Dissociation and integration

I have an understanding of what dissociation is and how it works that differs somewhat from mainstream psychological ideas. I have mentioned this, but I thought I would explain in more detail.

The standard definition is that dissociation has to do with a separation from an awareness of reality. But what is reality? It’s so many things. There are a thousand bits of sensory input from the external world—some of them important, some of them not. There are sensations in the body, how your skin feels, your heart beating, the sensations in your core that are your enteric nervous system and are part of how you experience of emotions. Then there are your thoughts, the pictures playing out in your mind or the verbal chatter of your mind making sense of things or imagining the future or remembering the past or just commenting on life. That’s all reality. Inside and outside of you is reality. It’s a lot of stuff, and normally we focus our attention on some elements of this reality that seem to be important and away from elements that seem to be unimportant. We cannot possibly maintain our conscious attention on it all, because it is too much to pay attention to at once.

We control our attention. All of us have only so much stimulation we can process and respond to at one time, and we do what we need to do in order to keep it in a range of what is possible and comfortable for us. Dissociation is this control of our own attention.

During traumatic experiences and later, the degree of mental and sensory stimulation is too much, and we shut certain things out of our awareness in the same way we normally do, but to a greater extent. This gets the degree of input down to a manageable level, so that what we are taking in is at a level of intensity we can make sense of and respond to. The more intense the experience, the more constricted we need to make our awareness.

We might shut out stimuli that are very painful so that we aren’t saddled with trying to respond to the pain in addition to doing what the moment demands of us—carry on a conversation, think about maths or whatever—or we might shut out everything but the pain so that we can deal with the pain and not what amounts to trivia. Or we might shut out one kind of pain so that we can attend to a second kind of pain. The stimuli are still being recorded. The knowledge of those stimuli is going somewhere, but we aren’t giving it our conscious attention and it isn’t being processed in the same way as what we are giving our conscious attention to in that moment.

If this goes on very regularly, you end up with a very fractured experience of life. You have a fractured experience of yourself, your past, and the world around you. This fractured experience does not occur separately from your social experience and development. If you are a child, and your personality is developing, your sense of self is going to occur in the same fractured way. So awareness of certain kinds of experiences, certain thoughts or certain feelings, is going to be separated from other kinds of experiences, and they are going to feel like different senses of self.

This creates problems.

It creates flashbacks, for one. As we move through life, we are automatically comparing the present experience to other experiences in the past to see which experiences it might be like so that we can use that information about past experiences to help us be successful in the present in how we respond. At the same time, we are discarding experiences that might at first glance seem similar but aren’t.

But trauma is in bits. The process of mining the past for comparable experiences becomes very difficult, because the memories aren’t rich enough or integrated enough to yield discomfirming details.

I’ll use my bathroom floor as an example. So, as most of you know, my bathroom floor is a kind of pebbly concrete that has been painted red. When I go in the bathroom, I see the floor first. It’s quite bright and noticeable. The most intense memory I have of red, pebbly surfaces involved murder and blood. It’s the first experience that comes to mind for comparison.

When this memory wasn’t processed at all, there was no way for my mind to discard walking into the bathroom as being quite unlike witnessing a murder. The rest of the pieces of that memory of murder weren’t processed. They were either totally unsorted—recorded, but not organized in any way—or stored separately. So every time I walked into the bathroom, the closest bits of that memory arose and presented themselves for sorting and processing and making sense of. Which was, of course, too much. I dissociated them again. And the process continued. It went on for quite a long time this way, until finally the memory was processed and integrated and not stored in a fractured way and so I can automatically discard murder as a memory quite unrelated to walking into the bathroom.

Dissociation of that kind also means you keep experiencing the world in a fractured way. The whole world becomes my bathroom—a possibly related experience that prompts memories of intense, overwhelming trauma—and it continues to be necessary to keep your attention restricted in order to keep life to a manageable level of input. So, it’s self-preserving.

One of the things I have done that has been helpful is to use this deliberate control of my attention to help me process the trauma. I went in the bathroom, and I didn’t pay attention to everything. I continued only paying attention to as much of the stimuli as I could and not more than that. I changed what it was that I paid attention to, but I didn’t try to do more, because biologically I can’t. I focused only on the emotion from the traumatic memory and on my attempt to regulate that emotion. About 1/100 of my attention was on scrubbing the laundry—that is what happens in the bathroom that involves looking at the floor for the longest stretches of time. But everything else was on the emotion and on my attempt to regulate. I shut out the pictures of what happened and the sounds of what happened. I shut out most of my awareness of the laundry. I definitely didn’t let my mind trot on to to worrying about what to fix for breakfast or for how the day was going to go. I kept controlling my attention so that it was focused on the piece that was going to help me.

