, peers… well no wonder.

Then I thought about the children I am seeing and have seen who’s early life was tumultuous and terrifying, and they have all been brought along by someone else, usually an adult who has some working responsibility for them and needs help. I have routinely asked all these children what had made a difference to them, dealing with all they were dealing with, and the thing that stands out is the rare, infrequent, connection with someone who cared about them and believed in them. It may have been a grandparent or other relative but was commonly a trusted teacher. The thing that helped was not that they intervened in the violence and tried to fix it, but that they somehow allowed the child to believe in themselves.

Neuroscience has given us an amazing understanding of the traumatized brain and the trauma response but has made no difference to the effectiveness of treatment. As Cloe Madanes famously said “Satisfying human relationships can be the most healing “medications” of all. No amount of exercise, meditation, massage, stress reduction or broccoli is an adequate substitute for love and affection for promoting health.

It then occurred to me that if we really want to make a difference to children it might be good to look at things from their perspective. What would be helpful for a child who is suffering, but is protective of their parents and doesn’t want them to get into trouble? What would help the child who stays silent because they perceive that the social interventions in place to help would actually make things worse for them? How do we ask the questions that might actually make life better for such a child and their family?

I think it will take a cultural change. Humberto Maturana, Chilean biologist, gives the best description of how cultural change happens in his talk/writings about the origins of patriarchy. It starts with a change in emotion, which is taken on for some reason or other, not as a manner of living for the adults, but for some greater good. But, when children are born into this new way, they take it on as a manner of living, and it becomes transparent.

What if doctors, nurses, antenatal nurses, obstetricians, child health nurses, pediatricians, social workers, early childhood intervention and family workers, child care workers, Centrelink officers, drug and alcohol workers, psychiatrists, psychiatric nurses, police, ambulance officers, the justice system, family law courts, teachers, teachers aids, sports coaches, gym coaches, bank tellers, shop assistants and tv celebrities, started with love, affection and broccoli anytime they were confronted with a child or family exhibiting what trauma experts would know as the hyper-arousal of trauma symptoms, hitherto thought to be bad behaviours by all of the above.

“Satisfying human relationships can be the most healing “medications” of all. No amount of exercise, meditation, massage, stress reduction or broccoli is an adequate substitute for love and affection for promoting health.” Cloe Madanes

A simple blueprint for resolving trauma.

Human responses to trauma, the symptoms, the diagnosis, the neuroscience, the varied treatments and the possibility of chronic mental ill health if treatment is not effective,  make working with trauma daunting to the young practitioner. The more we complexify it, the more family, friends, communities and workplaces step back from ordinary human healing connection and defer to experts.

I like to emphasise human resilience, and come from the belief that human beings are actually pretty good at healing, if we keep it simple and ordinary and link it to an established process. Sir William Osler said “I suture the wound, but God heals it” (whatever your God may be)

We get good at trusting that if we cut ourselves or break a bone it will heal, but in our culture we are not so good at learning to trust that our emotional wounds will also heal. If you break your leg, you put a plaster on and it heals, but we aren’t so good at knowing what the plaster is for an emotional wound, and tend to let these wounds get poked, adding to the pain and slowing the healing.

I like to tell clients who have suffered trauma that people get over trauma the way a woman gets over childbirth. The experience is often pretty intense and commonly medicalised and a bit frightening. But then theres a baby to distract you from your own experience and then there are visitors with joyful smiles who want to listen to you share your experience, so you get to retell it in a different emotion, and lay it down again in your memory with a softer, safer emotion. And you retell it many times to many visitors until the emotion becomes bland. By the time the baby is about 6 weeks old you start to think, “That wasn’t so bad, I could definitely do that again.”

Some years ago I was in the immediate vicinity in the moments following an armed robbery. The shop senior was assaulted and I was presented with her immediately following the event. She was in a state of distress, almost howling in a possessed way. The person with her was noticeably distressed at her distress.
I just sat with her…I think I asked a question and cracked a joke about our small town, how that kind of thing doesn’t happen here. She stopped wailing and looked curiously at my calm demeanour and began to speak of what had happened. She kept saying she felt like such a twit. She was the senior and SHE fell apart, everyone else was fine. I pointed out that they were fine because she was dealing with it so they didn’t need to. She kept saying she felt like such a twit. She was OK as it was happening, gave him the money after being shoved around, and then when he left she fell apart.  I said… “you see that in war…the captain gets blown up by a mine, goes on to secure the situation, make sure everyone that he is responsible for is ok, and then looks down to discover his leg’s been blown off.” She looked at me in a certain steady way, there was a moment of silence as she was making connections, and then she said… “I’ve got to get back”, and spoke about the shop junior, implying her responsibilities.

