Can You Ask Your Healthcare Provider To Adapt Their Treatments?

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The short answer is “yes”.

What you request, when you request it, and how you request it are important things to consider if you want to use adaptations successfully to reduce your fear, pain, and risk of being triggered.

Not every treatment can be significantly adapted.  For example, injections still need to be injected.  There are methods that decrease pain, such as cold spray or use of the Buzzy device.  But they usually only diminish the pain of injection, and cannot be used in every type of injection.  If you know an adaptation that has worked for you in the past with a treatment, then ask for it in future treatments.  But be aware that it may not work exactly the same way every time.  Have confidence, but don’t have unfettered hope.

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Some providers are more open to adaptations than others.  And some may have adaptive ideas they come up with in the moment, once you have expressed the desire for them to alter their treatment to help you handle it.  If you don’t get a cooperative or even a curious response from a provider, you may be left to request very simple adaptations.  These include more modest draping, so less of your body is exposed, or asking for a momentary break before an injection or procedure so you can use a stabilization strategy.

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Asking for alternative equipment is best done before the treatment begins.  Providers may need to source out different equipment or reserve a different room. Asking for this on short notice can create stress for the provider, and you will perceive that stress as frustration or annoyance…with you.  No one that has endured childhood abuse handles the experience of feeling they are the source of irritation well in a dental or medical appointment.

Do I have to tell them I have DID to request an adaptation?

Requesting adaptations does not mean that you have to reveal your diagnosis.  You can state that you would be more relaxed or less stressed if adaptations were used.  Most providers are aware that many of their treatments are stressful or painful for their patients.  The decision to reveal your DID diagnosis should be based on the pros and cons for the situation, not knee-jerk reactions to fear or pain.  Don’t fall into the trap of revealing too much information in order to reduce your internal stress.  The other trap is telling nothing to anyone, thinking that sharing anything could lead to disaster.  It isn’t likely to work.

Remember that “now” is not “then”, and you have agency in life.  Every time you request an adaptation and it works, even a small amount, you have concrete proof of your agency in life as an adult.

Want more information on how to adapt common treatments when you have DID?

I wrote a book for you!

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“Staying In The Room” describes many treatment adaptations in detail.  It discusses how to make ER visits, GYN appointments, hospitalizations, and well visits better without compromising care.  These include specific equipment choices and positioning that can reduce discomfort as well as triggering.  Some items can be brought with you to appointments and used there; you will not need to make a request to your provider at all!

Because being able to “stay in the room” is usually complicated for adults with DID, the book teaches readers to use a wide toolkit of strategies.  You will learn how to help fearful or angry parts handle appointments, pick the stabilization techniques that have the most powerful effects on dissociation and switching, and how to speak with providers to get good results.

“Staying In The Room”  is available as an affordable read-only e-book or as a paperback on Amazon .

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How Eating Disorders Affect Interoception and Keep You Trapped in Trauma Responses

Current trauma theories are recognizing the role of disordered eating as misdirected attempts at self-calming intolerable emotion.

I couldn’t be happier.  Seeing disordered eating as a self-calming strategy that has become additive gives trauma survivors and therapists a chance to address these issues with more compassion and effectiveness.

Disordered eating harms the body, and it has some unique “add-ons” in terms of sensory processing problems.

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Disordered eating damages the ability to be connected to your body through interoceptive processing.  This is not a good thing.  If your therapist has asked you to use quiet meditative visualization, and all you can feel is the quart of ice cream you ate 30 minutes ago in your gut….If your therapist has ever told you that you needed to ground yourself and you couldn’t feel your body, or asked you how your sadness or anger felt in your body, and you had no answer to give….

You were most likely experiencing a lack of interoceptive registration or discrimination.

We know a considerable amount about how disordered eating affects interoception.  Here are some of the highlights:

  • Chronic starving decreases the sensation of hunger, and to some degree, thirst.  Anorexics don’t mind.  They generally don’t want to be hungry.  But without those signals, the body and the mind are now less connected via interoception.  This is a loss of sensory registration, and no brain can process information it DOESN’T RECEIVE.
  • When food is consumed, the sensory experience is now very intense in comparison, and awareness of the body is sudden and often unwelcome.  Like a foot that was numb from being sat on for a while, the normal actions of digestion can be incredibly strong.  When the digestive system is deprived, processes get more difficult to tolerate for many sensitive people.  Now interoception is a poorly regulated/modulated sense.
  • Binges increase interceptive awareness.  Filling a stomach or intestine too full too fast will massively increase interoceptive awareness, because the largest number of receptors for interoception are, wait for it, in the tissues of the abdomen.  All that distention and digestion will bring someone in a numb or depersonalized state back into their window of tolerance briefly.  The reason it won’t last is because it will soon become too stimulating.  But at the beginning, it will return them from that ‘checked out” state.
  • So does purging.  The effect of rapidly emptying the stomach or colon is intensely interoceptive in nature.  The strong sensory input will stimulate that vagus response and allow depersonalization and derealization to abate.  But this isn’t a promotion of purging.  It is an explanation of why it is so addictive.  Again, it is rapid and effective way to not feel so numb.  The cost of purging to your body is severe and progressive.  It might be one of the most difficult disordered eating behaviors to let go because of its strong effects on interoception.

