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If you've ever been affected by a traumatic event, you know how confusing and difficult it can be to try and understand what happened. The brain is a complex organ that we still have much to learn about. Many of us carry the effects of trauma long after the event has passed.
Join us on Therapy Talks as we discuss Trauma and how therapists can help. Trauma is more than just a stressor, it's how that stressor is held in the body. This week, Coral Compagnoni joins Hailey Kanigan to discuss different types of trauma and how we can differentiate its causes and the ways trauma affects us.
In This Episode:
Coral Compagnoni is a Licensed Marriage & Family Therapist practicing in the Silicon Valley in California. She is a clinician and educator specializing in complex trauma and dissociation. Coral received her MA in Clinical Psychology at Pepperdine University and her bachelor’s degree at Carnegie Mellon University. Coral holds an ISSTD Advanced Certificate in Complex Trauma and Dissociation, she is a certified EMDR Therapist, and is a Child Parent Psychotherapy (CPP) clinician.
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Disclaimer: Therapy Talks does NOT provide medical services or professional counseling, and it is NOT a substitute for professional medical care.
Hey, it's Haley. Welcome back for another episode of Therapy Talks. Today we have Coral joining us. She is an EMDR consultant and we talk about single incident trauma, complex trauma, and the different forms of dissociation and how to apply EMDR as a modality.
I would love, if you don't mind just introducing yourself and your background and maybe a little bit about yourself and the feel of psychology and what you do, and then we can branch off from there. Absolutely. So my name is Coral Ka and I'm a licensed marriage and family therapist, and I'm licensed in California, down in the States and also in Utah.
My practice is located in the Silicon Valley and in the San Francisco Bay area. And I'm working both in person and remotely right now, and I'm primarily in private practice. I also work one day a week at an intensive outpatient program in the area where I do trauma therapy and EMDR therapy. And I'm also, yeah.
And I'm also an adjunct professor at Pacific Oaks in which is a college down here in California in their marriage and family therapy program, teaching in the areas of complex trauma. Wow. Lots of different things that you're doing. You're doing private practice, a bit of outpatient treatment support, professor, all of these different things.
So maybe you could just share a little bit of what led you to work in the area of trauma and complex trauma. Sure. Huh. Where should I start that story? So this is a second career for me, like so many therapists you've actually had on this podcast. It's really interesting to see. And so my first career was in theater and entertainment.
And when I decided to make the transition to being a therapist, I wasn't sure what my specialty would be. And then in that first year of graduate school, I had a class that was on. The sort of neurophysiology of therapy and mental health, and that was very fascinating to me. And there was a class lecture on PTSD and what happens in the brain with ptsd.
And that was just the most fascinating thing I had ever heard. And at that point, I was introduced to a well known traumatologist named Bessel VanDerKolk. And this was back in 20. 11, 20 10, 20 11. And I actually come from a line of therapist. My father is also a therapist and when I was in grad school he said, Why don't we go to a professional development conference together and you can pick which one you wanna go to.
And I had, I saw that Bessel, Vander Cole was gonna be coming to San Francisco and doing a two day training on the new frontiers and trauma treatment and all of the different, That they were finding really effective, and he was talking about things like theater and meditation and yoga. AMDR was one of those modalities as well.
And because I had switched careers and I had come from this performing arts career where I had. Done theater and dance, and I had, I've been meditating my whole life pretty much, and had this background in yoga. When I heard that all of these were different modalities being used for trauma, I went, Wow, maybe I'd be a really good.
Trauma therapist. And I felt like for that first time I really felt my previous career and this career integrating. And since then, they just integrate more and more. And I'm so grateful for that background. But that is what really got me started thinking like, Oh wow. Like I might have skill sets even from before I was a therapist that could really help me as a trauma therapist.
And it's just been off to the races since then and I haven't looked back and I just love working with people who have been impacted by adversity and watching them heal and overcome that. And it's such a powerful thing to watch someone Yeah. Heal from something that's been. Hurting them and holding them back for so long.
. And I just see your whole face and your eyes light up over this story of falling in love metaphorically with the field of psychology and the trauma therapy and really bringing in your own background of the movement, the entertainment, the dance, all of that performing arts kind of pieces and really showing that connection of how it could be really healing for someone who's experienced adversity and trauma.
And also I was really smiling at the idea of you bringing up Be or Vander. So maybe you could just explain who he is and like how he really relates to the field of trauma from a professional standpoint. Yeah. So I would say in the world of trauma, he is he's a sort of a grandfather, . It's a world of trauma.
He is a very important man who's impacted the field a lot and. He's outta the Boston area and has been affiliated with a lot of different institutions there, educational institutions over the years, like Harvard and also the trauma center. And he is a researcher, really and clinician, and he has done a lot of research into what's going on in the brains and bodies of traumatized people and the various modalities to support them.
And he's been a big advocate of a lot of different modalities and needing. To incorporate a lot of different modalities into healing. And he wrote a wonderful book called The Body Keeps the Score that was published in 2015 that I highly recommend. It can be a little bit triggering, but the first half of the book really goes through what happens in the minds and bodies of people when they experience adversity and trauma, especially in childhood.
