Understanding Dissociation and DID: What It's Really Like, and How People Recover w/ Dr. Milissa Kaufman and Dr. Lauren Lebois

0:07Forrest Hanson: Hello and welcome to Being Well. I'm Forrest Hanson. If you're new to the show, thanks for joining us today. And if you've listened to before, welcome back. Today we're going to be talking about dissociation in general and dissociative identity disorder, or DID in particular. Most of what people know about DID comes from movies and short videos on social media. And DID was once known as multiple personality disorder, which means that depictions of it often portray a person quickly switching between sharply different personalities. And in movies, this moment is usually played up either for drama or sometimes for horror.

0:41Forrest Hanson: And they also have very little to do with what DID is actually like. Today, I am joined by two very special guests who are going to help us learn what dissociation is, from the everyday versions of it that most people have experienced, all the way up to the clinical end, the relationship between DID and childhood trauma, how our understanding of it has changed over time, and hey, maybe the most important part here, what people can actually do about all of this. So I'm joined by Dr. Melissa Kaufman, a trauma psychiatrist at McLean Hospital and Associate Professor of Psychiatry at Harvard Medical School.

1:13Forrest Hanson: So Dr. Kaufman, Melissa, thanks for joining me. How are you? Thank you. Good to be here. I'm also joined by Dr. Lauren Labois, a cognitive neuroscientist and an assistant professor of psychiatry at Harvard Medical School. So Lauren, thanks for being here. How are you doing? Great. Thank you so much for having us, Forrest. Really excited to do this with you guys. I learned so much when I was preparing for this conversation. I did not know how little I knew. And it was just such an interesting topic. So to let you know a little bit more about them, Dr. Kaufman founded the Dissociative Disorders and Trauma Research Program at McLean, and she and Dr.

1:48Forrest Hanson: Lebois co-direct that program. Lauren is also a former chair of the Scientific Committee for the International Society for the Study of Trauma and Dissociation. And along with her clinical and research work, Melissa had DID herself, went through treatment, and made a full recovery. And I wanted to start by asking, Melissa, if you're comfortable talking about it, what is DID like? And particularly, how did your experience with DID differ from some of the portrayals of it that people are familiar with? To begin with, as far back as I can remember, I had this internal sense of having what I called inside people, this sort of gang of kids that felt to me that lived inside my mind.

2:33And I really didn't think much about it. It just had been with me since the time I can remember, certainly some of my first memories. And as I got a little bit older, I started to realize that people around me didn't talk about having people living inside their mind, and there started to be this sense of a lot of conflict inside my mind. I didn't want to have these inside kids in my mind. I didn't understand it. The stories that they sort of discussed, if you will, became more frightening. there was a part that I pictured inside that of a little girl who lived inside a box that none of the other people wanted to be around a lot of arguing and I felt it felt very real to me as I got older I started to think like well this this isn't really possible you know why is this happening and I became really aware of being symptomatic with it sometimes.

3:41And I didn't know at the time, but I was sort of having very dissociative like flashbacks where you know I wasn't really aware of what would trigger but something would trigger me and it would feel like I was experiencing the feelings in my mind of what it felt like were the insight kids. So if you know If I got triggered, it would feel like an inside person would sort of come into my mind, and I would feel their fear, or I would feel, see, hear very frightening things. And then it would stop, and I would think, where did that come from? So it really was like sort of having flashbacks, but at the time, it felt very much like it was sort of not me.

4:29That wasn't me. That was someone else, even though I knew that that wasn't really possible. So I grew up being very puzzled with myself, confused, concealing things. It was very hard.

4:42Forrest Hanson: Are there particular differences between the way that DID looks when it's shown in media and your experience that you would like to kind of call out here? Yeah, there is. You know, DID tends to be a hidden disorder. It's sort of famously, someone called it a disorder of hiddenness. And it really is. It's very alive and intense internally. But most people, you know, you don't see these sort of dramatic switches unless someone is highly stressed, triggered in some way, really having a lot of post-traumatic symptoms. and in that way it can look like you know we've all seen movies uh probably of you know vietnam war combat veterans who come back and they hear a cloud you know thunder or the backfire of the firecracker tire yeah right exactly and they hit the floor right and they're literally reliving what's happening and that can happen and it does you know there are flashback like moments and again And as I said, the difference there is that it is a flashback, but then there's this sense of it not belonging to self.

5:50A movie that I think about is Sybil. It was a best-selling novel, and then there was a movie made about it starring Sally Fields. She won an Emmy for it. It was very affecting, but what it showed was her switching into people that had different accents, had different wardrobes. It was a very externalizing sort of manifestation of what was going on inside. And I think that that was the intent of the writer, was to show what was happening internally. But I don't see that I've never worked with someone that's sort of dramatic in that way. And again, there can be a lot of shame, misplaced shame for sure.

6:34But it typically doesn't, people don't really want to show it. That's been my experience clinically. And there's been studies about it where about 95 % of people are sort of subtle and internal. And about 5 % of people have a more overt, outer, and maybe more dramatic presentation.

6:51Forrest Hanson: So backing up a little bit, I would love to connect that kind of experience that you're describing here to the more mild versions of dissociation that most people have experienced, maybe even without realizing it. So Lauren, I would love if you could kind of get into here with us. What is dissociation? And maybe you can lay out a kind of spectrum from those more mild experiences all the way up to clinical forms of dissociation. Yeah, that's a great question, Forrest. I was smiling to myself because I feel like dissociation is a little hard to define because it can encompass so many disparate experiences.

7:31But I think at its core, when the typical experience of consciousness is disrupted in some way, I think that's a good catch-all definition. But like I said, it can manifest in so many different ways. So like you're saying, a more typical experience of it might be, I think a classic example is highway hypnosis, where you get in the car and you drive somewhere and you get there and you realize you weren't really paying attention. You're so absorbed in some other thought that you aren't aware of the steps that you took to get to that destination. Maybe moving a little more extreme on the spectrum would be experiences of depersonalization or derealization, which are a sense of detachment from your surroundings.

8:22That's derealization. And that can look like kind of that feeling like you're in a movie or things are a little surreal or like you're walking through a watercolor painting or something. And then depersonalization, more of a sense of detachment from your body or your sense of self. That could be like observing yourself from above. Something that unifies those is that someone has lost a sense of agency and ownership over their own thoughts, feelings, emotions, aspects of memory, aspects of their sense of body, sense of self. So it feels like their own thoughts, feelings, et cetera, et cetera, are not their own.

9:07Somehow they belong to someone else, Though, of course, that doesn't quite make sense. Like we know that that's not possible, but that's just how it feels. Yeah, and it is. It's a hard word to describe. There's many ways to define it. I think exactly what you said, there's this discontinuity. And the discontinuity is sort of an integration. It could be of anything. It could be a discontinuity in perception, which would be depersonalization, derealization. A discontinuity in memory, which would be amnesia or gaps in recall. A discontinuity in attention, which is that highway hypnosis kind of example.

9:47So you could have a discontinuity in motor control. So sort of feeling as though you're moving in some way or sensation feeling in some way that you can't quite relate to. It's not really integrated. And what's fascinating about all this is that there are neurobiological indices that help us to explain why these things are happening.