I felt the emotion in my body and I controlled my breathing. Mostly that is what I did to regulate my emotional state. It’s hard to do a lot else when you are in the bathroom and the floor is wet with laundry water. Sometimes I stood up, because that helps with the emotions too. (Being close to the ground is its own trigger.) But mostly I controlled my breathing, because that helps me stay calm. If I were in a different situation or had had more soothing skills, I might have done something else, but what I had was breath control, so I did that. I did that nearly every day for about six months.

Outside of the bathroom, I went on working with that memory. I shut out my awareness of where I am now, and I only thought of maybe one element of the sensory experience, one thought, one emotion, and I went on doing something to try to keep the emotional intensity down in an artificial way. I controlled my breath, or I wrapped myself up in blankets, or I cuddled a hot water bottle, because those things are calming. I kept using my attentional controls to help me process only the amount of the memory that could be successfully processed until I finally had an integrated, whole memory that my mind now understands is quite different than walking into the bathroom.

And I think that is how you recover from trauma. You do something to lower the intensity of the emotions of the trauma—you do a lot of self-soothing and self-regulating—and you focus your attention very carefully so that it is on what needs to be processed but not more than that. Your attention is on only two things: one piece of the trauma and on the self-soothing. Until the trauma memories get sorted. But I am convinced that this is where it is mostly at, from the standpoint of what one needs to do: self-soothing or self-regulating and attentional controls.

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Warm

Motivated states—mental states where we feel very strong emotions or very strong desires—influence our thinking. How it influences our thinking depends on the kind of motivated state it is. Anger makes us more certain and anxiety makes us notice details more. They usually make us more impulsive.

They are adaptive changes in our thinking for the most part, but when you spend a lot of time a hot state because of a traumatic past or because there is just something really wrong with your present (as in, it’s abusive), it usually doesn’t work out so well.

But if you are too “cold,” too uninfluenced by emotions in your thinking, you make bad decisions too. People lack emotions because of a brain injury can’t even gamble sensibly.

The best decisions are made in a “warm” state.

I’ve found, too, that the key to healing from trauma is trying to stay “warm.” For years, I practiced doing nothing in the grip of strong emotions. It was very useful later when the trauma work got really underway. Reducing impulsivity was terribly, terribly important, because once stuff is out of the dissociative box, you never know what you’ll get. It’s usually “hot” though, and it usually makes me think I want to do something I don’t want to do. Not doing it is just so very important, especially if it turns out to be a lot “hotter” than I expected or am prepared for.

And recently I have worked at getting things to stay “warm.” “Warm” seems to be magic. My brain stays on, it can start to make sense out of the memory, and it can link up various parts of the past and present that go together, including the emotions. It can’t do that in a hot state—it stops thinking properly then. It can’t do that in a cold state—I lose the emotions then. It has to be warm.

So the memory pops up—something triggers it out—and I just try to keep it warm. I try to dial it down, not through an act of will, which is what dissociation is to an extent—but by comforting myself and creating a calmer mood.

What comforts me might not comfort you. What comforts you probably won’t comfort me. This is something I have learned. I spent a long time trying to calm myself by grounding myself in the present. It doesn’t work for me—it triggers more trauma. Instead, I look into the past and I use what calls up those moments in the past when I felt safe—or safer than I am in my traumatic moments. That works.

Trauma work is really, really hard. Honestly, I don’t think there is much that might be harder. But I’ve come to the conclusion that it’s simple: you learn how to do nothing and you learn how to stay warm. Once you have those two things, everything else flows out of them.

 

A butterfly in the house

Kind of like that one.
Kind of like that one.

In the morning, when I was first getting up, a butterfly flew through the hall. Was this a good omen?

I can’t say. I’ve had a cold for the last three days, and on top of that some stomach problems that don’t seem to be any kind of waterborne illness, but just one of those things. (The doc prescribed some tablets. They’re helping.)

These things are difficult for me. They’re probably difficult for a lot of us who were badly mistreated as children. Sickness, first of all, doesn’t always bring out the best in abusive parents. Sickness in a child is something out of the parent’s control. It’s an inconvenience, and it’s also solid evidence that the world does not always operate according to the parent’s wishes.

So abusive parents often abuse their children for being sick. I say that not because I’ve read extensive studies on this or have come across hard evidence, but just because it’s something people seem to keep telling me. Being sick when your parent doesn’t parent is awful.