I reminded her how it can feel to be jetlagged. You arrive somewhere and it’s as if your experience has to catch up with you. All the emotional responses that were appropriate during the robbery were put on hold and then happened all at once afterwards. I presupposed she’d now caught up with herself. I mentioned the thing she did in not taking him seriously at first resulting in getting pushed around as an opportunity to learn, but she stopped me and said that it seemed like minutes but was probably only seconds, she thought he was joking and laughed at him, he shoved her, and then she reacted appropriately. She was convincing me!

Then she started saying “what a twit” a few times and I realised she wasn’t speaking about herself anymore so I said “him?”…and she said “Yes!!” and ranted about what an idiot he was, how he wasn’t even wearing a balaclava. She said with certainty that she would recognise him again, that she knew what he looked like. Then she said again that she had to get back. The whole conversation had taken little more than five minutes. She stood up confidently and said to me…I feel like hugging you…who are you again? I laughed and told her my name, and felt very sure she’d recognise me again!
She dropped back an hour and a half later to tell everyone they were back in business and the police had left. She looked very much back in the driver’s seat of her experience.

The next morning I was told by someone who had checked on her that she was teary, and hadn’t slept the previous night. They were worried and thought I should know. It seemed important not to respond straight away, so I worked until lunchtime and went down to discover a very calm, confident woman, who had told the story to dozens of customers who had heard and wanted to find out what had happened. She told me she hadn’t slept. I said I would be worried if she had. That I didn’t know any normal human beings who would have slept well after such a day. I said I expected her to sleep poorly again, and maybe even for a few more nights, perhaps as many as 5 nights, but by the 6th night I expected her to be sleeping more normally. She agreed and said that after a few hours she had decided to watch a movie, and then she got a little sleep. I congratulated her and revised my estimate of her sleeplessness to 3 or 4 nights. She went on to tell me the “twit of a man” went on to the next suburb and did the same thing there. That shop assistant was sent home and wasn’t doing too well. She told me with authority how wrong it was that she was sent home. And talked in detail as if to teach me the appropriate management of such a person! I then made the observation to her that she had a lot to offer in assisting everyone else involved.

Dissociation is a very normal and very human response to a traumatic event and allows us to function in that event. In reflecting on what is useful in reconnecting an individual, either immediately or years later, it seems a process of associating them, and focussing them, while allowing the emotion to settle, or by attaching a more useful emotion or body experience to the traumatic event.

I have also noticed that people with no training often respond very usefully to someone in distress. The people who put their own responses aside are usually humanly helpful. I remember a story of a small boy who was saved from near drowning by his 8 year old brother who had a vague idea of CPR. Some acronyms are useful. I wonder if mind body resuscitation (MBR) might bring a more useful focus to trauma management, and help to redress the fear and paralysis that “PTSD” brings.

It can be so simply satisfying to observe and be part of another’s reconnecting. I would say that MBR involves;

D-Disconnecting from your own upset in order to be useful to the other.
S-Sitting with and being present and allowing the other to be present.
M-Marrying the emotional response to the events and allowing them to settle.
4-forgetting unhelpful acronyms.

WORKING WITH DISSOCIATION: When reconnecting is not enough

As a medical undergraduate, I found Psychiatry to be such a strange abstraction, that seemed to be about types of people that I’d never met. I was taught that neurosis was something that was within normal human experience, but that psychosis was not. It just didn’t prepare me to deal with patients in General Practice who suffered from extreme forms of dissociation, and I felt ill equipped to help. Somewhere in the next 10 years I discovered how to see the person, not the DSM category, and got to know many interesting individuals, who reminded me of a lot of people I had met in my life. I could see that my part in actively building our relationship helped them. When I then began to learn about Solution Oriented Therapy and then the work of Milton Erickson, I finally discovered that there were ways that I could be more useful.