10:10Forrest Hanson: What's layered on top of dissociation to get to a DID diagnosis or to get to the kind of experience that you were having, Melissa? So I would say that DID sits atop the foundation of complex PTSD or, you know, sometimes we would call it the dissociative subtype of PTSD. So all of the same symptoms and signs of the classic sort of PTSD presentation, such as intrusions, flashbacks, avoidance of trauma reminders, negative alterations in mood incognitions, and hyperarousal, such as startle, all those types of symptoms that people tend to be more familiar with. And then on top of that, moving from conventional PTSD to the dissociative subtype of PTSD, you then have very severe symptoms of depersonalization and derealization.

11:06And then to arrive at a diagnosis of DID, you have two additional diagnostic factors. One is gaps in awareness or amnesia for day-to-day events, as well as past events, traumatic events. And then you have what's called identity alteration, which is sort of how I described it's this sense of your thoughts, your feelings, your memories, somehow not fully belonging to you, or completely, you know, there's this felt sense of a lack of agency in terms of what is happening in your mind. There's this metaphor that Sachi Nakajima uses. She's a survivor and advocate and speaker and author, but she describes kind of the symptoms of classic PTSD or like you're riding a roller coaster that you can't get off.

12:01And then if you have the dissociative subtype of PTSD, you're mentally able to mentally take yourself off the roller coaster, get a little bit of distance from those symptoms in a way and watch yourself on the roller coaster while you're sitting on the ground. And then DID on top of that is you're able to take yourself off the roller coaster on the ground and watch, but now you're watching someone else on the roller coaster or it feels that way. But I really love her way of describing that.

12:31Forrest Hanson: I think that's a great description. And I'm wondering, I think that that description actually partially answers this question, which is how is DID an adaptation to the kinds of childhood experiences that you guys have, I've both heard your name as a prerequisite for this condition? It really is an adaptation. And, you know, DID starts in early childhood. It's a post-traumatic, it's like a developmental post-traumatic adaptation. And what I mean by developmental is that it universally begins in early childhood. And it begins in early childhood when a child is exposed to severe and prolonged abuse and neglect.

13:12But to be precise here, and something that may surprise people, is that trauma alone doesn't actually cause DID. It's necessary but not sufficient. There has to be a biological capacity to dissociate and to compartmentalize experience. And lots of people have this biological capacity. It's kind of a normal distribution, but at the tail end, there's this sort of heightened capacity. And so it's a child who has a heightened capacity to dissociate and then has very, very difficult, challenging issues during early childhood and it becomes sort of a primary psychological defense. Little children have this natural capacity to displace and externalize thoughts and feelings.

14:09and little children also have a natural capacity to personify their thoughts and feelings. And to give you an example of that, you can think of a small child who sits the first day of kindergarten and their mom is telling them they need to get dressed, get going, they need to go to school. And you can imagine a child saying, my stuffed animal hates you, but not me, something like that. So or another child might say, I'm not scared, I'm not a little baby, I'm big and strong like Superman. So what they're doing there is sort of displacing and personifying their thoughts and feelings that in the moment feel conflicted.

14:57And that's a very natural developmental way of handling sort of relational conflict in that way. And that's important to understand that this is a normal developmental way that some children sort of deal with things that are hard to deal with. And it's not role-playing because children at that age don't know that they're not going to grow up one day to be as big and strong as Superman, right? Children believe in Sam Claus. So keeping that in mind, imagine another little child who is dealing with kind of desperate conflicts, being abused and neglected. And you can imagine a child who thinks to themselves, it's too frightening to feel that fear.

15:44That's not me. It's too overwhelming to feel such anger. That's not me. It's too frightening to feel what's going on on inside of my body. That's not me. So this too is a very adaptive way, and at the time, developmentally pretty normal way of dealing with extreme conflict. And that's where DID comes from, and it really is on some level that simple. And if it keeps being repeated over and over again for many years. It really gets cemented into the way that a child deals with enormous stress and interpersonal conflict. And the conflict can be that I'm not a bad little girl. My daddy doesn't hate me.

16:41That's not me. Or this is not happening to me. Some little girls may imagine a boy who's big and strong and may imagine that sexual abuse might not happen to a boy. And it just, whatever the child sort of needs happens. And it's not conscious. That's a really important thing. This is not a conscious decision. It's not role-playing. It's not play-acting. It's really an unconscious adaptation that helps the child psychologically survive.

17:12Forrest Hanson: I'm really curious what that's actually like to the extent that you're comfortable talking about it? Are these distinct, comes from the earlier language, but essentially, do these feel like distinct characters or distinct personalities, whatever term you want to use here? When two of these self-states are both going on in the same time, is it like a conversation inside of the head between two people you know? What's that actually like? I really want to try to convey that. I will say, I gave a sort of example of my internal experience when I was growing up, and it's important to say that everyone is different.

17:47And, you know, I have, you know, I had my own experience. I've talked to many, many people who describe these types of experiences, and no one has the same exact experience. But having said that, a lot of people have described having this sort of sense of an internal, their mind is like in some ways kind of like technicolor and their mind has dimensionality to it. And it can be like watching sort of other people who are familiar and have been with you for a long time, but you don't know why they're there. You don't want them there a lot of the time. It's weird and strange. Some people really don't have that internal experience so vividly early on.

18:35It's only sort of later when they sort of become more aware of it. Yeah, it can feel like, I mean, if you can imagine, you know, you might have had this experience forced where you're debating, you know, I don't know what you might be debating. What was the last thing you kind of debated in your own mind?

18:54Forrest Hanson: Totally know what you're talking about. Yeah, anything ranging from where am I going to go to get dinner to how do I feel about a particular topic? You can have this feeling. And for me, it all sounds like me. It all sounds very forest, and I'm just kind of operating on these different perspectives. But it's absolutely a voice inside. For me, I get like internal vocalizations. Like I hear my voice inside of my mind, which I didn't even know that. Some people don't experience that at all. Some people don't experience that at all. You're exactly right. So everyone's different, but this is a sort of capacity that you have to sort of immerse yourself internally and kind of hear, if you will, your own voice.

19:34I don't know if you visualize yourself going back and forth, but again, that's a natural capacity. and I think that people with DID, I don't think it, I know it, are really on that far end and so it is, it's like hearing your own thoughts but it feels like someone else and because it's so personified and people with DID have this intense ability to kind of absorb and you know it's often accompanied by a you can see this other sense of self. You can, you know, I saw, as I told you, sort of a little girl in a box. And it never changed. It was always a little girl in the box, nothing. And it was, to me, it was, I'm not a very artistic person, and not a very spatial person.

20:25It was really kind of like a stick figure, but a sort of little 3D stick figure in a box. And I saw a little boy who was angry all the time and would sort of hear, but not the way that you're hearing me. There is a difference. I didn't hear it externally, but it was like hearing your own thoughts, but it didn't feel like my own thoughts. It felt like someone else's thoughts. and I would visualize. I mean, again, it wasn't conscious. I would just, I would see them inside my mind. And it was always the same kids and very relational. They had these stories about being angry or stories about being frightened or stories about being smart and able to go to school when I didn't feel so smart, those kinds of things.

21:13Forrest Hanson: So given how vivid these self-states are, What's the problem with the phrase multiple personality disorder? Why did we kind of move away from that as a phrase? Yeah, that's a great question, Forrest. I think the problem there is that to name them personalities in some way reifies them as real, full-blown, inside different personalities, whereas using the term self-states or dissociative self-states makes it a little more clear both for scientists and clinicians talking about this but also matching the lived experience of well it may feel that way that these are inside people they actually aren't there's just one person one brain one mind and their own as melissa's been saying your own conflicted thoughts and feelings come alive in this technicolor internal landscape.