Even when this kind of parent isn’t actively abusive, she is often neglectful, leaving the child to deal with discomfort and fear and the physical issues involved with being unwell on his own. I’ve seen both ends of this, as well as a third factor that is also connected: abuse tends to make you sick. So body aches and nausea are reminders to me of horrifying maltreatment. Being sick can sometimes feel like one long flashback.

It felt that way this time. Sometimes, when the full detail of the memories surfaces for me, it feels impossible to grasp the inhumanity and the cruelty of how I was treated as a child. Knowing even that my father was a psychopath, that my mother was only sort of living in the real world, it’s just difficult.

And yet I do know.

Psychopathy has four dimensions: grandiosity and lack of empathy are two of them, and they work together. Because of the extreme degree of my father’s sense of his own importance, he believed that the normal rules of society didn’t apply to him. Yes, it’s wrong to torture and rape your own children. He knew that. But not for him. He was special and he had his reasons. He knew things about life (or so he thought) that ordinary people don’t know, and he was entitled to privileges they don’t have.

I’ve also come to see that his belief in his own importance was a part of the attraction the women in his life—his wife (my mother) and his girlfriends. There’s something about spending your life in the company of genius, and of course my father isn’t really a genius—not in the slightest, although he’s no slouch either. He’s a smart enough man. But he has yet to determine what really causes gravity or why light behaves as both energy and matter–or anything else useful, really. But if you can’t have a genius, you might be able to find someone who’s simply convinced he is. And that’s what my mother had done. All that importance provides a kind of reflected glow. My life was the collateral damage.

So I do know. But I also can’t grasp it. The extent of the wrongness is just so great.

Why we have flashbacks: the somatic marker hypothesis

ventromedialEvidently, it’s all about the ventromedial prefrontal cortex.  I had to read this sentence 3 or 4 times before I understood it, but it seems to express the entire occurrence of flashbacks very neatly.

“The ventromedial prefrontal cortex is a repository of dispositionally recorded linkages between factual knowledge and bioregulatory states. Structures in ventromedial prefrontal cortex provide the substrate for learning an association between certain classes of complex situation, on the one hand, and the type of bioregulatory state (including emotional state) usually associated with that class of situation in past individual experience.”  Bechara, et al. Emotion, decision making and the orbitofrontal cortex.

The hypothesis being described is the somatic marker hypothesis. This hypothesis specifically claims the following:

“When subjects face a situation for which some factual aspects have been previously categorized, the pertinent dispositions are activated in higher-order association cortices. This leads to the recall of pertinently associated facts which are experienced in imagetic form. At the same time, the related ventromedial prefrontal linkages are also activated, and the emotional disposition apparatus is competently activated as well. The result of those combined actions is the reconstruction of a previously learned factual–emotional set.”

So, I think that pretty much sums it up.

What’s interesting, of course, is that although having traumatic material activated in that way is something akin to torture, people who don’t do this, who have lesions in this area and aren’t able to activate associations between experiences and somatic states make terrible decisions for their lives generally. In a gambling experiment, they continue to place their money on bet that over time will lead to greater losses than gains. Even when they know that this is happening, they continue. Apparently, you need that little nip of fear in order to follow through on making a better decision.

So, while trauma memories suck, the normal tendency to recall previous experiences in the body when facing current experiences is generally a good thing.

A Confusion about Words

David Vetter, 8 years old. Baylor College of Medicine Archives.
David Vetter, 8 years old. Baylor College of Medicine Archives.

Years ago, my therapist said something about my beginning to feel safe at some point in the mystical future. I suppose she was hopeful and thought this would make some kind of difference or being important to me in some way.

I didn’t really believe her, and it didn’t seem like a realistic or important goal.

I am still very aware of the dangers in my life. I’m not sure that will ever go away. It’s like I looked over the edge of the cliff at some point, and I now know how far the drop is. But it doesn’t really stop me. It may slow me down sometimes, I’m not sure. But generally, the risks seem mainly acceptable–acceptable enough that I’ve chosen to keep on adding more.

I didn’t know what she meant.

It’s begun to occur to me that “safe” doesn’t really mean an absence of danger. Our lives will always be dangerous to a greater or lesser degree. None of us can keep ourselves packed in cotton forever, and we could live like the boy in the bubble did, but I don’t think he would have recommended it to us. We all know that’s no way to live.

Safe doesn’t mean no one and nothing will ever hurt you. There is always something that can, and from time to time it will.