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As an occupational therapist, I have been trained in physical treatment methods to increase a client’s interoception that are based in neurology and physiology.  They don’t require clients to talk about their past or their current struggles to use effectively, and clients can be taught how to use them outside of a clinic setting.  For trauma survivors, thoughts and emotions related to the past can come up when sensory processing treatment improves their connection to their body.  Psychotherapy with a skilled trauma therapist will help trauma survivors with disordered eating to take their improved interoceptive skills into their counselor’s session and make progress in healing the past and the present.

For more information on interoception, read Why Interoception Should Matter to Adults With DID  .

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Is Your System Resisting Learning More About How to “Stay In The Room” at Doctor’s Appointments? This Can Help

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My book, “Staying In The Room:  Managing Medical And Dental Care When You Have DID” has been available on Amazon.com since July 2021.  It is already helping some people get the care they need and deserve.

 

But not everybody.

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I have received feedback from a few people (and know this is the tip of an iceberg!) that they eagerly bought the book.  Their system has not allowed them to open it.  And they don’t know how to move forward.

 

No one who works with adults diagnosed with DID should underestimate the fear that can exist around receiving medical and dental treatment.  Nor should they believe that thinking about these appointments is much easier than experiencing them.  

 

To believe that, you would have to forget that people with DID can “know” and “not know” something is true at the same time.  Their ability to be triggered into greater dissociation from a distressing thought or visualization is part of what makes having DID so challenging to treat, but also very difficult to live with.  

 

Parts/alters have opinions and beliefs that are not shared by the entire system, and those can be resistant to change.  Even when the change is positive.  No system forged in trauma is eager to take chances if they perceive greater risks in the unknown.

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So what can potential readers do when they want to build skills, and their fears, or the fears of their system, creates resistance?

  1. Orienting to the present is essential.  Without knowing that “Now” is not “Then”, and “These People” are not, and never will be, “Those People”, it isn’t safe to explore and experiment.  You have to ability to learn how to orient to the present without needing your therapist to guide you every time.  Therapists have many strategies to help adults with DID feel more clearly that they ARE adults, and are seen as adults.  All adults have strengths and status that children do not.  Without feeling like an adult, it can be too difficult to consider assertion and communication with healthcare providers.
  2. Using stabilization techniques before reading, during reading, and after reading information about appointments and procedures.  Again, therapists can teach their clients many different techniques, and they may need some practice before these are familiar and useful.  But they need to be used.  They need to be used even when it doesn’t seem like they are needed.  This is because dissociation is a brain-based emergency strategy.  It happens quickly  fast and can overpower the adult with DID that is unprepared.  
  3. Find out what parts think they need to feel safer, and give them the support they want.  This may include excluding them!  Just as we don’t take children to the gynecologist, some parts do not want or need to be present while reading about appointments.  Learn how to use visualization or imagery to help them not be present.
  4. Pick the right moment(s) to read about things that are difficult to think about.  But don’t assume that you have to wait for it, or it will never come unless you jump in.  Not every free moment is the right one.  Not every day is the right day.  The right time and place could be in a therapy session.  It could be on a day off from work.  There is a strong temptation to either “muscle through” and read, or to put reading off until the perfect time comes along.  Neither are probably going to work well.  
  5. Envision the positive outcome of learning more about handling appointments, not the appointment itself.  Most people with DID are able to use visualization, so the right kind of visualization can be helpful.  Rather than imagining a successful appointment, imagining the scene after the appointment works better.  Imagining feeling healthier, feeling stronger, and recovering from the stress successfully can empower without risking being triggered.  
  6. Work on the easy things first.  If thinking about nightmares is terrifying, work on making your bed more comfortable.  If going to the gynecologist makes you freeze up, try getting a manicure, haircut, or massage and making a request for how you prefer to be touched.  Just so your system can see you do this with confidence and get a positive outcome.  The first step doesn’t have to be off a cliff.  The surprise?  Making a tiny change can resonate throughout your system, be explored in therapy to learn more about yourself, and be refined so that you have a new skill that you can count on when things get rough.