22:13So I think that's at the crux of it. And I, yeah, I feel like that's very important not to reify them in that way, which of course is so, it's so hard to do because it, something that maybe distinguishes DID from other conditions is that there is this intact reality testing where someone is aware that, as you've just said, Melissa, when you're describing these things like, oh, I know this isn't possible. This is just kind of how it feels as opposed to being lost in the belief that this is a, this, I don't know, as you might see in psychosis where, oh, I really am hearing that voice from the radio.

22:55I am getting messages from this famous person.

22:58Forrest Hanson: I'm curious about the real, not real part of this, Melissa. What I mean is you said a little while ago, toward the beginning of our conversation here, that you kind of knew that this was not the way that most people were relating to their internal experience. But there is something in it that is so vivid and so real and so engrossing, like the way that you're describing these different self-states, the imagery you're using. How did you reconcile that internally? Were you just like, there's something deeply wrong with me? Did you, I mean, what was your frame on it? I was so baffled. And again, there was this real press not to tell.

23:43And I think part of that is, you know, I didn't want anyone to think I was crazy. But also the things that sort of I was experiencing internally were frightening and scary and reminiscent of things I didn't want to think about. There's, and you know, one way to really think about what dissociation is in this context is sort of this ability to know and not know simultaneously. And that's exactly the experience. You know, but you can't know. Yet you know, but you just, you can't know these things. And it sort of manifests as, I can't know that I have these people inside, even though it feels so real.

24:27I can't know that. But what's behind that is other reasons, other things that you can't know. Why can't you know about the internal people, the inside people that I talk about? Well, because I don't want to know what their stories mean. They're holding tremendous conflict. If there was no conflict, there would be no DID. And you don't want to know. And yet you can't help but realize this is happening. It was part of my day-to-day life. So yeah, it's perplexing, very perplexing. Didn't want to tell anyone.

25:06Forrest Hanson: Yeah. And as you've already said, there could be an enormous amount of shame associated with this experience for somebody because there is that feeling of deep differentness that is so tied to shame psycho-emotionally. You know, there's the shame of being different. And there's the shame that, you know, people that have been through child abuse and neglect, small children, have this way of feeling that it's their fault. and because, you know, children, the world around, you know, revolves around little children and if someone is harming you, it must be your fault because, you know, why would a parent who is supposed to love you, you love?

25:50And that's where the conflict arises. And it's also a form of mastery. If it's the child's fault in some way, then they can have some more control of it. So I've personally never met someone who was abused as a young child or had DID who didn't have a lot of internal shame that, again, was sort of compartmentalized off, which is not to say that I ever would think that someone with DID should have shame. And I bring that up because I think my discussions about shame sometimes have been misperceived by folks. And it's a very misplaced sense of shame. And no one should have to feel shame about having a psychiatric condition or having DIV.

26:41But it is a very sort of natural thing that happens when you grow up like that.

26:46Forrest Hanson: One of the things that can contribute to this and certainly doesn't help is that there is a long history of skepticism toward the DID or multiple personality at the time diagnosis that I was actually completely unaware of before preparing for this conversation. And it goes all the way back to Freud and even predates that to some extent. As an outsider to all of this, it also felt to me like some of the exaggerated presentations that we've seen of DID in the media probably contribute to that kind of skepticism because it's just, it's so over the top or disconnected from people's kind of lived experiences.

27:18Forrest Hanson: And one of the things that has come along in a really cool way that has helped, I mean, obviously, there's total credence to people's experience of DID, but it's helped kind of like show people, hey, this is a thing, has been some of the brain science related to it. And so, Lauren, I wanted to ask you about that. You were talking about that roller coaster, classic PTSD, then this dissociative subtype of PTSD, then maybe all the way up to DID. And both out of my own curiosity and maybe to kind of help people along with this, do these things look different in the brain? Is there a difference in a scan of somebody experiencing one versus the other or somebody who doesn't have DID doing a sort of performance of DID versus somebody who actually does?

28:01Forrest Hanson: What does this all look like? Yeah, yeah. Those are great questions for us. And there's a rich neuroscience of dissociation and DID. Our lab has done some of this work. Simone Reinders has done a lot of this work and Ruth Lanius. And there are some, I'm trying to think what would be the most helpful. I think there are some, there are three key kind of buckets of the foundational neuroscience of DID that might help clarify some of these things. Some of the work focuses on this type of paradigm called a symptom provocation paradigm, where they have folks come in, narrate personal traumatic events that they've had.

28:40Those recordings are played back to them while they're in a neuroimaging scanner. So you can, in some way, trigger someone and get what's happening in the brain while they're actively symptomatic, listening to these memories, these traumatic memories of the past. and when you look at what's happening for folks with classic PTSD there for our purposes today we can focus on two regions in particular that come up time and time again one being the amygdala which is involved in lots of different functions but most basically we can think of as like a salience detector that's helping to alert us to things that would be important to pay attention to for our survival.

29:25One example of that is potential threats. There's also the ventromedial prefrontal cortex, which is, we can think of broadly as an executive controller helping to regulate our physical and emotional reactions to things. So these two regions, they can communicate back and forth with one another in classic PTSD. So folks without those more intense experiences of depersonalization and derealization, having more of those experiences of being emotionally flooded, hyper aroused, when they do the symptom provocation paradigm on average, you'd see hyperactivation of the amygdala, helping them mount this full body stress response to deal with this potential threat in their environment, which of course is just listening to a recording of a memory from the past.

30:18And then there's a deactivation of regions like the ventromedial prefrontal cortex, which, so it's not putting the brakes on that amygdala activity. And that matches what they're saying of their subjective experience, that they're emotionally flooded, on guard, hyper aroused. When you look at folks with a dissociative subtype doing the same paradigm, we actually see the opposite pattern where there's increased activity in ventromedial prefrontal cortex, decreased activity in amygdala and other regions. So it's like the brakes are on too tightly. They're not mounting that full body stress response through the amygdala.

30:57And that matches what they say about feeling more numb and detached when they're triggered and dissociative. And then Simone Reinders has looked at folks with DID doing the same syndic provocation paradigm. And she has folks with DID listen to the trauma narrative twice, once in a self-state that more of a sense of ownership over a trauma memory, has more of a subjective experience of being more hyper-aroused, I would say. And then also in a state that is more numb and detached and has more distance from the trauma memory feeling as if it didn't happen to them personally. And she sees that folks with DID oscillate between those two PTSD patterns that we just talked about, depending on what prototypical self-state is active at any moment in time.

31:50So if they're in more of a numb, detached state, oh, we see the brakes are on too tightly. Oh, if they're in more of a state that feels more hyper-aroused, more of the re-experiencing of the trauma memory, that the brakes are off. You get that hyperactive amygdala activity. So I think that's, I find that set of studies really helpful for, you know, placing DID on a continuum.

32:16Forrest Hanson: Yeah. Yeah. With PTSD and the dissociative subtype. Totally. And it helps people understand that experience. Yeah. And that idea of the brakes being really on or as opposed to the whole body activation that you were talking about really gets to the kind of experiences that people have with this and I think can help us have a little bit of insight into what this actually feels like. In terms of the—you mentioned Dr. Simone Reindeers and colleagues, and I thought that the simulation studies that I bumped into this were so interesting, where they basically had somebody who was acting out DID and somebody who was having, you know, more genuine experiences.