But there is this other thing, that might be what she meant and that is simply having the support you need to get you through life. It is having enough warmth and affection, enough good intentions, and enough advice from people older and wiser who know better than you. Those things aren’t safety in a literal sense, but it is safety in a felt sense.

There is another word I think I’ve been confused about and that is worth. My therapist has mentioned that as well in the same kind of wishful way–“when you feel more worthy…”

But when you’ve raised to think about worth in terms of economics, as only being about a measure of utility, and the idea of “deserving” as being about something earned, then worth isn’t a simple thing. It isn’t even a desirable thing. Being worth more only means more people have more reasons to harm you.

There is this other thing that has to do with just being a person.

We saw one of these. It was cool.
We saw one of these. It was cool.

I was out with a friend the other day. We went to a museum. She’s a science-y person, and I have very few science-y friends. So this was a rare opportunity for me to go and look at something science-y with someone else.

We spent most of the day looking at bones. It was fun.

I often have the sense when I’m around other people that whatever I say should have some merit. There should be some special reason someone else should listen to it: it should either be something the listener doesn’t know or hasn’t thought of yet, or it should be witty and funny and entertaining. In other words, it should not just be whatever garbage falls off my brain and out through my mouth.

There’s something to be said for holding yourself to that kind of standard. In a committee meeting for example, that kind of thinking is priceless. If everyone did that, meetings would never last more than an hour–no matter how complex the topic. We would all get the work done lickety-split and get to go home. Sadly, I found very people do.

Nonetheless, if you’re out with a friend looking at bones, a little garbage might be okay. In fact, it might make someone feel more connected to me. They will think they know more about me, and also be comforted by the fact that what falls off of my brain and out of mymouth is no more sparkling and brilliant than what falls off of their brains.

So I lowered my filtered. I said trivial things. I said boring things. I said whatever came to mind.

And my friend listened politely, even with interest.

That is worth.

Photo credit: Pfinge
Photo credit: Pfinge

It was given out not because I was so fascinating or brilliant or charming, but because I’m a person, and she’s a person. And basically people like other people. And it also helped that we both enjoy looking at bones and wondering things like whether walruses spit out the clam shells they’re eating or poop them out or what. It helped as well that I care about other people and I have some moral standards, because that’s the kind of person she is and who she prefers to be around.

And I am just going to stop there. Because I want to think about that last statement. I want to think about it for a good long time.

Empathy, Mentalization, and Complex Trauma

Affective (or emotional) empathy and cognitive empathy have been compared to nested Russian dolls, but I prefer to see them as distinct systems that work together to help us interact with and understand our worlds.

It amazes me sometimes what I don’t know, and what I know now that I didn’t know before.

Mados tells me that empathy has two components: an emotional component and a cognitive component. It turns out that she is absolutely right.

The emotional component allows us to literally feel what others are feeling and seems to have something to do with our mirror neuron system. It is what makes histrionic personalities so difficult to be around and can make meditating with others who are also meditating especially calming. Emotional empathy makes affective states contagious.

Cognitive empathy involves mentalization–being able to think about someone else’s thoughts and feelings–and perspective-taking. The Sally-Anne test is really a test of the very first stage of the development of cognitive empathy: recognizing that a different person with access to different information will have a different thought about a situation. Children without Autism Spectrum Disorders (ASD) have a good grasp of this idea by the time they are four years old.

Children with ASD don’t, because they seem to have delayed cognitive empathy skills, although they may have perfectly average emotional empathy. Difficulties with cognitive empathy have all kinds of other implications, including problems with developing social, language, and academic skills, because our ability to understand the minds of others impacts how well we are able to learn from them.

We notice the social aspects of ASD because social interactions are such a high priority for most of us–human beings are among the most social creatures on the planet. But I’m not convinced they are causal. Difficulties with social information processing may result from general difficulties processing sensory information that interfere with taking in and making sense of social cues.

ObstacleCourseTires1However, this post is not actually about ASD. It is about how our empathic skills work together to help us interact with and understand our worlds–or don’t.

Just as with ASD, some of the difficulties associated with complex trauma may have to do with skill gaps in cognitive empathy that also lead to a vast array of other difficulties, including difficulties in mentalization–thinking about our own minds and the minds of others.

I am involved in several online groups for family members of people with Borderline Personality Disorder (BPD), and many of the struggles new members have revolve around difficulties with mentalization–perhaps not generally, but in regards to the BPD. Most of their questions boil down to, “How is she thinking? Why is she acting this way? What motivates her?” And, “What can I be doing to help?”

Mentalization.