And then the second half of the book outlines different treatment modalities that are. Effective and each chapter focuses on a different one. So it's a wonderful read for anyone who's interested. And he really narrates the book from his own personal experiences and his life journey in the experience of researching and applying trauma treatments and stuff.
And in that way it is still quite dense, I think, to the lay person. But at the same time, it really does bring you along on the story of his journey of exploration of different trauma therapies. Absolutely. . Yeah. And so for you, Why emdr? What made you really step into that wonderful modality?
Yeah, such a great question. So that was my first modality that I picked up. So I started it almost 10 years ago. I started training in it and out of the different. Modalities that I now do, and the ones that were really being talked about, the BeWell Vanderbilt talks about, that one seemed like one of the most foundational to me.
Like I don't know how I could be a trauma therapist and not know how to do emdr. And of course there are many good trauma therapists who don't do emdr. But that for me, that was just a really foundational. Peace. And I do feel that way. I don't know how I could do trauma therapy and not have that in my toolkit, so to speak.
And it was also just very practical. There was a training also. There was a training in my area. It was open and available. There are some trauma trainings. There are so hard to get into where there are cost prohibitive. But EMDR was it was, reasonably priced and it was in my area and I just loved, I fell in love with.
Immediately, and I started doing it as a client myself, cuz I don't like to do anything as a therapist. I don't like to do anything with a client that I haven't done myself. And I found it really transformative and powerful in my own work and my own healing work. And I just started seeing radical effects with it, with clients and I just continue to embrace it more and more, and I'm a certified EMDR therapist and an approved EMDR consultant.
. And so maybe you could just share with everyone, like what would be the process to get that level of training? Because I think a lot of the time a lot of clinicians go, I'm training emdr, and that's wonderful, but I don't think that a, like a common client would understand the the difference in experience and expertise that would be needed for those different levels of training.
Sure. Yeah. So there's various tra, there's a lot of training institutions out there right now. Back in the day there was just one, the EMDR Institute started by Fran and Shapiro who founded emdr. But now there's many different places to get trained. And what's important is that it's MDR approved. So MDR is the EMDR International Association, and that is a certifying body that has.
Standards of practice and training. And that's also the route that one would go to get certified. So you go to a different training institute and have about 50 hours or so of of basic training that involves. Practicum and lecture and consultation. And then at that point, once one has finished all that, you are officially an EMDR therapist and you can call yourself that and go out and use the EMDR therapy.
And you have that, foundation, you know what you're doing. Certification is that next really important step and I would say as a therapist, it shows that you're really committed to the process of emdr and you wanna really make sure that you really know what you're doing from the inside out.
And so a client seeking a certified therapist just knows that they have that kind of extra level of training. So it means they've had at least 20 more hours of consultation. It means they've Worked with at least 25 clients that they've done, at least 50 reprocessing sessions. But usually by the time one gets certified, they have many more clients and many more hours than that.
But it's just this extra level of oversight and attention to the process and make sure that. Making sure that you're really doing it in fidelity with the model. And then from there, if you're interested, you can go forward into being ANR approved consultant. And then this is a therapist who helps other therapists in their process of certification and While you're working on that, you're called a consultant in training or a C I T, and in this process you're just continuing, like you're expanding your skill now to consulting with other therapists and you're going to consultation for that.
So you're getting consultation of consultation and so it's obviously enhancing the practice even more. I really do believe that saying the best way to the It's the best way to learn something is to teach it. So go. When I started becoming a consultant in training, it just deepened me into the knowledge and practice of EMDR so much more.
And and then once someone has become an approved consultant, it's possible for them to go on to be a trainer. So I'm not on that track just yet, but that would be the highest level as being a trainer in Embr. Wonderful. I think you do a really good job at breaking it down. And so if a client is looking for emdr, what would you suggest?
Like a client's level of expertise that they're looking for, depending on what they're presenting with. So if a client had something happening or their experience like such as dissociation or ptsd, would you recommend a certain level of expertise within that schema? Yeah, that's a great question.
And yes, so emdr Fran and Shapiro says in her EMDR textbook that EMDR therapy is only as effective as a therapist using it. And so it's an EMDR itself doesn't suddenly make one qualified to treat everything. So EMDR can be used to treat a whole range of things, but just because for example EMDR could be effective in working with eating disorders, but if I don't know anything about eating disorders, I shouldn't go applying EMDR to working with eating disorders.
I should know something about that. As a client seeking the therapy, I would make sure that the therapist is, you're not just seeking EMDR therapy, but EMDR therapy and a therapist who also has a lot of experience in that particular thing that you want support. And so am I correctly understanding that you do have a focus and specialty within dissociation?
Yeah, so complex trauma and dissociative disorders is where I see my practice is at right now. So I've been working with complex trauma for the last 10 years, and I've been studying dissociative disorders, like dissociative identity disorder for the past seven or eight years, and I've been treating it for the past couple of years.