32:56Forrest Hanson: And the pattern of brain activity was really quite different between these two groups, which again, just helps like lend credence to people's experiences, which, you know, it's a shame sometimes that people need that, but it's nice to have it. Yeah, I completely agree, Forrest. Those are great studies. In fact, the majority of studies in DID have a simulator group that's, and Simone's studies, they do train them very well. Sometimes they're paid actors. They teach them a lot about DID to try and do exactly what I think some of the alternate theories of what DID is, the role playing, the suggestion.

33:35They ask them to do those things. And then they compare them to someone who's genuinely diagnosed with DID and in not one instance have they found that the, across, you know, dozens of studies, have they found that the brain patterns are matched. So I do think that's great evidence to show that it's not a disorder of, you know, cultivated by the media or therapists, overzealous therapists, or, you know, this condition of role-playing in some way.

34:05Forrest Hanson: That's really interesting. I do. One other thing I will add, though, is I feel like it's a little bit of an unfair, like, I don't know, we don't ask folks with anorexia to have an anorexia simulator group. And then, oh, you know, it feels kind of like an unfair thing that we have to do sometimes in the DID world to spend money on very expensive imaging for folks who are just, you know, we've asked to simulate this to show. But hopefully we're moving past that phase. We'll be back to the show in just a minute, but first a word from our sponsors.

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36:28Forrest Hanson: That means no small talk. Crazy weather we're having. No, it's not. It's just weather. It is an introvert's dream. Give it a try at mintmobile.com slash switch. Upfront payment of$45 for three-month plan,$15 per month equivalent required. New customer offer first three months only, then full price plan options available. Taxes and fees extra. See mintmobile.com. Now, back to the show. So I did want to ask you guys about something that gets to this a little bit, which is this idea of therapist suggestibility. My fiance, Elizabeth, is an associate therapist, and she focuses on trauma work. She had a couple of clinical questions that I thought were really interesting.

37:02Forrest Hanson: and one of them I just wanted to steal from her, so full credit to Elizabeth here. And they get to some of the past controversies in this space. Her experience is that in therapy, when she's asking about somebody's experience or has gotten to the point of developing safety in relationship that allows her to offer some kind of a perspective, there's often this healthy process of the client pushing back on what the therapist says, at least to some degree. Saying something like, you know, that's not quite right, or that doesn't align with my experience or whatever. And then there's this sort of healthy negotiation process.

37:36Forrest Hanson: There are even people like Dr. Jacob Palm, who works with CPTSD and similar things, who talk about this process of rupture and repair as kind of like a critical part of the work. But that requires that the person who's in there with the therapist have a strong enough sense of who they are, what they care about, what they like, what they don't like. In other words, me, to feel comfortable kind of like pushing back on the clinician a little bit. And this made us wonder if people who are more dissociative in general, going all the way up to DID in particular, are more susceptible than average, the average population, to clinical influence, and if that's led to some of the pitfalls that people have experienced with this.

38:19Forrest Hanson: And she also had just a practical question about, if so, how do you navigate that when you're working with somebody? Yeah, I'm happy to take that question. I think, so what you're talking about really is suggestibility. And what I can tell you is that folks with DID, highly dissociative folks, are not more suggestible than, you know, someone without, you know, a psychiatric control. And that's been a point that's been hotly debated, and maybe not so much anymore, but something was in the late 80s and 90s. There was a lot of uproar about false memories. What is more related to severe dissociative symptoms?

39:00Is it trauma history or is it this type of suggestibility? And what they found was that in all cases, it was trauma history and that folks with DID in many cases were no more susceptible than anyone without a psychiatric condition and surprisingly were actually less suggestible in some way. There is something called hypnotic suggestion, and I think that these terms got somehow conflated early on. And what hypnotic suggestion is, is how susceptible someone is to going in and out of a trance state. And people with DID are highly susceptible to going in and out of trance states. That essentially is what's happening.

39:46If you're in a trance, you are going to have perceptual discontinuities. You're going to have sensation discontinuities. That's part of what hypnosis is, but it is very, very different than memory suggestibility. So I think that's where things got confused. So does that answer your question?

40:10Forrest Hanson: It does, yeah. I'm not sure about this because I'm not a clinician, so I'm vamping a little bit here, and I would love it if you guys guided me however you think appropriate. I think that part of the experience that she is speaking to is in a clinical setting working with somebody where there's not a really cohered, for lack of a better way of putting it, sense of self, sense of total I that you're interacting with. People sometimes will use parts language related to this. IFS has become enormously popular. Parts work has become a phrase that a lot of people use these days. And it's sort of easy to start conflating these terms, self-states with parts, with I'm sure other terms that people have for this language.

40:56Forrest Hanson: And so I think that she's talking a little bit about the practical work when you're, you know, as an associate trauma therapist, with people who have more of a sense of these different parts or feel like there isn't as much as they'll use in that kind of language tradition, self-energy, or whatever term you want to use for that kind of a thing that's involved and how to support that person, essentially, including in that natural process of, hey, I like apples, not carrots, that you're kind of doing clinically sometimes with people. So that's where I think some of the question is coming from. But I would also love you guys to kind of peel apart Yeah, the parts thing, like are these parts, are they something different?

41:36Forrest Hanson: How would you like to clarify the language here? People with DID are one person who have a singular mind who subjectively at times have these experiences, these not-me experiences. And that means that the sense of self is less subjectively felt as cohesive. But I wouldn't want someone to fall into the trap of thinking that there's not a developed sense of self in someone with DID. It's a subjective feeling. And sometimes given the language, we can fall into like, oh, they must not have a sense of self. People with DID have a strong sense of self, but it's fragmented, if that makes sense. And so it's not like there's nothing there.

42:18There's no real person. It is a subjective self, a sense of self. It's a compartmentalization. But there's no more or less sense of self than what you have, what Lauren has, what I have now. So it can be sort of the language can be misleading. So that's sort of important to point out.

42:38Forrest Hanson: Great. Yeah. No, I appreciate that. And in terms of, you know, thinking about IFS, I'm not an IFS expert, but, and, you know, please correct me if I'm wrong, but my sense of it is, is that you have someone come in and, you know, they have a sort of very cohesive feeling, sense of self, and there's a sort of relaxation into feeling the sort of sense of internal multiplicity that, you know, and, you know, we all have self-states. you Forrest are you know you're you're a boyfriend to someone you're a son to someone you're a podcaster to millions of people and you may act a little differently or feel a little differently right in in these kinds of scenarios you're probably very different you know when you're out to eat with you know your friends and you are here on the podcast and that's just self states.

43:32And so I think there's just, again, correct me if I'm wrong, but sort of this relaxation into this sort of sense of having multiple sort of senses, ways of being in your mind. And then in IFS, it sort of gets grouped into what I'm recalling as sort of managers, protectors, firefighters, if you will, and the exiles, which may be the sort of scared and frightened parts that we all have, but it's really not as compartmentalized as folks with DID and there are no amnestic barriers. And so there's just sort of letting go into this where with DID, the whole point of treatment is to, from day one, begin to help a person gradually over a long period of time to begin to move from a sense of not me to, oh my God, that's me.

44:26No, it can't be me, it's me but it's not me, to like, oh wow, that was me all along. And that takes a lot of time, it takes a lot of working through what the tremendous desperate conflicts are, but over time someone with DID becomes more able to face those things. And with that, you know, there's a shift from that's not me to like, my god, that was me all along, because they're sort of done dealing with the very difficult thoughts and feelings and experiences and memories that they have and are strong enough. And I say strong when people with DID are strong, but are emotionally have this capacity then to own what could not be owned.