Understanding how someone else’s mind works, what they are thinking and feeling and why, help us to interact with others in successful ways. It is like knowing how to navigate an obstacle course. When we know how high to jump to get over the wall, how fast we can manage to run through the tires without tripping,  and how low to stoop for the tunnel, it is almost fun.

When we know how someone’s mind works, we can navigate them too. We can make ourselves understood, we can repair breaks in communication, we can provide comfort and support when others need it. When the minds of others are incomprehensible, we can’t. And it isn’t fun.

The Sponge People. Click the image to follow link.
The Sponge People. Click the image to follow link.

It is frightening.

It is frightening when we can literally feel the distress of others, but we can’t make sense of it and we don’t know what to do about it.

And it isn’t just a practical problem. We use mentalization to regulate our own affective states. When we “catch” someone else’s emotional distress, we consider their mental state to reframe the distress as nonthreatening. We use it to take action that relieves their distress (and ours). When the distress is incomprehensible, we have one less tool with which to manage it.

When have never learned to properly understand our own minds either, because those around us had disordered minds, then we are doubly disadvantaged. We become sponges, with nothing to dry us out again.

Distress Tolerance: Part 2

Since I shared with you my decision to tackle my terror of writing and before that my terror of cleaning house, I thought I should let you know the outcome.

The world is a beautiful place. Oh, and I recognize my hands as belonging to me. Life is good.

It took two days to get there. Writing, it turns out, terrifies me quite a bit more than dusting the furniture. Perhaps I would have gotten there faster, but I had a cold. And coldy brains just don’t work as well.

Yesterday did not go as well as today. I was coldier. Or maybe it just took me a while to get the hang of it. But today I’d say has been a success.

I began in the same way I approached cleaning house: in 10-minute increments. But I found tolerating distress while writing is harder than tolerating it while cleaning. Not more painful, perhaps, but more difficult in a practical sense. Because writing uses a lot of the brain. And so does distress. Cleaning, not so much. You can get all choked up, dissociate, have flashbacks, start thinking about ways to take revenge on your perpetrators all while giving the sink a good scrub. Do those things while writing and you often find yourself not writing anymore.

Also, cleaning has a clear end in sight. Even though I was working in 10-minute increments, there was no defined endpoint for when I should actually stop writing if I continued to be able to get through each set of 10 minutes. Endpoints help with motivation. They keep us focused on a task. Endpoints are good. I didn’t have one, and that made it harder too.

So, today, I changed it up a little. Ten minutes first. Then 20. Then 40. Then 80. Eighty provided an end-point. If you can handle doing something for an hour and 20 minutes, you are probably good to go. Or at least that was my reasoning. And it did help. I stayed more focused. I dissociated less. I kept writing through the distress.

Interesting things happened. First of all, I was okay for eight minutes. Eight minutes into it was when the anxiety began to set in. Funny, isn’t it? I have a remarkable sense of time, although I can get lost in it as well as anyone else. Still, I know pretty well how long a minute is, how long 10 minutes is. And I imagine my mom must have had an average. Eight minutes to get up out of bed (she was always in bed), use the bathroom, head down the stairs, and into my room. From whence the screaming and throwing things began.

So the challenge became getting to the eight-minute mark and then waiting for the anxiety to subside. And it did. Eventually. Not quickly. But eventually.

What’s interesting to me about distress tolerance as a therapeutic technique is that it makes your mind cease to be the enemy. In PTSD, you are no longer in danger, but your mind continues to be an unpredictable place. Distress tolerance doesn’t change the distress, but it means the distress ceases to be terrifying. And that reduces a great deal of the feeling of overwhelming powerlessness that is the core of the problem. You still cannot stop the distress. You can’t make it go away. But you can outlast it.

I believe distress tolerance also unlinks the chains of a fear structure, so that particular triggers no longer activate self-propelling sequences of memories and thoughts that maintain an association between those triggers and terror. In that sense, and I wasn’t expecting this, it is more effective than thought-stopping (which also has its uses.)

It works because the thought and the emotions simply stays where it is, rather than getting routed to something else–say a comforting image of a loved one or a favorite place–that may eventually link back to the terror again and in that way keep the structure intact. (Since so many things do link back to terror.)  In distress tolerance, you simply stay in the same place. So that the link becomes trigger->terror->nothing. The associations don’t link back to anything that can then re-activate the terror.

As far as why it made the world seem like a more beautiful place and why I recognize my hands as being mine again, it’s a little harder to explain. And I’m tired now. I still have a cold, and it’s time to try dusting again. So that will need to wait for another day.

But you should really check out Quratulain Balouch. She’s awesome.