Could you maybe just explain like what complex trauma is, what dissociation is, and maybe even give some examples of client presentations? Absolutely. Let's see if I can do this concisely and briefly. I could talk about this for many. Don't for that. Let kind back up. Even with single incident trauma, , we could think of single incident trauma as something that happened.
Let me actually just back up and talk about trauma. So a lot of times people think about trauma, they define it by the stressor. So a trauma is being in war or being sexually assaulted. And those things can often be traumatic, but it's not so much the stressor that makes the trauma, but the way that the stressor.
Impacts how it's held in the brain. So one way that I like to talk about it is there's stressors and then we have our coping capacity. And our coping capacity are all the external factors that can help us cope with something and be resilient as well as all the internal factors. And when something happens to us, if this is my coping capacity here and something happens is stressor happens, it's here, I can, I have the resources to cope with that.
Likely, not necessarily, but likely not going to imprint in a traumatic way and be held in a traumatic way in my brain. But if that stressor is above my coping capacity, there's a greater likelihood that is going to be, I'm not going to know how to integrate and digest that experience on a sort of neurological level, and it just gets stuck and stored in the brain.
So I like to just start by talking about trauma. That way because I think a lot of people do define trauma by the stressor and say Oh, I haven't had that type of stressor, therefore I can't be traumatized. So when we talk about a single incident trauma, we're talking about a standalone event and and that could be.
An environmental thing a natural disaster being in a fire a car accident type of a thing, or an interpersonal assault of some kind, an interpersonal event. When we're talking about complex trauma, now we're talking about something that happens repeatedly. It's chronic. It happens repeatedly over time, and not always, but frequently.
There's multiple Adversities that are happening simultaneously. So these different types of adversities in the chronicity stack up over time. And it was previously believed that really complex trauma could only start in childhood. And often it does. But now we know that of course, complex trauma can even can start in adulthood.
So even sometimes people with secure attachment and good enough childhoods might go through a series. Of adversities in adulthood that can lead to the complex trauma Now one of the sort of hallmarks of complex trauma that, and I'm using complex trauma as a sort of Catch all or umbrella term, and there's different disorders that we could say are the result of complex trauma.
But there's this construct that's coming forward that really identifies the hallmark of what makes the complex trauma. Disorder different than maybe more simple ptsd. And we think of that more simple PTSD as being a more fear-based response. And with the complex trauma, there's this piece that's called these disturbances of self-organization and these disturbances of self-organization have three parts.
And one of those is emotion regulation difficulties. Whether that is being. Overcontrolled and rigid, or feeling very laid and outta control with the emotions or being, alexathymic and not even knowing what's going on emotionally. So there's this emotional dysregulation piece that's one part.
Another part is this sort of disturbance of self concept. So having a negative. Self image and poor self-esteem. And then there's the third part of the, that disturbance of self-organization has to do with interpersonal relationships. So there's challenges in the interpersonal relationships, and that could be chaotic or enmeshed or violent.
Relationships are quite the opposite. A lot of isolation. And difficult being in relationship. And so those, when we're seeing someone who's struggling with emotion regulation and that disturbance of self identity and interpersonal distress, as a therapist, we start to go Oh, I wonder if there's some complex trauma going on here.
Cuz we know that the, that's one of the major ways that complex trauma impacts someone is in those three domains. I'm gonna keep going, but should I pause for a second? Do you have anything you wanna Sure. Ask her. I'll maybe just give some like just branch into some more tangible examples, just because like I'm keeping pace with you and I believe a lot of other clinicians probably are, but I love for the lay person who's just listening to be able to have an idea.
So if you don't. Mine will share a personal example for you. And it's like an example of a single incident trauma. So unfortunately I was in a car accident in the fall, and so because of that incident it was my normal route home. And unfortunately I got hit by a semi, totally fine, very grateful.
But that created a lot of fear-based response symptoms in me. And so with the wonderful knowledge that I have around anxiety and fear-based responses and trauma and mdr, I was like, you know what? I. Like to avoid having that fear based response when I'm driving home every day after work. And so because if there's only one way home and I have to take that road, so even my mind was considering how do I not go that way to get home?
So that would be a symptom of that as well. And so fear based symptoms such as increased heart rate, or whenever I see a semi, I would be like, you know what, I'm gonna go under the speed. Extra so I don't have to drive near that semi. So some avoidant strategies, or I would find that I maybe even get a little bit sweaty possibly.
And so I knew that was something that I personally wanted to process through so I could have a more pleasant experience. And that would be more of like a single incident trauma because of that fear-based response. And through the process of emdr, we can desensitize that experience and we can also see that in a new light.
And so for my, for myself, One of the ways that I, as Fran Shapiro would say, take the train down the track, was I thought, Wow, like what a wonderful experience to have gratitude for life because I'm so cognitive. I'm like, car accidents happen. That was my bit of my blocking belief, like this took totally happen again.
. But for me, my like I said, my personal way of moving through that was having gratitude and appreciation for life and which created that shift in the way that I emotionally felt about that incident. For example, That is a great example. Yeah. That's perfect. That's wonderful.