45:13Forrest Hanson: So I would love to turn more toward the what to do about this piece that you're already talking about here. What does therapy for DID look like, or maybe therapy for dissociative symptoms more broadly? I think most basically because DID, the relationships, the interpersonal relationships were the problem, therefore they are the solution in treatment. And so I think Melissa and I are on the same page of relational psychodynamic therapeutic approach is the gold standard treatment for DID. And the International Society for the Study of Trauma and Dissociation has expert consensus guidelines that much like there's a phased treatment to PTSD, there's also one to DID where phase one is, and Melissa, I'm sure you can add a lot of color to this, but focused on stabilization, building safety, building a language together, learning to regulate emotion with maybe a little more awareness or less reliance on dissociation, being able to ground practicing those skills either very overtly and explicitly or kind of as things are coming up in conversation.

46:31Phase two moves into more of trauma processing, getting into the traumatic memories phase three is more into integration building a life without using the dissociative defense to cope with the stressors that come up in all of our lives and I think maybe an important thing to emphasize is that I've made it sound very linear and of course it is not it's a very fluid coming back going forward coming like working all these things at once as well. I agree that it's good to think about it in terms of phases. One thing to think about is that folks with DID have PTSD and they're starting to process trauma from day one of treatment.

47:22And the memories, the thoughts, and the feelings, it's there. It's a part of their life. So what can be really helpful in stage one is to learn how to manage those feelings as long as talking about grounding, even before you begin to ground, to recognize when you're starting to dissociate. And that's a really important thing that the trauma therapists do is to notice and say out loud, what's going on? I look a little Bobby or you know where are you and that's often the first time that someone has ever said to someone like you know what's going on here and over time with the the treater noticing things the the patient will begin to notice as well and that's the first step towards sort of taking agency over your own symptoms and along with that which I think is really important is that during this stage, it's very important for a treater to help the patient understand and titrate out trauma.

48:32So for example, if someone starts to, you know, talk about a traumatic memory, the therapist and, you know, looks distressed, the therapist might say, you know, you're looking kind of distressed. You have the choice about whether you want to talk about this right now or later. And over time, that begins to sink in. And there begins to, you know, first the therapist is sort of modeling that over and over and over again. You don't have to talk about this right now. You can, but you don't have to. And if you don't want to, I'll work with you to develop the skills to sort of deal with the symptoms that you're having.

49:11And gradually over time there is this development of a sense of control. I don't have to talk about this if I don't want to. I can talk about it, but I don't have to. And I can't really stress how giving, you know, modeling and giving the person back this sense of control over their own mind. You know, I can't, I don't know how to say how important that is. Very important, you know, starts in phase one, but continues on throughout. And it's not really as basic as is on paper, but that's really important.

49:52Forrest Hanson: So I've heard you both mention trauma-informed treatment in different interviews you've given and conversations, and you both really emphasize the importance of trauma-informed treatment, particularly for something like DID. That term has become very popular, and people will use the phrase trauma-informed on any number of social media posts having to do with all manner of things. Is this a codified approach to therapy? Is it an adjective that's applied to different kinds of therapies? What makes something trauma-informed? I'm glad that you asked that because for noble reasons, everyone wants to be trauma-informed these days, and that's really important.

50:34But through that, I think that the word itself, trauma-informed practices, has become somewhat diluted and can mean many different kinds of things. And that's actually something that the Department of Health and Human Services actually commissioned a document where a number of us got together and really started talking about, you know, what does it actually mean? How do we measure it? How do we define it? How do we know it's working? But I can, you know, sort of, I guess, boil it down how I think about it, you know, just my own self, in terms of trauma-related practices, which is very different, actually, than, you know, trauma-related treatment.

51:16But practices start with something simple, and that is recognizing that, you know, there's a high prevalence. Experiences of traumatic stress are pretty prevalent. So you recognize it. And then when a patient comes in to, you know, seek treatment, you ask about it. So recognize it and ask about it before, you know, the patient has to try to discuss something that's very different. You ask about it. Secondly, you recognize that But sort of problem behaviors, such as dissociation, avoidance, aggression at times, substance use, things that are typically seen as problem behaviors. In someone who has a trauma history, there's good reason for it.

52:04And so understanding and looking through the trauma-related lens at these kinds of behaviors. I guess also really understanding that there's a power differential. And for people who have been traumatized, power and control is with them all the time. It's something that you really need to be careful of and reflective about in your interactions with people who have been traumatized. This is really important at the individual level, but the most meaningful way to make change is at the structural level. at the institutional level. And that can be hard to do. It's more than being kind. It's more than attending an annual training on what is trauma-informed care.

52:54And, you know, I'm glad to hear that at the highest level at the Department of Health and Human Services, they're looking into that. I think that's really important. Just in the realm of treatment, I did want to call out there is now a standardized empirically based manualized form of phase one called finding solid ground. And, um, Bethany Brand, Ruth Lanius and Hugga Shilke have developed this. They, um, recently finished a randomized control trial that has beautiful results. And so I, this has done, it's very exciting in the field because once you have something that's a little more standardized, it's easier to research it and get funding to research it more broadly than what they've already done.

53:44And this is the first time we've been able to do this in the field to study treatment in this way, in this particular way. So I know Melissa and I are really excited about this, and I just wanted to shout out to them. It's really a landmark.

54:00Forrest Hanson: Yeah, that's great to hear about. And I'm trying to wrap my hands around something that I'm not quite sure how to talk about, and this is a little bit more vampy. I'm curious what your feelings about it are, where it feels like y 'all are as serious as it gets with this stuff, for lack of a better way of putting it. You work with serious hospitals, serious institutions doing very, very serious academic work. And there's also something about the way that trauma is becoming talked about in very, very serious places that sounds just vibe wise, much softer and fuzzier than some of the very manualized approaches that I kind of will hear people talk about, you know, more kind of CBT top-down approaches, just the title like Finding Solid Ground as a approach to therapy that we're then going and testing and doing like these great investigative studies on.

54:54Forrest Hanson: And so there's this kind of like funny convergence that's happening maybe between the more academic side of the coin and the more practice-driven or humanistic side of the coin. I'm not even quite sure how to talk about this because I'm not deep enough into the weeds. But as I'm just kind of talking about this, I'm curious what you guys are thinking about what I'm saying. Let me try to unpack this. So I think I understand what you're saying. So yeah, we're talking about these empirically validated treatment studies. We're talking about publications. We're talking about grant funding. These are all very serious things.

55:33What we're not talking about are the really important types of treatment that may not have some sort of gigantic clinical trial, but a lot of patients really find a great use from. And this can be body-oriented treatments. This can be yoga, trauma-informed yoga. This can be IFS. of us. This can be all sorts of modalities that we're not talking about in terms of these gigantic clinical trials, that sort of thing. Is that what you mean?

56:08Forrest Hanson: Yes, I think a little bit. I think that even getting to something like the phrase trauma informed, when a phrase becomes popular, it gets used as signaling a lot by people. So I'm sure there are many, many clinicians out there who have the phrase trauma informed that appears somewhere on their website. Most of those clinicians probably have some formal training that leads them to use the phrase trauma-informed. For some, it might be more vibes. And I think that codification of these things is good on a lot of different levels. But there are probably also plenty of people who don't necessarily use the phrase trauma-informed, but they've got a good feel for phase-based work.