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What Does “Slack” Have To Do With Living With DID?

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The concept of “slack” isn’t new.  It isn’t trending or hot either.  It comes more from behavioral economics than from psychiatry.  But it is a valuable concept for anyone seeking healthcare services if they have DID.

WHY?

Because creating slack in your appointments and in your self-care could prevent you from being triggered, help you recover from triggering much faster, and improve the outcomes of your treatment.

Ready to learn more about slack now?

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“Slack” in behavioral economics would be having some extra money or extra time, held in reserve to allow for the shock of an unexpected expense or a meeting that goes over schedule.  Slack in a healthcare appointment looks different, but has the same purpose.  

Here are some examples of building in some slack for appointments when you have DID:

  • You requested the earliest appointment of the day.  Your provider is not exhausted or rushed because they are running late.  You are not exhausted and running late.
  • You work hard to floss and brush as consistently as you can.  Your efforts shorten the amount of time and the amount of force the dental hygienist needs to scrape the tartar off your teeth.  You get compliments on your efforts from them and from your dentist (feels great!) and you get out of that dental office faster and with less pain, because there was less work needed on your teeth.
  • You requested that your provider write out how to take a new medication, and asked them which symptoms indicate that you have to call the office or come back to see them.  You asked which side effects would mean that you shouldn’t take this medication again.  And you asked them if there was anything you should avoid doing while taking this medication.

There are more ways to create slack for healthcare appointments.  Some of them require effort, and some are the best kind of slack:  “crockpot slack”.

What the @#$% is “crockpot slack”?

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Set-it-and-forget-it.

Doing something once, and letting it reap benefits over time, without having to keep working at it.  

An example of this would be having a great first aid kit at home.  Buy it once, and it should contain a lot of what you would need for small illnesses and injuries that happen over a long period of time.  All sitting there, ready to help you out immediately.  If you know where it is and how to use it, then a sudden accident is less likely to be a trigger for you.  You may still have to go to urgent care or even the ER, but you will have had some tools and something you could do to help yourself.  Your actions could have reduced the amount of pain and fear that are natural for anyone in an accident, but are dissociative triggers for trauma survivors.

Want more information on navigating healthcare when you have DID?

 

I wrote a book for you!

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“Staying In The Room:  Managing Medical And Dental Care When You Have DID” is a practical guide to getting the care you deserve with less fear, pain, and struggle.  Readers understand where their reactions are coming from, why the healthcare system isn’t as responsive as they need it to be, and how to empower themselves in appointments.  There are chapters on how to communicate with providers to get better results, how to use stabilization skills more effectively, and how to request that providers adapt their treatments without altering the quality of their care.

“Staying In The Room” is available as an handy e-book and also as a paperback (you know you love to highlight and write in the margins, right?) on Amazon.com

Why Doesn’t Your Therapist Know How Difficult Healthcare Appointments Are For You?

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Actually, they probably do.
 
But perhaps not all of them do.

Dr. Bethany Brand, a leading trauma researcher, did a study almost 7 years ago.  The TOP DD study looked at what dissociative patients thought about their lives and their psychotherapy treatment, and what psychotherapists treating trauma survivors with dissociative disorders thought about treatment foci, how their patients were dealing with dissociation during the day, and more.

 

You can find Dr. Brand’s comments on her findings on YouTube videos by the APA.  I will give you a super-short summary:  she makes it clear that far too many therapists underestimate how frequently their clients dissociate, they under-appreciate how disruptive it is to their client’s sense of basic safety and ability to function, and that therapists do not spend a huge amount of time focusing on building their client’s stabilization skills to use in daily life.  And these are all therapists strongly committed to working with trauma survivors.

 

This isn’t to say that they aren’t working hard for their clients.  They are.

 

Making inroads into everyday life events like dental and medical appointments might not be on every therapist’s radar.

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I have to be honest.  I won’t throw all therapists under the bus.  I must mention that they aren’t mind readers.  Although some will inquire about their client’s ability to handle self-care and physical care, many expect that their clients will raise these concerns.  And if that doesn’t happen, they move on to the issues brought to them in session, or that they witness in session.

 

It is so important for adults with dissociative disorders to bring up issues that make everyday living difficult in their therapy sessions.  Sometimes trauma survivors haven’t been clear about how impressively fearful, dissociated, or avoidant they are about these appointments.   Or an adult with DID will not realize that their appointment earlier in the day was a HUGE influence on switching, self-harm, or other reactions.  They attribute their reactions to something else that occurred during a rough day.  Some days are just like that.  Some weeks, too!