. And that really exemplifies how. People will experience a single incident trauma with those various fear reactions and the avoidance strategies that you mentioned. And then with com, with complex ptsd. So someone can have complex trauma and it's not necessarily complex ptsd, but complex.
PTSD is that marriage of the classic PTSD that you just described, those PTSD reactions with these disturbances of self-organization? So in addition to having maybe flashbacks and avoidance and these more traditional post traumatic reactions, there's also the difficulty with, negative self concept and interpersonal relationships and emotion regulation.
And I see. I work, as I said, mainly with complex trauma, but it can manifest in so many different ways. I have some clients who experience a lot of adversity as children. For some of them it continues on into adulthood. And though they probably would've met criteria for PTSD when they were children or adolescence, the way.
The the effect, the long term effect of those experiences is changes. It can change how it's being stored in the brain and the body. And for some clients that just becomes this sort of long standing major depressive disorder and coupled with an anxiety disorder of some kind. So a lot of people will come to me without classic PTSD symptoms, but they'll have this longstanding depression or anxiety.
And when you dig a little deeply, you see there's also like the emotion, like the low self esteem and the emotion regulation challenges and interpersonal difficulties. So that can be another way that the complex trauma looks right. Definitely. So could you maybe just give some tangible examples of what those experiences could be like in childhood and then how they could maybe manifest an adulthood?
Absolutely. We often think in terms of both abuse experiences and neglect experiences. I'm gonna talk about attachment in just a moment cuz that's a whole nother thing. I like to think of abuse experiences as something happening to us that really shouldn't have happened to us. It's this additive negative experience that shouldn't happen.
And this can be like physical abuse or sexual. Verbal abuse, psychological abuse, witnessing violence in the home, things like that. Neglect. People often think about physical neglect, but it also encompasses, I would say, emotional and psychological neglect. And so with neglect, these are experiences.
These are things that should have happened to. But didn't, things we should have received like tender loving care but didn't receive. Responsive, attuned caregiving didn't. So those would be more neglect experiences and at least in America, I'm not sure how it is up in Canada, but the majority of the vast majority of reports to Child Protective Services are actually for neglect, not abuse and So neglect is a very big problem, and again, most people think, Oh, this means I didn't have food or I didn't have clothing or shelter, and that can be part of it. But that emotional neglect that not having a safe supportive, attuned, emotionally safe place home that would be the emotional neglect.
And and these things can happen to us over the course of childhood, and when events happen to us, impacts the outcome too. So developmentally, we often talk about the first five years of life. Though a lot of the research is saying now, really the most impactful time for brain development and laying down of the personality and all that is those first two years of life are really impactful.
And a lot of times people like we don't have. Most of us don't have that sort of conscious, explicit memory, but we are still remembering with our implicit memory. So memories are still being held and encoded in our brain and they're experienced as body sensations and emotions. Versus a sort of declarative recall that I remember that I, went and got coffee yesterday morning.
When events happen to us, neglect or abuse experiences happen to us, makes a long term difference and. What's happening in those first five years of life? Children tend to have more dissociative reactions. They're not able, especially the younger you are, you're not so able to run away.
You're not so able to fight like that sympathetic activation that we so often talk about that fight. Flight freeze that's not as available to us when we're a lot younger. We have that dissociative defense that's more available. So that really shutting down, that numbing out, that tuning out so that we see dissociative responses more in younger children.
And and so understanding sort of what happens to someone in different periods, like the zero to five period versus that middle. Childhood age, like six to 12 versus an adolescence. Can have really different, like long term impacts because of what's happening developmentally in the brain.
And this is what's known as developmental trauma. So developmental trauma is when the adversity collides with development. So we're all on a developmental trajectory, especially, for those first 18, 20 years, even though the brain continues to develop beyond there. But the trauma can really derail, develop.
Or just stop it, it can send it in a different direction or stop it in some domains completely. And so people might hear the term developmental trauma. And that's what we mean is that trauma is intersecting with development. And then I wanted to just touch on attachment a little bit.
So this has to do with the relationship between. The the caregiving system and the child and attachment is an innate biological system that's in us that elicits caregiving, it elicits care, and it's there to really. Protect, like for depend, whether it's children or animals, for more dependent beings to be cared for and to seek to have safety come to them.
Basically to have a place that is secure and safe to protect them and Really a secure attachment, which means you're getting like attuned, responsive caregiving enough of the time. A good enough parent. That is one of the biggest buffers against all adversity, having that safe foundation and When there's what's called an insecure attachment, that in and of itself is very traumatic and that you can have an insecure attachment where there's no overt abuse.
There can be, and there can be different things going on with caregivers, like their own mental health issues or substance use issues that or their own trauma from their own childhood. That just makes it difficult for them to really attend and be attuned and responsive. And when there's these misattunements and this insecure attachment, that would be attachment trauma.
And so one could have attachment, trauma and other kinds of trauma and childhood, or one could have a secure attachment, but still experience adversity out in the school system or the community like bullying. So these things can layer on top of each other in different ways. But if there's that secure attachment that is again, like I said, one of the greatest buffers and resources to pull upon internally and externally moving forward.