Now, another 16 years on, I would have some things to say to my younger self. I would tell her that dissociation is in fact a normal human experience. I would remind her of the imaginary games she played as a kid where textured stories unfolded and it was as if these things were really happening.  I would remind her of her daydreams, where quite bizarre realities could feel very real. I would remind her of the time she had a fever and floated around the ceiling looking down on herself, managing not to be afraid because of the soothing voice of her mother. I would remind her of the time when she was sitting in the sun in the family room and saw her old grey tabby cat out of the corner of her eye, and then, when she turned to talk to him, it was just a bundled up jumper, not even the right colour really, and she was so surprised at how real he had seemed that she tried to get that vision again out of the corner of her eye… but couldn’t. I would remind her of the creative spaces she would get into, drawing, building, creating, with ideas that defied logic, as the “real world” disappeared and time sped up, or slowed down. Then there were those optical illusions, and magic eye images. If she could be so easily tricked, couldn’t anyone?

She knew then, that in the moment of perceiving, there was no way of knowing the difference between an illusion and reality, so what was so hard to understand about someone hallucinating, or getting stuck in an unhelpful delusion. By seeing dissociation on a spectrum of normal everyday experiences it is easier to understand, and therefore easier to connect with clients who experience it.

Dissociative skills are helpful when fear and trauma drive someone to want to get out of their own experience. Dissociation becomes a haven, an escape from an unwanted bodily experience, but the mood of this dissociating is sometimes very different to a playful daydream. It is a very useful skill while the danger and damage is still happening, but can be problematic if it is hanging around when the danger has passed. The most remarkable description of the protective nature of dissociation I have heard was from a man who’s childhood was a constant barrage of verbal, emotional, physical and sexual abuse, and yet somehow he managed to really believe that he was lovable. He let himself experience love, sometimes in magical ways. In primary school he pretended that his loving teacher was actually his father, and every morning his teacher greeted him he felt it as a ‘good morning’ from a loving father. He went on to have a successful life, married and had children, and had fulfilling relationships with all of them. He developed enough control of his dissociation that it became psychologically protective in any dangerous situation, and shielded him from pain. If that was possible for him, just imagine what we are able to co-create in a therapeutic relationship.

Most people have daydreamed in class but remain aware enough of “reality” that they hear their name if asked a question, even if they weren’t present for what was said. People rarely wet themselves because they were so absorbed in a daydream that they didn’t attend to a full bladder. You can be absorbed in a book, but still answer the phone when it rings, adjusting quickly to the new reality.

Neuroscience informs us that what the brain practices it gets good at, and people with extreme dissociation have certainly practiced. If there were a competition for dissociative skills, these people would be the Olympic team. Olympians, however, leave their skills on the field. They don’t tend to hurl javelins at the dinner table, and so don’t appear strange to us.

My take on dissociation, when it is a problem, is just that control has been lost. Fear gets in the way of learning, so the more ordinary we can make these experiences, the more connections to everyday examples we make, the easier it is to learn, and to reclaim control.

I have noticed that people who dissociate in a problematic way, very often have learned a few tricks to stay in the room. I had a client who would scratch his palm with the fingernails of the same hand, another who placed a hand on her shoulder under her shirt and kept the awareness of the touch. Others who pick at clothing. I have noticed that complimenting them on finding a way to stay in the room often surprises them as they don’t know they are doing it, but as soon as they realise they are more in control. I then wonder with them what other things they do that they don’t even know they are doing, and often surprising rememberings appear.

The phenomenon of dissociation can be seen in all problems that clients present with, from learning difficulties in school children, through fears and phobias, trauma responses, to the more extreme end of the spectrum of dissociative disorders, and schizophrenia. Most therapy models generate an experience of reconnection, so that a client goes from a disconnected (all over the place like a mad woman’s knitting) experience, to a connected (cooking with gas) experience, where client resources become available again, and learning can happen. However, when the client does not have control of their own dissociative experience, simply generating reconnection will not be enough.

Dissociation is a powerful skill, that can veer out of control when no-one is in the drivers seat. By understanding and utilising this ability, a therapist can work with a client to enable them to grasp the wheel of their own experience. When helping a client to explore the phenomenon of their own dissociation, we can be a useful mentor in the passenger seat of the client’s experience as they discover that they can drive.