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If you are a trauma survivor and haven’t shared how stressful healthcare appointments are for you:

Remnants of living in trauma can make it hard to reveal any areas of struggle to another person (and many times even to yourself).  Going to therapy does not mean that it is easy to share the reality of living with a dissociative disorder.  It can be hard to be in relationship with someone willing to see all of you, when you may have been ignored or devalued as a child.  It can feel unsafe to be vulnerable.

 

This is completely understandable.  Growing up unsafe means using any and every strategy you can find to feel a bit safer.  Not revealing the full extent of your struggles to any single person can truly seem like a way to retain control when things feel mostly out of control.  Again, this makes complete sense from the view of someone who grew up under direct threat.  In fact, it is a rather clever plan in the midst of danger.

 

But when that danger no longer exists, it is a barrier to receiving help.

Read Why is it so Hard to Use Many Common Stabilization Strategies in Medical and Dental Appointments?  for more ideas about how to improve appointments by targeted use of  what you have learned in therapy!

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I wrote “Staying In The Room:  Managing Medical and Dental Care When You Have DID” because I know that too many people do not feel safe enough to speak about their fear, avoidance, and increased dissociation when they see a doctor or dentist.

Learning how to build a more effective and comprehensive toolkit can allow adults with DID to get the care they deserve.  And they can start by using some skills they already have.  Skills they might not realize could help them immediately!  

And it doesn’t have to be scary to read the book.  I wrote it in a way that is easy to read, easy to find the sections that you need at the moment, and easier to get helpful ideas without having to read too much about the details of treatments if they trigger you.  I have your back!

My book is available as a paperback (you know you want to underline/highlight/write in the margins!) or an affordable digital download on Amazon  .

 

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Want to Get Better Results at Your Next Medical or Dental Appointment? Don’t Make This Mistake

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No, it isn’t revealing your mental health diagnosis.  Although doing so can go either way to get better treatment.

And no, it isn’t listing every illness or injury you have had in the last 5 years.

When your appointment is wrapping up, please do not ask a “doorknob” question.

What is that?

A “doorknob” question is the one you ask as your provider is about to close the door of the exam room so that you can put your clothes back on.  

Unless the question is “Where is the nearest restroom?”, you have placed the provider in a very awkward situation, one in which any answer you receive will make both of you feel badly.

Providers are fairly stressed these days.  Between pandemic concerns, providers stretched thin, and the mountain of documentation they are expected to complete, this is the WORST TIME to ask a question.  Hands-down, the absolute worst time.

They are often jogging to the next exam room.  They are mentally moving onto the next case.  They may even be thinking that they need the restroom too!

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Trauma survivors often have a really hard time thinking clearly under the stress of medical and dental appointments.  They may find that only after being with a provider for a while do they feel comfortable enough to raise a question.  And if they ask it at the very end, they get a rushed, or a frustrated, or even a visibly irritated provider responding.  That is hard to experience without feeling that your doctor or dentist doesn’t like YOU.

DO NOT DO THIS TO YOURSELF AND YOUR SYSTEM.

No one should place themselves in that bull’s eye.

In my book I try hard to explain how to plan out your actions in an appointment to give yourself the best chance at a successful experience.  I don’t think I was clear enough about not asking “doorknob questions”.  Thus…this post.

Even if your system is not helping you much, please take a moment at home to think about what you want to ask, and use your stabilizing strategies as much as you can.  You could write it down or add it to the notes on your phone.  This will allow you to be able to ask a question sooner, when you will get better results from your provider.  Allow yourself to get used to the space, and get some familiarity if they are new to you.  And of course, if your parts have questions, try to respond to them so that they know you are looking out for everyone inside.  But avoid asking a “doorknob” question at your next appointment.

Want more information on how to make your next appointment better?

 

I wrote a book just for you!

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It is so important to me to share what I know as a healthcare provider.   Care is incredibly important, but not that easy to navigate.  There are chapters in my book that explain why receiving care is exceptionally difficult for trauma survivors.  I don’t stop there.  I am an occupational therapist.  We are focused on function, not theory. I include chapters on how to improve self-care at home, how to handle difficult treatments like surgeries and pelvic/prostate exams, and how targeted practice of your new toolkit in everyday life can help you prepare to handle healthcare appointments with a sense of empowerment!

You can grab a paperback copy (you know you love to highlight/underline/write in the margins!) or a digital download that can be read on any device using their free app if you go to Amazon .

Four Ways To Recognize A Healthcare Provider With Partner Potential

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I am not referring to finding a romantic partner, or a business partner.  A great healthcare provider can be your partner in developing better physical health.