And secure attachment. It would be fair for me to use the example as a youth or a child feeling as though their parent or guardian is constantly there for them. Not necessarily physically present, but that there's that emotional kind of connection that. If the child would do something wrong, there's still that unconditional love, positive regard not feeling left out, feeling included, feeling hurt, those types of things.
That's exactly right. Yeah. The sense of psychological and physical safety. Just gonna get the parents out there, just like a, an example. So they're like, Am I being insecure? Attention , and there's a lot. Again, we could have a whole podcast series just on attachment, it's such a fascinating and.
Piece, but it's when we're as trauma therapist looking at, working with a client and trying to help them, we're looking at these different pieces. What is the attachment history? Are there disruptions in the attachment relationship? And that might be addressed somewhat differently than bullying experienced in the school system.
Or witnessing community violence. Definitely they all have this effect, but it just comes in different ways. And so I really just wanted to reiterate that wonderful sentence that having a secure safe attachment is one of the main ways to avoid adversity later in life. Yeah. Yeah. And what we're finding is that or what research points us to is that when.
We do experience an adversity in childhood or adulthood, a big determinant on whether or not that experience gets encoded trauma dramatically is how our community responds to it. So if something horrible happens to me and I go and I tell my friends, my family, my teachers, and no one believes. Where people say you were asking for that.
It's far more likely that experience that I had is going to be held dramatically in my brain that I'm gonna have PTSD from that, whereas I could have this. Horrible thing happened to me and I could, go to my family and friends and have them wrap around me. Oh my God, And just give me everything I need to heal, really have my back really support me.
I still might have trauma from the incident. , but it's less likely to occur. Understanding like the cont the systems that we live in, the context that we live in and how our community responds to us is really important on how the adverse, the long term impacts of the adversity on us.
, definitely, and I think that's a really important thing to note, is that not every upsetting or hurtful experience will be stored in the body and the brain. It just depends on like how that's cared for or how it's processed. Yeah. And so that leads us into kind of like that wonderful theory of adaptive information processing AIP behind emdr and how we.
Apply EMDR to these experiences that do get stored dramatically in the body. Yes. Okay. And I also realized I, I didn't go too deeply into dissociation, so I can do that a little bit later. I can do that now. I can talk about aip. Okay, so let me, before we talk about aap, let me just mention a little bit about that.
With dissociation is a word that has many meanings. So I think it can be very confusing cuz I can use the word dis dissociation and you can use the word dissociation. We could be talking about two very different things. I could be talking about a depersonalization experience and you can mean someone shut off from their emotion.
I think just one thing that I just wanna call that out, like it has many meanings, so that can be a little confusing. And some would argue that there's some dissociation in every traumatic event, that there's some pieces. We, if we think about with single incident trauma, for example, The memory being stored in its original with its original state dependent components, you could say that it's fractured.
It's not really integrated. And we could say that is dissociative in that larger sense of that word, that there's this lack of integration. I like to use, I got this from Paul Dell and John O'Neil, who are experts in the world of dissociation. And they talk about three distinct types of dissociation.
And I think that this is really, it's really helpful for me. So one bucket being depersonalization derealization experiences and that depersonalization is where, I am feeling disconnected from myself as a person. It can sometimes be feeling out of my body. Sometimes it can be feeling, I have people describe it as feeling like a robot or an automaton or just like they're floating or they just don't really feel like their body belongs to them.
They can feel. As opposed to feeling outside of oneself, you can feel really pulled back into yourself. There's, for anyone who's seen that movie, Men in Plaque, I guess there's this one alien that sits inside the head of someone who looks like a human and sort of drives things. And I've had people describe that it can feel like that for them.
So this is a depersonalization experience. And then a derealization experience is where. The world around you doesn't feel very real. So it can feel foggy, it can feel again, like a video. Some people will describe it as a video game. It can feel muted. It just doesn't really feel solid.
And people can have depersonalization to realization together or they could be separate. And this can come from trauma. It can come from. Drugs can induce depersonalization derealization experiences. So there can be different sources to depersonalization, derealization and typically with ptsd. When we talk about PTSD with dissociative features, we're talking about a depersonalization derealization effect.
Another distinct bucket of dissociation would be dissociation of mental faculties, and this means that things that we would expect to be connected, like memory and emotion and thoughts and behavior, that they are disconnected. Somatization, for example, what might be an, an example of this or amnesia where I'm not remembering.
Things that I would expect, I might remember. So these pieces that I think should be connected, and sometimes I see this with clients, that they have this whole story, but their emotions are nowhere to be seen. , the emotions are just, they are just not there. So the emotion is really disassociated.
So this is what we'd call this dissociation of mental faculty. So things, I, if something's really integrated, I can tell you this story. I can have feelings about it. I have, a sense of like self and story consistently over time. And my behaviors are in alignment with what I'm thinking.
There's just this whole integration. But again, any of those can be Dissociated to a great degree. And then the third bucket is what's called multiplicity. And this is a whole nother type of dissociation, completely. And this has to do with distinct centers of autonomy and consciousness. In the brain.