56:43Forrest Hanson: They've got good pacing. They're good at developing a relationship with the person. They kind of understand dissociative process. Okay, great. They're not using the term, but they could be a very good trauma-informed clinician. So I don't know, I guess I'm just kind of dancing around some of the intrinsic fuzziness of this whole thing right now with both where the field's at broadly and just like the reality of practice for people. Trauma-informed started off as, again, sort of something structural, something that would be mandated at the institutional level so that patients didn't get ignored, so patients didn't get pigeonholed as bad or, you know, I don't know.

57:26It's been taken now to sort of an individual level for, you know, someone to practice individually as a trauma-informed treater. You have to take these courses, you have to fill out these forms. Good treatment starts with things that, you know, What makes a good psychotherapist? What helps patients? I don't think you need to have a plaque on your wall to say, I am trauma-informed. So yeah, I see what you're saying. It sort of has lost its meaning in some way and become this badge in a way. I think it's very important, but people who are sensitive can do good psychotherapy, have good boundaries, care about their patients, care about keeping up with the literature.

58:16I mean, that's all part of being a good treater. You don't need to have a plaque on your wall to say that you're trauma-informed. Having said that, there have been people that practice in a way that's not trauma-informed. There are institutions that are not aware or recognize that a lot of their patients have histories of trauma, and there's probably a different way that you should do your admissions process. There's probably a different way that you should organize things to just sort of help people to understand what it's like to walk in the world with these kind of trauma-related issues. But is that sort of what you're getting at?

58:53Forrest Hanson: Totally, yeah. Yeah, no, for sure. And I think that some of it, what I'm feeling is that there's a softening of vibe, for lack of a better way of But again, in terms of the way that some of these things are talked about at a very, very high institutional level, that is more thematically similar to some of the warm and fuzzy humanistic approaches of the past. And so there's something there that I just found really interesting and lovely in how you guys were talking about it and how you're talking about this slow process and establishing that kind of relationship and learning how to tune in to yourself as a person and to the person you're working with as a clinician, which also means to some extent tuning into yourself because of the natural back and forth of it all, right?

59:48Forrest Hanson: And I think this takes us maybe to some practical takeaways for people. Back to the show after a quick break. This episode is sponsored by Huel. Out of every sponsor we have ever had on the show, I think that Huel is the one that Elizabeth and I have used the most. It's always been tough for Elizabeth to eat enough protein, and she's been trying to build some muscle recently. And while we're both busy during the day, it often feels easier to just grab something rather than taking the time to make something that's actually healthy, But what if you could do both? Huel, that's spelled H-U-E-L, has solved that problem for us.

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1:01:09Forrest Hanson: New customers only. Thank you to Huel for partnering and supporting our show. Sierra has all the best active and outdoor brands you need. From athletic stuff, like a full court pickup game, swish, to athletic stuff, like a half mile stroll. Get those steps in. And for morning hikes up the mountain trail, good pace, to nighttime ghost choice from the camping chair. What a twist. Whatever level of active, Sierra loves it all. Head to Sierra or Sierra.com for the brands you want at the prices that let you do it all. From athletic to athletic-ish, Sierra's got it. Now, back to the show. Most people listening do not have DID.

1:01:52Forrest Hanson: But almost everybody listening probably dissociates in some small way at some point, right? All the way up to more frequent and intense forms of dissociation. And I'm wondering what you think people who experience more mild or everyday forms of dissociation, including ones that are intrusive and frustrating for them, what they can take from what you've learned about working with DID, like the very far end of the spectrum. I like that question. I never heard that before. I would say that understanding that dissociation is not a defect. Dissociation is an adaptation. That's very, very important.

1:02:32There's nothing wrong with someone for dissociating. There's a reason that you're dissociating. There's a brain basis for why you're dissociating. It's not as mysterious as it might feel to you. It's not as mysterious to most clinicians. So I think that that's really important. I also think, kind of tacking along with what you're saying, Forrest, is that the relationship is everything. Relational psychotherapy, humanistic psychotherapy, being a good therapist is really important for people who are dissociative, whether or not they have, you know, DID or if they have depersonalization, derealization disorder, if they are just incredibly absent-minded and they don't really know why.

1:03:19all sorts of different ways that dissociation can come up in a treatment. It helps the relationship is of central importance and finding someone who just practices good psychotherapy really is the best kind of help, I think. And this is a little off topic in some sense, but I think it's really important to note that severe dissociative disorders like we're talking about, like DID. I mean, it'd be great if all therapists were trained in how to treat DID, but they're not. And it can be very hard to find a therapist who has specific training in DID. So does that mean that people with severe dissociative disorders can't be treated?

1:04:03It doesn't. You can be treated by someone who is a good relational psychotherapist, who has very good boundaries, who is very consistent. And if they need consultation or to do some learning, it's out there. But you don't have to be a master clinician to treat this. And I think that's really important because I've heard a lot of clinicians say like, oh, I can't take this person with DID. I won't be able to treat them. You can treat them. It's really like treating anything else.

1:04:35Forrest Hanson: I also wanted to ask at some point here, what does recovery look like? What does it mean to be recovered from DID or severe dissociative states in general? Maybe to start off, it'd be good to separate recovery from the related but adjacent concept of someone's healing journey. So I think more basically in this context, recovery from DID is not having dissociative self-states anymore. It's having a sense of agency and ownership over your feelings, thoughts, memories, and being able to trust yourself enough to allow that. But again, to separate it from someone's healing journey and for someone with DID who gets to a point of more awareness of having states, dissociative self-states, more cooperation, more of a sense of fluidity or ease, but still having the experience, an internal experience of dissociative self-states, that could be a great place for them to land in their healing journey.

1:05:47And I guess I just wouldn't call that recovery from DID because they would technically still have DID, but that may be what healing looks like for them. Yeah. And I think, I guess I also want to be careful not to, I feel like we're walking a careful line of like, I don't want to imply that there's like a better place to land in someone's healing journey. I would never, never tell someone they have to get to a certain place. And at the same time, if someone is in that place of still having dissociative self states, wondering about what might be underneath of it. What fear is there of letting go of having that experience?

1:06:28And something that does come up that Melissa and I have talked about with some research participants or in the context of groups of folks with lived experiences, a fear of losing an aspect of self, that it would be gone, which I think, of course, demonstrates part of the symptomatology of DID because in reality, of course, it is all them. You won't lose an aspect of self. You'll just have a sense that it's you, but that does come up a lot. And so I guess I feel curious about if someone is saying they don't want to move past that place, what are the reasons why? And could they enter into those spaces with some curiosity as well.

1:07:14Melissa, what would you add to that? I think it was well put. Nothing. I think you did a crit shop with that.

1:07:22Forrest Hanson: I did want to ask you, Melissa, if you're comfortable talking about it, because it's a little bit gets to some of, I think, what Lauren was saying about concerns over losing these self-states, losing an aspect of perceived identity is maybe a way I would describe it. I don't know if that's quite right, but that's the language I would use. for lack of a better way of putting it, what was that like for you? Was that a concern that you had? Yeah, for me, it was a very gradual, very gradual progression. I went from having these, this sense of having these aspects of self that I didn't understand why they were there, I couldn't control them, to again, this sort of like, okay, you know, it is me, but it's not me.

1:08:08sort of and then gradually over time arriving at this point where like my god that was me but like sort of right before I got to like this is all me I did have this sense when I became much more sort of conscious that these different aspects of self were because I held conflict I was conflicted about things and you know once you can sort of understand this is this is me having being very conflicted about difficult things that have happened you almost don't have to anymore and as I was sort of at that phase I got worried because I had aspects of self that I realized I mean this is sort of a I don't know if it's a silly um example but whenever I had to speak publicly during school there was a sense of self uh that I called the nice lady who was very, you know, it felt like she was very composed and it would just sort of happen when I'd publicly speak.