Healing from severe trauma requires a degree of physical health.  For many different reasons, adults with trauma disorders are at a greater risk of health concerns over their lifetime.  Facing any type of illness and injury uses your valuable energy, your time, and some of the attention that could have been used instead to make a better life in the present.  All of us have only so much of these precious commodities every single day.  And even if your system struggles to accept that your body is indeed the body for all of you, it is still the vehicle that all of you inhabit.

A great healthcare provider can be your partner in building (and maintaining) a healthier body that takes you on your journey of healing.

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The more complex your medical or dental issue, the more you need to be able to work in partnership with your doctor or dentist.  Your own ability to be in partnership is important too, but that is a topic for another post.  This post is intended to help trauma survivors spot a provider that has the skills and openness to be in partnership with them.

Because healthcare providers are delivering a service that you need, being as discerning a consumer of healthcare as you can be will improve the results you receive.  When you are gravely injured/ill and in the ER, you might have no choice who ends up treating you.  But if you have options for providers, it helps to know how to identify those with the potential to work in partnership with you.  This is not the same as reviewing their scores from an online forum, or even looking at their clinical affiliations and CV.

To be a great partner in healthcare, a provider doesn’t need to be an expert in understanding structural dissociation or even fully understand more than the basics of trauma.

Really.

Of course, it will be amazing to find that your healthcare provider knows a great deal about DID.  It is rare, but I would never say that could not happen.  It should not be expected, and there are some skills that can largely overcome initial ignorance about DID.  They include (but are not limited to):

  • They need to be good at perceiving and responding to your needs.
  • They should be able to listen to your felt needs and incorporate it into their treatment when possible.
  • They need to be flexible in their clinical thinking and with their treatment approach.
  • They are able to feel and display a degree of compassion, without becoming overwhelmed by your history or your diagnosis (if you decide to share it).

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Here are four suggested methods to identify a healthcare provider with partnership potential:

  1. Listen carefully to the way they speak to you.  Tone, topic, and prosody can tell you a great deal.  A provider that is using a curious rather than a critical tone is likely to see you less as a problem to be solved than as a whole human.  Asking questions about how your illness or your injury is affecting many aspects of your life also shows awareness that you are more than a broken bone or an infection.  Prosody, or the rising and falling emphasis placed on speech, can alert you to their emotional availability.  Many trauma survivors are experts at detecting threat in another person’s speech patterns.  In this case, prosody can signify warmth and openness, or rigidity and doubt.  Listen for it.
  2. Listen EVEN MORE CAREFULLY to how they respond to what YOU say to them. If you are not used to being listened to with compassion, this could be difficult.  You may experience discomfort when you are treated well.  IT might be something you don’t know how to respond to!  That is hard to explain to people who are not trauma survivors, but it is fairly common for adults with DID.  Their attempts to make eye contact with you, to ask questions about your statements, and their body language will all provide valuable information.  Some providers will ask you about what has helped you in the past.  You may not remember if you were co-conscious or switched during past treatments.  You can respond with something you do remember, something as simple as asking them to slightly dim the lights, or be allowed to keep more clothing on during exams.  Your responses do not have to be complex or clinical.  Then listen to how they respond…
  3. Observe their actions, but use as objective a filter as you can generate.  Trauma can cause misinterpretation of another person’s actions.  Silence is an example.  A provider may be silently considering options, but that silence can be interpreted as disinterest.  When providers enter documentation, it can seem as if they are ignoring you.  They may need to enter all of your information because it is complex, and they want to get it in correctly.  Waiting until after patient hours to do documentation is a common way to get things wrong.
  4. Note their actions during their physical treatment of you, particularly when you tell them that a treatment is painful or frightening.  Compassion mixed with open and collaborative exploration of alternatives (if further treatment is needed) indicates a degree of responsiveness and flexibility.

Looking for more information on navigating healthcare?

I wrote a book for you!

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“Staying In The Room:  Managing Medical And Dental Care When you Have DID” is a practical guide to building a stronger toolkit for appointments.  It covers how to use a wide range of stabilization strategies effectively when you are receiving care, why strategic practicing your tools leads to greater success, and how your provider can use simple adaptations to their treatments that could make you feel safer without compromising their ability to do their job!

It is possible to get the care you deserve.  Today.

You can grab the paperback edition or the digital download on… (where else?) Amazon  .

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Two Reasons Why Being Told to “Relax” Isn’t Very Relaxing For Many Trauma Survivors

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For too many trauma survivors, the suggestion to relax has exactly the opposite effect.

Does this mean that they are too stressed to chill?  Nope.

Maybe they don’t like being told what to do?  