And so this is what we see in dissociative identity disorder or other specified dissociative disorder. And someone who has multiplicity is experiencing the other kinds of dissociation. But just because I experience the other kinds of dissociation doesn't mean I have multiplicity. So these are all types of dissociation and all different types of dissociative disorders and going back to what we were saying earlier, the types of trauma at certain ages might really impact, with d I d for example, let's really believe that is laid down in those first six years of life with chronic adversity, without relief, without reprieve and disorganized attachment.
So that's a little bit about dissociation. Anything you want me to clarify about that before I go into adaptive information processes? Sure. I'll just try and summarize some of it. So even within that explanation, it just really highlights the importance of like really great strong history taking assessment and rapport building all within the first few phases of emdr.
But what you're really trying to distinguish is that dissociation, again, is that umbrella term. And under that umbrella, there's all these different experiences. You can have one or you can have many, or you can have one of them and not the other one, basically. And they're all different things.
And there is the commonalities of that distancing of some sort in many ways. So distancing from their own emotions, distancing from the real environment around them, or distancing themselves within their own like soul, metaphorically. Yeah, very well said. And the, and the, what you said made me remember really an important piece here, which is that all forms of dissociation, like you said, it's a distancing thing and dissociation is meant to go hidden from the self and others.
It is, it can be a very subtle experience. And a lot of dissociative experiences happening internally, and so people around you, you're having a lot of dissociative experience. People around you may not notice at all. Very different from if you're having like an intense flashback or panic attack and you're having right, these really observable behaviors with a lot of dissociative experience, people around you aren't noticing at all, and most clients, some of them know they're having it, but a lot don't even know they're having it.
I experience a lot where people just say, The exper, the way their mind works, they say, Isn't this just how everyone's mind works? Like they might be missing huge chunks of time in their day after day, so there isn't any continuity. But because that's their mind and the only mind they've lived in, they might just say isn't this just how everyone experiences time?
Isn't this just how it is for everyone? Doesn't everyone hear other. In their head or have a lot of noise in their head. As clinicians, it's really important to ask about this stuff because it's not the kind of thing that most clients are going to offer up, either because they're not aware that they're even having these symptoms because they're worried you're gonna think that they're crazy if they talk about them.
So oftentimes when I do ask about dissociative symptoms the vast majority of the time clients will say no therapist has ever asked me this stuff before. . For sure. Because it's like you're saying, it's not, it's like unaware of the client. So if I go back to my, even my own personal example, the way that the car accident was happening, I can clearly identify that in that moment of knowing it was going to happen, right?
I can't really remember that moment of impact because I knew that my mind was like, Oh, that's gonna happen. Let's distance myself from that moment of impact because it's going to be upsetting in any shape or form. So that can be like a temporary memory loss. I don't have an image of the impact per se.
Or if with a client, when we're assessing if they're having dissociation, you would ask questions like, Does time seem to go missing or rezoning out? Or you know that example of when you drive home and then you're home and you arrive safely and you can't remember your drive. So we would ask those types of questions to identify and then, Themes of dissociation that are happening.
So what are like maybe some of the main assessments that you use as an MDR consultant that would screen for dissociation in clients? Great question. So my favorite, so there's different ways we can go about this or screening instruments. Like the very common one is something called the dissociative experience is scale of the des and it's pretty easy to do, takes about five minutes or so for the client.
To fill out. And this looks at both norm normal associative experiences like daydreaming or zoning out, when in cases everyone might do that to more severe dissociative experiences. There's also somatoform. Which is basically somatic association screening questionnaire. So a lot of times in the MDR we really recommend at least screening for dissociation so we understand the severity of it.
And then there's assessment. One of my favorite tools for that is something called the mid. The multidimensional inventory of dissociation created by Paul Dell, that is really helpful. And there is something being developed now called the Mid 60. And the MID has a website for all you clinicians out there.
You can go and, get more information on the website. The mid 60 is a screening instrument and there was a recent article in the EMDR Journal of Research and Practice really advocating for use of the mid 60 as a screener over the des. Because it might actually be more accurate. So there's always changes and updates happening in the field about what tools are most effective.
So I'm just starting to explore working with that mid 60 as a screener. And then back in the early nineties, Richard Lowenstein, who's also an expert in the dissociative disorders world created. A mental status exam for dissociation. That's so beautiful and so comprehensive. And it's basically a clinical interview and it outlines all these different kinds of questions, including, like you said, questions about memory and time and As well as looking at more, most, more post traumatic things as well as experience experiencing internal experiences that feel intrusive and disruptive, that might be coming in the form of emotions or memories or body sensations.
And so I love that mental status exam. That's really helpful. So we can Really get it dissociative experiences in different ways simply by asking questions like using the mental status exam and also giving questionnaires. Definitely, and I would like to just take a moment, even when we think of like dissociative identity disorder, I think that there's a lot of misunderstanding of like how that could present in a client.