1:09:11And, you know, there's reasons that I was very conflicted about public speaking. A lot of people are pretty phobic of it. I'm phobic of it and I really don't like people, I don't like the experience of people looking at me or I didn't. That was very conflicted for me. So I had the nice lady who, you know, always seemed to sort of come out when I had to speak publicly and as I was getting better, I realized, my god, you know, someone had called me to do some sort of talk and I was like, how am I going to give this talk if the nice lady goes away? And I also was sort of aware that the nice lady is me, but she also feels like not me, what's going to happen?

1:09:53And as it turns out, I no longer feel that I have a nice lady inside. I still really don't like to speak publicly and really being on your show, Forrest, just so you know, don't love it. You know, having to speak like this, but there is this sense of a loss, I think for some people, not for some people, there is a, in the end, your sort of compartmentalized self-states are protecting you. and as you begin to sort of understand that and understand the sort of perceived roles, there is this fear like they're going to go away. How will I cope? And that was the original conflict, right? It's a child who does not know how to cope and the conflict becomes conscious.

1:10:42But before it really becomes all you, you do have this thought of like, oh, are all these people going to go away? How will I get on with life? And so it's a very natural place to find yourself in the progression. I hope that makes sense. It's hard to put into words, but I hope that makes sense.

1:11:02Forrest Hanson: It makes total sense. Yeah, absolutely. And very understandable that a person would feel that way. I think it makes interesting evolutionary sense as well. Just from a standpoint of, as humans, I feel like we're supposed to be with other people and in relation with other people. and as a child going through this experience and you're alone with it because the person who's supposed to take care of you is doing this to you. I don't know. I've been thinking about that a lot lately of like, wait, this makes evolutionary sense that you unconsciously would cultivate people to be with, to help you with this inside your own mind.

1:11:38I think, I don't know. We haven't really talked about that a lot, but I feel like that makes a lot of sense. I think you're very, very right, Lauren, in the end. And that's getting back to your question. You know, it's an adaptation. It's not a defect. It's not, you know, it is something that really serves the child well. It becomes, you know, very difficult as one gets older and living with the idea I wouldn't really wish upon anyone. but it is an adaptation. It is protected. It's how a child survives. So I think you're right. What do children know? Children know their parents, their friends, other people.

1:12:15So it is of no surprise that they're personifying aspects of self to help them get by.

1:12:20Forrest Hanson: Well, this has been completely fascinating for me and I need to get you guys out of here. Otherwise, I would hold you hostage and ask you about a dozen other questions about this. But I feel like I've learned so much about it already. it's been so interesting to hear you talk about it and I really appreciate both of you and Melissa also really appreciate your transparency and openness here about your own experience and your willingness to talk about in this kind of way I think that's part of what makes your your work and your influence here very unique and that you can wear you know both of the hats you can wear the clinician hat you can wear the the researcher hat and you can wear the person who's experiencing this hat.

1:13:01Forrest Hanson: And it really helps people understand and translate that to a broader group. So I just really appreciate it. Thanks, Forrest. I do want to say that it's not easy in some ways to sort of feel this vulnerable. It feels at times, it still feels a bit risky to do this, but I am an admirer of your show. I've seen other guests who I admire speak in this way, It did give me a sense that this would be a good place to talk about these things in the service, not so much of autobiography or, you know, I'm not special. Nothing that I'm describing is special or unique. A lot of people have these kinds of experiences, but it does feel risky.

1:13:46And there's something about the way that you interview people and how, I don't know, how respectful you are that made me feel like it was okay to do this. So thank you. Thank you.

1:13:57Forrest Hanson: That's really very genuinely touching. I truly appreciate that, Melissa. And Lauren, thanks so much for joining us as well. Like you've really added a lot of great color here for the cognitive neuroscience of it. Oh, thank you, Forrest. And I just want to reiterate what Melissa said as a great admirer of your work on here and their ability to translate for the broader audience. Because I feel like that's so much of the barriers to helping folks is that the information isn't translated. it, it's not accessible, and just so grateful for your work in this space. Thank you. And it honestly really means a lot to me.

1:14:31Forrest Hanson: And again, thanks so much for the time, both of you.

1:14:40Forrest Hanson: I really enjoyed today's conversation with Dr. Lauren Lebois and Dr. Melissa Kaufman about dissociative identity disorder, or DID. Once known as multiple personality disorder, DID is characterized by a combination of severe forms of dissociation. So this could include depersonalization, where a person feels detached from their self, their body, their thoughts, or their feelings, and derealization, the world feels kind of dreamlike or far away. There's a sort of unreal quality with intrusion of different self-states. So Melissa talked a lot during the conversation about this feeling of not me, where she was experiencing something, but it also felt like she was somebody else who was experiencing it.

1:15:27Forrest Hanson: And also there would be what are called partially dissociated intrusions, where these various self-states would suddenly feel quite loud or pronounced in her experience. She even talked about characterizing them in different kinds of ways. She talked about the nice lady who handled the public speaking, which is something that she still doesn't like very much. And I really appreciate Melissa's willingness to have this conversation and her openness about her own experience, particularly given her mixed feelings about that kind of public speaking, which I thought she did phenomenally well during this conversation.

1:16:02Forrest Hanson: And she also talked about the girl in the box and this almost kind of stick figure characterization of it. And then a more angry part, I think that she even characterized it as a boy, if I'm remembering correctly, that was more assertive or carried more of those kinds of feelings and emotions. In order to develop dissociative identity disorder, a person needs a combination of things. First, they need the ability to dissociate. This is an ability that is distributed in the population kind of along a normal distribution. So there are some people who are really extreme dissociators or have strong dissociative tendencies, and there are some people who barely dissociate at all.

1:16:40Forrest Hanson: So to develop DID, you're probably going to be more out toward the tail of those big dissociators. Trauma is a necessary condition for dissociative identity disorder. And Lauren and Melissa did a really good job of explaining how this can develop in a kid. Kids have personification mechanisms. So a young kid might naturally say that the stuffed animal is mad, not me, when expressing a feeling to their mom that they feel, you know, they're not really supposed to communicate to their mom, but you know, my teddy bear's mad at you, that kind of a thing, right? And the line between reality and not reality is quite fuzzy.

1:17:17Forrest Hanson: The Easter bunny is real, Santa is real, Superman is real. And so you can see how a highly dissociative kid under repeated harm conditions could use that kind of ordinary tool to separate out the unbearable, awful stuff that is happening onto a kind of not me. And over time, that fragmentation becomes more significant, and it becomes a real adaptation, a coping mechanism. And that's something that Melissa and Lauren also really hit over and over again during the conversation. This is an adaptive response to trauma. That's why people do this. And it's a very functional response. A lot of the time, it's what somebody has to do to protect themselves.

1:17:58Forrest Hanson: It's normal for people to experience enormous amounts of shame related to DID and shame related to dissociation in general. I have some friends who are stronger dissociators, and they often feel quite embarrassed about it. This is a tough thing for somebody to manage, and popular presentations of DID, which are often really exaggerated and over the top, are not helping here because they can make it easier for a person to feel like something is deeply wrong with them or like their experience isn't even being captured by these kinds of dramatic presentations. We talked about the spectrum of PTSD and dissociation from classic PTSD all the way up to DID, and Lauren explained it a bit like being on a roller coaster.