No, that’s not it either.  At least, not most of the time.

If neither of those things are true, what are some of the reasons this is such a problem?

  • Being told to relax, particularly in medical and dental appointments, can be traumatic because it can closely resemble statements from abusers.  This can be a huge trigger for a flashback or for switching identities as the adult remembers past abuse.  Even if the person has amnesia for most of their abuse, the human mind after trauma is complex, and trauma is “sticky” to the brain.  Events stay around long after they are over.  Hearing statements that are similar to the statements of an abuser can shake up a trauma survivor who has no conscious recall of those words being said to them as a child.
  • Unfortunately, many adults with DID associate relaxation with being less vigilant.  This can be terrifying.  Being tuned into their surroundings and the actions of people in their home, let alone in their room, is as natural as breathing.  It had to be.  It was a survival strategy.  Because the day-to-day experience of living in an unsafe home is not well-explained in trainings for trauma-informed care, this can be completely lost on providers that absolutely wish to be supportive.  They simply don’t know what they don’t know.

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Chapter 7 of my book is devoted to this topic.  It adds some other reasons that being told to relax can have a paradoxical (med-speak for an epic fail we didn’t expect!) result.  And some strategies to improve care.  Obviously, it would help if healthcare providers would not use phrases that are triggering.  Sometimes saying nothing, or messaging calm by modeling it, works far better.  Taking a slightly deeper breath is helpful for stressed providers, and because of mirror neurons, patients often unconsciously imitate this behavior without a word being said.

Being too calm can be difficult to handle.  Trauma therapists know this, and will help you gradually ease into learning ways to calm your body and mind.  If you have lived your life on edge, feeling intense calmness might be scarier than being hyper vigilant, or even depressed.  It might be a trigger for dissociation or self-harm.  Just like re-feeding anorexics, it is dangerous to put people who live in constant stress into the opposite state without preparing them!

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It is incredibly important for trauma survivors to understand their negative reactions to being told to relax.  And I believe it is important for new providers, both healthcare and psychotherapists, to understand that they themselves have to appreciate the details of the effects of trauma disorders in order to improve care.

“Staying In The Room:  Managing Medical And Dental Care When You Have DID” is available as a paperback and a digital download (readable on any device with their free app!) on Amazon  .

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Sleep And DID: Could Better Sleep Be As Important As Therapy?

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Matthew Walker PhD doesn’t treat adults with DID.  But perhaps he should.  

 

He is a sleep researcher, possibly one of the best in the world, and one with an amazing book that makes it clear that your physical AND mental health, and your sleep quality, are inseparable.  

If you are a science geek like me, you will love the hundreds of research studies he references in his bestselling book, Why We Sleep.  If you are not, you will still be grateful for the list of sleep aides and actionable ideas in his book, and his appreciation for the ways in which worrying about your sleep quality tanks efforts to get better sleep.  He doesn’t live in an ivory tower.  He is a pragmatist.  Dr. Walker understands we all live in the real world, and that there are many things contributing to our choices at any one time.  He wants us to make the healthiest choices we can make without becoming obsessed or discouraged.

 

The best news?  He has stated that increasing the amount of your high-quality sleep, particularly your late-am REM sleep, by only 15 minutes per day, every day, can be transformative for improving physical health.  Your REM sleep is your brain’s  mental health first aid kit.  It turns out that small wins in life can be big wins.  Since the impressive power of small wins is one of the principles of my book Staying In the Room:  Managing Medical And Dental Care When You Have DID, I am now a permanent fangirl of Dr. Walker’s!

 

He has stated in an interview that he is unaware of any mental health diagnosis that is not associated with alterations in sleep.  The list of possible issues in DID that interfere with sleep is long.  I didn’t create a list; there is already a fairly comprehensive list in the book Coping With Trauma-Related Dissociation from Boon, Steele and Van Der Hart. They listed 21 common different sleep issues for people with dissociative disorders.

Twenty-one!

They range from waking too frequently to narcolepsy.  Without question, getting a good night’s sleep when you have DID is very difficult for far too many adults.

 

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Most of the suggested strategies in “Coping With Trauma-Related Dissociation” focus on what doctors call “sleep hygiene”, as well as working with your system to cooperatively plan for sleep, and dealing with the aftermath of nightmares.  Read Three Common Sleep Issues for Trauma Survivors for more information on some of the most troubling sleep symptoms, and why they shouldn’t scare you as much as they do.