So do you mind just giving like an example, because I don't know why, but I think there's this image that. If, which was formally called multiple personality disorder, but there's this idea that someone's gonna have this complete shift of being in the way that they are, but that not always is the case.
So maybe could you just give a little example of how maybe that would show up for clients so that we can maybe repel some of the unhelpful stigma around that? Yeah. I'm so glad you asked about that and what you're saying is true. I think there is this Myth or this idea that there's gonna be these really overt, obvious switches, from one personality state to another.
And that rarely is the case. Actually, only about what the research is showing is only about 6% of people with d i d make their switching really overt like that on a regular basis. So usually it's quite. Subtle, and I'll go into some examples of that in just a moment. But I wanna also just spell the myth that it's super rare because there's also this idea that the idea is super rare.
If we look at the dsm Prevalent, which is in America, that it's like our, the Diagnostic and Statistical Manual of Mental Disorders and it lists currently the thinking about all the different types of mental. Concerns one can have. And the prevalence rate for d i D is 1.5% of the general population.
So this is five times higher than schizophrenia, . This is, three times higher than bipolar disorder. It's higher than O C D. So there's all these things that we as a field. Don't really think twice about and are trained to assess for. And then we have d i d which is, it's a higher prevalence rate than most of these things, but the way our current educational system is we don't learn a lot about that generally in our training.
I've mentioned Paul Dell a few times. He created the mid and I appreciate his phenomenological perspective of dissociation cuz I think as a therapist and a client, it's really helpful in what the phenomenon is going to be. And so frequently what a client will experience is intrusions from other parts of self.
So if we think about. The mind in order to protect itself has these different parts with really high walls between them so that you could think of these really high walls and some parts can see over the walls and other parts can't see over the walls and have no idea. There's other parts.
So we're talking about this distancing at the level of the personality, level of the, that the the sort of. Personhood can be in these different pieces. So a lot of times, whichever part is front and center, but there's these other parts of the mind that sort of front and center part will experience intrusions from other parts.
They might hear other parts talking, They. See them internally, they might feel emotions come over them that don't really feel like, Wow, I'm feeling this emotion. It doesn't really feel like mine. Or, I'm doing this behavior and I'm not the one moving my body. It doesn't feel like mine. Or, I'm hearing all this chatter in my head, which is different than anxiety thoughts.
Some people will describe it sometimes as multiple simultaneous storylines. So that can be part of the internal experience and As clinicians, once you start asking about some of those questions, like we won't necessarily notice some of those internal experiences. Although once we get to know a client, we might notice just subtle little shifts when they're attending to that internal experience.
Sometimes a switch from one state to another. Like I was working with a client the other day and the part of her that usually comes into session, sits like this. And then when another part came out, she sat like this and got really tired and the voice changed very subtly.
So it was, It's the kind of thing that if you're not looking for it, it could really go missed. It could really go. But once you know it's there, oh, this part of self hold, really holds itself in a different kind of a way. But again, it's it could not be very obvious. Definitely, and I like really to use like a new, like that percentage of 6% of individual suffering from dissociative identity disorder have that very erratic or obvious change in personality or appearance and personality.
By the way, everyone is just a collection of thoughts and behaviors and emotions. It's. Not necessarily how we sometimes think of col personality, like someone being funny or not. It's just like a collection of those things. And so I think that's really great that we're highlighting that it isn't always super evident and obvious that shift of self and that's how D I D can really present.
Yeah, and it really It really isn't obvious, and I've had parts when I have gotten to know a client system better, I've had parts that will say to me like, Oh, I've been coming out and talking to you for years, but I acted like the other parts so that you wouldn't know I was there. And that's the thing is that.
A lot of times how these systems have stayed sa, how these people have stayed safe, right? And how collectively the internal system has stayed safe is by going unnoticed and unseen. And so being seen, being known, like it can be really scary for parts of self. When a therapist starts to see them and acknowledge them, it could feel really great.
Oh, my presence is being acknowledged, but it can also feel. Scary because the more attention the system draws to itself, potentially the more threat or danger it could, be under. And so as you get to know a client and you do really wonderful history taking an assessment and you're seeing all the different parts and things from now a case conceptualization standpoint through the EMDR lens, what, how would you approach this case if you are able to move forward into the bilateral stages?
Yeah. So big question . I know that's a lot. That's a loaded question. So generally, not Generally. I would say always the more complex, the dissociation, the slower that we go, the slower we move into that trauma processing. And if we think about Conceptually, I like to use that word distancing conceptually.
Part of how the individual survives and gets through the day is for things to be very separate. It's really like we can think about it. It's, it might be hard to function if I know certain things. It might be hard to function if I feel certain things. And EMDR is this amazing integrator.
EMDR can connect two things so quickly, and that is how, if we're looking at a a less associative case how these fragments of a memory can just, like EMDR can just pull it together and move it into this adaptive resolution and reduce the distress. Because EMDR is so powerful, that's.
Why with when we have that more intense, severe dissociation at the level of the personality, we want to be so careful because it would be destabilizing to start to bring those walls down too quickly. And EMDR could do that pretty rapidly. It could just pull a wall down because of what an amazing integrator EMDR is.