1:18:42Forrest Hanson: This was actually a metaphor that she got from somebody else, and I'm currently forgetting their name, but she said it during the conversation. So for classic PTSD, you're on the coaster, you're feeling the full adrenaline rush, the fear is happening to you. For the more dissociative form of PTSD, you're standing on the ground watching yourself ride the coaster, and this is that detachment of depersonalization and derealization. Then all the way up to DID, it feels like somebody else is on the coaster, and you're watching that person from far away. And you lose a sense of ownership and agency over the feelings, the memories, even the body of that person, to the point where it can feel like somebody else is living in your mind to an extent.

1:19:27Forrest Hanson: And Melissa talked about that experience and how incongruous it was for her, how it didn't really make sense, how she kind of knew that this isn't the way a lot of people experience reality. And then that again can lead to that experience of, wow, something is deeply wrong with me, and the associated shame that comes with that. I asked Lauren what these differences look like for somebody in the brain, or if it's possible for us to tell the difference between classic PTSD, dissociative subtype, and then DID if you take a brain scan of somebody? And my understanding is that the answer is kind of, and at the very least, there are these different patterns of activation that we see in the brain.

1:20:05Forrest Hanson: So there are these two important regions, the amygdala, which is a salience detector. It flags threats very quickly. And then the ventromedial prefrontal cortex, and this is an executive controller and we can think about this more as being the brakes of the car. In classic PTSD, the amygdala fires, so you get that whole body activation, and the brakes aren't as prominent in the process. There might have some activation, but it's not as activated. In the dissociative subtype, it's the reverse. There is more prefrontal activity and less amygdala. So the brakes are on too tight. The person is more numb and detached.

1:20:44Forrest Hanson: We really see that in these classic dissociative symptoms. So then in DID, the same person can show both the classic PTSD presentation and the more dissociative subtype presentation, depending on which self-state they're in. We talked a bit about the long history of skepticism toward DID, which again, I think is fueled a little bit by some of these more fictionalized presentations of DID that you will see in movies or even on social media. But this goes all the way back in the field to Freud and him wrestling with whether or not he thought this was essentially a real thing or not. I want to really emphasize that these days, inside of the field of psychology, there is no serious question about DID as a diagnosis.

1:21:30Forrest Hanson: This is a real diagnosis, people really have this experience, and it is much more nuanced and complex than is typically presented. We talked a little bit about some of the misunderstandings out here related to dissociative identity disorder. I asked a question that came from Elizabeth about working with DID and whether or not people who were more dissociative are more susceptible to clinical influence than people who weren't. Melissa really emphasized that they are not more susceptible to false memory formation or something like that, but they are more susceptible to hypnotic suggestion because there's a lot of similarity between a hypnotic state and a dissociative state.

1:22:10Forrest Hanson: Then we talked a bit about the difference between parts and self-states and the difference between IFS-based approaches and their work with DID. Everybody has parts in an IFS sense, but everybody does not have intrusive, dissociative self-states in a DID sense. We then talked a bit about what to do about all of this, including Melissa's personal experience doing long-term, psychodynamically oriented work with a clinician who was able to help her with her own experiences and get to a place of greater integration. The clearest thing that I took from this conversation when it comes to treatment or working with your own experiences is that this is built on the relationship first and everything else second.

1:22:59Forrest Hanson: With dissociation, a steady and consistent and well-paced approach to treatment in general and relationship building specifically is where most of the work is before you even get into exploring different experiences a person might had or helping them integrate their sense of self. You can't really get there until you have built this working foundation. That's very humanistic in terms of its tone and orientation or very relational in nature. Good clinicians work slowly here, and they're going to help you stay in that range where you're neither totally slamming the gas or totally slamming the brakes or totally slamming them both at the same time, as the case might be, and they're going to help you through that experience so you can really titrate yourself.

1:23:47Forrest Hanson: So when you're looking for a therapist who treats DID or dissociative conditions more broadly, you're looking for somebody that you think you can build that kind of relationship with, who you think is going to work at that kind of tempo, in that kind of speed. And sure, if they have additional certifications, additional terminology, trauma-informed, all of that good stuff, that can really help. But the thing to look for is that kind of relationship with as Melissa said a couple of times, just a good clinician. Toward the end, we talked about what making a recovery looks like for a person. And I think the truth is that this really varies.

1:24:22Forrest Hanson: And Lauren and Melissa kind of spoke to different ends of that, where Lauren talked about this difference between a kind of broader healing journey a person could go on and what they would describe as full recovery in a clinical sense. A person might still have these different self-states, but feel like those self-states are on the same team or rowing in the same direction, feel reconciled about that, feel good about that fundamentally. We may not describe that person as fully recovered clinically, but they've gotten to the place that feels good to them. Their symptoms are not bugging them in the course of their life, or they're mostly not bugging them in the course of their life and everything is all very managed and manageable.

1:25:08Forrest Hanson: That could be a great place that a person gets to. For somebody like Melissa, who went through this process and made what we might describe as a full recovery, she no longer has those self-states as distinct things. There is this sense of integrated I at the center of all of it. I am that person and I'm also that person. And as I think it was Melissa who mentioned during the conversation that I have self-states, I have parts. I have different aspects of myself that show up in different ways in different settings. I've got kind of podcast forest, and then I've got friend forest. That is a totally normal thing.

1:25:48Forrest Hanson: There's not a darn thing wrong with that. We all do that to various degrees. And that's the state that a full recovery might look like for a person, where sure, there's still these different aspects of who I am, absolutely, but it all is me. Really appreciate Melissa and Lauren for joining me today. Again, particularly with Melissa's openness to speaking to her own experience, this is incredibly sensitive stuff. It is very difficult to talk about. And I think that that kind of public-facing work that she's doing these days is really tremendous. this. There was a New York Times Magazine article where they spoke to Melissa related to DID.

1:26:25Forrest Hanson: And I think that it's just really helped so many people understand these conditions better and get a better sense of who they are as people. Get a better sense of what's possible for them, that these are real things that people experience. There are things we can do. We have good approaches to this stuff. And it is really possible to get to a place where you feel like you pretty much from top to bottom, and you feel good about that you. Lauren's work on the cognitive neuroscience related to this is totally fascinating. If you are interested in reading studies that have fMRI scans or similar in them, you would absolutely love it.

1:27:03Forrest Hanson: And they wanted to make sure that I directed people to the traumacontinuum.org website. That's trauma and then continuum, C-O-N-T-I-N-U-U-M.org or Trauma Continuum at Hill Center. It is a great website. There are a lot of resources there. Their resources are aimed at people who have been affected by psychological trauma and they're trying to deliver person-centered, trauma-informed treatment, research, education, and advocacy to the public. Their work is fantastic. Please check it out if you're interested in this. If you made it this far and you somehow haven't subscribed to the podcast yet, wow, you should really subscribe to the podcast.

1:27:42Forrest Hanson: It would help us out. You can do that on YouTube, on Spotify, on Apple, on wherever you listen to your podcasts. And you can also find us over at Patreon. It's patreon.com slash beingwellpodcast. For the cost of just a couple of dollars a month, you can support the show and get a bunch of bonuses in return. You can also find my writing over at Substack. I'm writing a little bit more regularly these days. You can check that out. And more than anything else, the best thing you can do to support the show is leave a comment, leave a rating, and a positive review. And hey, tell a friend about it. That is the best way that we got to reach new people.

1:28:15Forrest Hanson: So until next time, thanks so much for listening, and I'll talk to you soon.

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