  But there are some things I would add to their chapter.  I will probably have to add them to the next edition of my own book.  I am a certified trainer in newborn sleep/calming, and I have been a clinical OTR for a really long time.  I am in the process of being certified as a sleep coach through UC Berkeley.  Here is what I have learned about what helps people of all ages sleep better so far:

 

  • Screen use before bed/when awakening at night might be Dr. Walker’s most intense warning siren.  The effects of the light emitted from a screen has a direct negative impact on the brain’s ability to trigger sleep.  Even your phone’s light has consequences.  Looking at the time on a clock or phone needs to be more strongly discouraged.  The effect of checking the time on anxiety is simply too powerful not to emphasize it more clearly.  Turn the phone screen down to the table, and use lighting that eliminates blue light well before you go to sleep.
  • Nightlights left on all night long are going to harm the brain’s ability to remain asleep, but they can be set to be motion-activated if you need to see better to get to the bathroom without tripping.  A nightlight that emits a warm glow will not have the same altering effect of a bright LED.  
  • White noise is not all the same.  Crashing waves or rain showers sound trendy, but the sudden alterations in volume and frequency can be triggering for people whose brains are sensitive to threat.  High-frequency white noise is altering.  Choosing a sound that mimics the sound of a steady bathroom shower is a better choice.  With high levels of anxiety, beginning with a lower-frequency sound and dialing down into the bathroom shower level can “train” the brain to calm.  Who has such an app? Dr. Harvey Karp’s Happiest Baby on the Block white noise app.  I use it when I train parents of newborns.  Turns out they need some help to sleep too!
  • IMPO, the authors of “Coping” don’t place enough emphasis or detail on the need to orient to the present time right before bed.  Sure, they suggest checking locks on doors and windows if you or parts are concerned about safety, and allowing parts to have stuffed animals if desired, but they don’t address the way adults with DID so often live in “trauma time”.  This means that some aspects of the system do not realize that they are adults living away from abusers, and even that abusers may be too old to harm them, or even dead.  During sleep, parts that live in trauma time can be certain that it is 1999, 1983, even 1963!  They need more reinforcement to orient to the present, and closer to bedtime.
  • Of course, I wish they had made mention of sensory processing strategies that produce a calm state, like the ones I included in my book.  Because many trauma survivors have medical issues that make using weighted blankets or compression garments riskier when asleep, I am partial to the use of Binaural Beat Technology (BBT) prior to sleep for those individuals.  Be aware that Alpha brainwaves are the ones that allow you to quickly fall into a sleep state, and some adults with DID and OSDD become more anxious when in Theta or Delta states.  Underestimating the amount of tension that people with dissociative disorders live with every day was proven by Bethany Brand’s TOP DD study.  We need to clarify what that means for advice on daily living strategies.

Want more information about how to improve your day-to-day health when you have DID?

My book is for you!

 

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Chapter 9 is all about taking better care of yourself at home.  Chapter 3 covers sensory processing treatment strategies that are also stabilization strategies.

Improving your health with preventive care, and being able to manage mild injury and illness at home, means that you have less need of urgent care and hospital ERs!  Being healthier will always give you more bandwidth to allow you to heal from trauma.

My book is available as a paperback and a digital download from (where else?) Amazon  .

Why Interoception Should Matter to Adults With DID

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Interoception.
It sounds like a mis-spelled movie title.  It is not.
Spellcheck will ALWAYS ask you if that is what you really meant to write.

But for people with dissociative disorders, problems with interoception can be a big deal.  A big deal that very few psychotherapists understand at a neurological level (not basic right brain/left brain stuff they picked up in a free webinar), and know how to address in ways that make a difference.

It isn’t all their fault.  Neuroscientists are still trying to work out all the pathways for interoceptive awareness, and the specific ways in which it affects self-perception, health, and movement in human beings.  There IS a lot that is already known about interoception, and some surprisingly simple things that improve this sense.

Yup, interoception is a sensory thing.

It isn’t a psychological mechanism, but it does affect self-regulation.  Interoception is the ability to register and process internal (not surface) sensory input related to physical homeostasis.  Self-regulation requires the ability to attune to the physical state.  At least, attuned enough to know when you have physical needs.  Being in a condition of physical need and not being able to care for the body leaves you unable to self-regulate in the most basic way.  “Somatic tolerance” is what a trauma therapist calls being OK with having a physical body, experiencing it as yours, and being able to tolerate the perception of your body’s signals and connect sensation with emotions.  Greater somatic tolerance leads to being more grounded.