So generally, with these more complex dissociative cases, we. It's a while before we get into sort of that more traditional EMDR for traumatic memories. And it might involve working parts of self, might deal with things at different times, and there's a few diff, there's actually a handful of different modifications, EMDR modifications for working with these more complex cases.
And before you ever. Into working with traumatic memory. Generally what we see in these dissociative symptoms is this, these, this internal fear. Some clinicians call it an internal phobia of parts, and so there's some EMDR protocols to just work on reducing the internal fear of having parts, and that would be a first step before we even would go into memory processing.
Definitely. So I'll try and give an example to understand what this could look like. So a client, for example, I've had they had a, unfortunately a sexual abuse experience as a young child. And when they presented for rgr our therapeutic. Time together was quite long. Took a lot of preparation and whatnot, but they were like, I think this in spirits happened, but I'm not, I don't know.
It doesn't really feel real that it happened. And because of the age too as well, like you said, we don't maybe have that implicit memory of an image or like knowing for sure that happened. So that's PE part of it, but there was also that distancing from the. Trauma and the hurt from that experience.
And so part of the way was to integrate it back into their chronological history, to accept that it really did happen prior to desensitizing and reprocessing the experience within itself. Yeah. Beautiful. And we're still using all of the EMDR principles in this idea of Experience that is stored in its original state with Right.
Those distressing images and body sensations and memories. And it is just the degree to which that's true and the degree to which the self. Needs a degree of dissociation for functioning because we always, with all trauma therapies, we wanna keep the client as stable as possible along the whole treatment.
And and so sometimes to maintain that stability, we have to go really slowly and just start to integrate things piece, little piece by little piece. . , definitely. It's like that, very much that titration of kind of pulling everything back together into one collective experience, almost like I analogy I would give.
It's almost watching a movie from start to finish and like seeing the whole movie rather than missing pieces of the movie. It's like pulling it back all together in that chronological time of that movie experience. I love that. I think that's a great way to think about it. And. And using that, people can experience fragmentation of their themselves and their story in different ways.
For some, there might be a sort of consistency until a certain period of time, right? And then it's that was a really hard year and I feel like I don't really, I even, when I think about it, I feel a little disorganized and I, there's pieces. Time that I'm missing from that year. But then consistency picks up again for some people.
They they look at their whole life and they don't know how to put it together and it doesn't make sense to them and they're not sure who they are and there's large pieces of time missing. Yeah, this idea of Are we, have we seen the movie from beginning to end and do we know all the pieces and is this integrated flow of self and story over time?
And with that and a connection of emotion to the story being portrayed and experienced. Exactly. Exactly. Yeah. All those pieces of reality, if our, my thoughts, my behavior, my emotions, my capacity to take in sensory information, that all of that is present and there.
Definitely. Okay. What wonderful information. Was there anything else that you wanted to touch on or clarify from what we have spoken about so far? I don't think so. I'm sure there's probably a.
But hopefully this was helpful. A little taste of some information that could be helpful to some people. And I definitely think so because we're seeing emdr not just for the standard protocol of a single incident trauma, we're really trying to expand on how it works with dissociation.
Because I know that when, even with the first basic training I experienced, they're like, dissociation screen for that. If that's happening, don't go there. And so I think it's good to have an understanding. As a clinician practicing EMDR or client who's experiencing this association of what that looks like and what's going on behind the scenes.
I always say to clients, the more that you understand how EMDR works, the more you're probably gonna align with it. The more effective it is, the more you're gonna enjoy it and see like the magic of this experience that you can hold for yourself. Totally. Along those lines, I. Treated a client who had depersonalization, derealization disorder that was traumatic in origin and very attachment based.
And she did not have multiple internal multiplicity that wasn't part of it. So we still. We made sure we had a lot of grounding skills in place to really help her get as present as possible. So a lot of grounding through the senses and movement based stuff to bring her as present as possible.
And because depersonalization Derealization was a lot of just how she. Lived every day. We wanted to make sure when we would move into trauma processing, that we could get her as present as possible, but in the trauma processing she could tend to tend towards depersonalizing or de realizing very quickly.
So we just always had an eye out for that, Always working to make sure she stayed in that window of tolerance, that she could stay present and so processing would go. More slowly at the beginning and over time, the more and more that we process, the less she de personalized derealized on a regular basis.
And and she could just, her window tolerance grew over time. And, at a certain point in time it was just very much looking like standard processing that we were doing. But we were really attending to that depersonalization de realization in the. Yeah. What a wonderful kind of story to share that there is that opportunity for individuals who are suffering with these sorts of challenges that they can move forward and come together as that one standalone experience, right?
And really get the, those wonderful healing outcome that they deserve to have. Yeah. Yeah. Wonderful. It was so fun talking with you about that. Yeah. I was just like, I'm half big questions, but I know that you can handle them and I really appreciate all the knowledge that you hold and I really think that it's just valuable work that you're doing, so I appreciate that.
Thank you. Thank you so much for having me on.