Trigger Warning:  This section can be skipped if you are susceptible to being triggered by discussions of self-harm.  Jump to the next paragraph! When someone with DID or OSDD develops parasympathetic nervous system activation from a trigger, interoception tends to plunge.  Not being able to feel connected to your body, and not be able to change it, can lead to self-harm.  One reason self-harm works so well to bring trauma survivors out of a parasympathetic state is that damaging the body stimulates the internal sensors that send information to the insula, the brain’s home for interoception.  Two problems with this strategy are that the physical cost of self-harm is far too high, and it isn’t a permanent solution.  In fact, like many addictive processes, people find they need to use more severe self-harm to get the same results.  Understanding how to use other sensory processes to enhance interoception is so much more effective and kinder to people who have endured a lifetime’s worth of pain.

Anything that affects self-regulation is going to affect co-regulation, the “Mt. Everest” for a lot of psychotherapists working with trauma survivors.  Co-regulation is responding and connecting socially with other people, and allowing another person’s calm connection help you regulate your emotions and physiology.  Healthy attachment to a caregiver early in life is where co-regulation is first encountered.  Something that adults with DID were not experiencing as children.

As you read posts on this blog, you will learn that occupational therapists think that charity begins at home, and so does regulation.  Nobody has vibrant and easy co-regulation without being able to feel safe in their own bodies. Being able to perceive and manage your internal state is foundational for feeling safe.   This isn’t magic.  It is logic.  And OTs work on helping their clients feel safe and be able to self-regulate by working with their client’s body.  That is the site of the trauma in so many cases, and also the site of feeling truly safe.  The journey to a stable sense of safety starts there.  And feeling safe in their bodies is something that matters a great deal to adults with DID.

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One problem with getting help for interoceptive issues is that it is difficult for professionals without a sensory processing disorder or a dissociative disorder, or who haven’t done training to treat sensory problems, to understand what their clients are experiencing when they have poor interoception.  Some simply cannot imagine what it could be like to live disconnected from the body.

It is such a subtle sense. Essential, but subtle.  Interoceptive registration and processing issues can be confused with digestive issues, ADHD, even autism.  Interoception processing seems to most lay people to be so foundational a skill that they struggle to understand how an adult without brain damage or a diagnosable physical ailment could possibly NOT perceive and process internal physical input.  Not feeling tired.  Not feeling pain when injured.  Not feeling the need to drink for hours on end.  Lack of registration of body signals appears to be almost impossible to imagine.  It can be misinterpreted; a client with a trauma history is simply in denial, refusing to acknowledge their feelings of fatigue, need to eliminate, hunger, or thirst.

Not understanding the complexity of sensory processing often leads to incompletely addressing poor interoception.

Interoception is a physical sense, and OTs know that their clients of all ages can have pathways that are neurologically intact, and can send accurate information that is not processed correctly by the brain.

Limited awareness and ineffective processing can be due to developmental problems, and physical OR psychological trauma.  The mind-body doesn’t necessarily differentiate at a sensory level.

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How do occupational therapists work with a client to develop better interoception?

Well, it depends on their overall sensory processing abilities.  An occupational therapy evaluation includes understanding the wide range of sensory processing skills each person uses to get through their day.  Some sensory systems overlap and make interoception harder.  Knowing more about an individual’s abilities and challenges through an evaluation allows a skilled therapist to design a treatment plan that will work better than issuing a stress ball and a jump rope (this isn’t made-up; I have read this suggested in the literature!).

Treating interoception is usually done by creating a daily “sensory diet” that an individual uses independently.  What is a sensory diet?  Specific activities and targeted tools are used to enhance perception and processing throughout a client’s day.  It is always mindful of aiming to expand the length of a person to remain in a physiologically regulated state, in which a client is not overwhelmed from or deprived of meaningful sensory input.

Adults with dissociative disorders can have a tremendous amount of difficulty tolerating greater sensory awareness from a body that has been the site of past abuse.  While they may appear to be functioning well at work, at home, and in the community, it has to be assumed that trauma survivors are working incredibly hard at times to keep functioning, and are dissociating more often than others may notice.  Their sensory diet has to appreciate that sustaining a high level of function may be fragile.   Care needs to be placed on creating a sensory diet that emphasizes sustained safety throughout the day rather than on advancing multi-sensory processing quickly.

Want to learn more about using sensory processing to build stabilization in medical and dental appointments, and throughout your day?

I wrote a book for you!!

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“Staying In the Room:  Managing Medical And Dental Care When You Have DID” covers practical sensory strategies as part of stabilization skill development.  It also helps trauma survivors build a wide toolkit of skills that they can use to handle receiving physical care.  There are chapters on how to practice skills so they are available under stress, and specific adaptations that providers can use to make well visits, invasive procedures, and even pelvic and prostate exams less challenging.

“Staying In The Room” is available as a paperback (you know you want to underline/highlight/write in the margins!) or as a digital download on Amazon  .