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Our guest is Heather Hall, MD. She shares her experience of treating complex trauma, including differentiating between dissociation and detachment. She also shares about the impact of historical and societal trauma. Trigger warning for case examples and a reference to suicide attempt (but passing reference only, no details or discussion about it).
Diagnosed with Complex Trauma and a Dissociative Disorder, Emma and her system share what they learn along the way about complex trauma, dissociation (CPTSD, OSDD, DID, Dissociative Identity Disorder (Multiple Personality), etc.), and mental health. Educational, supportive, inclusive, and inspiring, System Speak documents her healing journey through the best and worst of life in recovery through insights, conversations, and collaborations.
Over:
Speaker 2:Welcome to the System Speak Podcast, a podcast about Dissociative Identity Disorder. If you are new to the podcast, we recommend starting at the beginning episodes and listen in order to hear our story and what we have learned through this endeavor. Current episodes may be more applicable to longtime listeners and are likely to contain more advanced topics, emotional or other triggering content, and or reference earlier episodes that provide more context to what we are currently learning and experiencing. As always, please care for yourself during and after listening to the podcast. Thank you.
Speaker 2:Our guest today is Heather Hall. Doctor. Hall is a board certified adult psychiatrist. She has over thirty years of experience. She combines her expertise in psychopharmacology and psychotherapy in developing a treatment plan tailored to the needs of each individual.
Speaker 2:Before establishing her private practice, Doctor. Hall was an associate clinical professor of psychiatry at UCSF and UC Davis. She is currently on the board of directors of the International Society for the Study Dissociation, and specializes in treating complex trauma. Doctor. Hall is a graduate of Smith College in Northampton, Massachusetts.
Speaker 2:She completed her medical training at Drexel University in Philadelphia, Pennsylvania, and her psychiatric training at the Institute of Pennsylvania Hospital, also in Philadelphia. Welcome, Doctor.
Speaker 1:Psychiatrist working in The United States living in California. I specialize in treating complex trauma patients.
Speaker 2:How did you start getting involved with treating treating complex trauma?
Speaker 1:When I was in training as a as a resident, I had my first DID patient admitted to the unit that I was working on in Philadelphia, and I happened to Rick Clough was actually working at the hospital, that same hospital, and he offered to supervise me with this patient. And it was was a very eye opening experience. So I learned a lot treating him. And then a couple of years later, when I was in my private practice, one of my patients who had been treating for bipolar disorder suddenly came in saying that calling herself by another name and tell me about this child abuse history. So by the time that happened, I I'd already seen it, and I sort of knew what I was looking at.
Speaker 1:And then throughout the years working as a psychiatrist in community mental health programs and safety net, inpatient units, I just saw so much of it in my psychiatric caseload.
Speaker 2:What did you learn about dissociation dissociation from a cleft while he was supervising you?
Speaker 1:It's been such a long time now that it's hard for me to go into detail about what I what I learned from him. I sort of learned to recognize it up to understand what DID was and to work a little bit between the parts and to realize that one of the main things he taught me was that the part that came in should be the part that leaves. And that was really important advice for me when I started treating my own patients. I didn't really have I didn't know about the ISSTD at that time. And so I I really focused on that as my guiding principle that I would always try to have the part that came in be the same part that left.
Speaker 2:How is that helpful?
Speaker 1:Well, I guess it gave me a bit of a peace of mind that I hadn't done something to alter this person's ability to cope. They came in in one altered state, meaning that they arrived at my office intact, and that that would be seem to me to be the best way to have them leave in the same state. It seemed like a safety issue.
Speaker 2:How do you talk to your patients or people that you work with about DID or dissociation?
Speaker 1:Well, when I when I see a patient who dissociates, I try to get, just an outline of what their trauma history was in childhood. I don't go into detail at that time. And then I I asked them how they coped in childhood with all of this. And, usually, what you'll hear is that they use some sort of fantasy play. They would go off into their head and either pretend to be someone else or to be someplace else.
Speaker 1:Quite often, would have fantasy play with toys, action figures. I had one patient who had a picture of an angel above her her bed, and she would talk about going to Angel's Landing. And as a grown woman woman, she still spent a lot of her day in this place called Angel's Landing. And I tell my patients that when you're a child in a painful environment and you can't escape physically as children can't, then you're forced to escape to escape mentally. And so children always find a way to buffer themselves, to separate themselves from the pain by using their imagination to go someplace else or be someone else.
Speaker 1:And I talked to them a little bit about how I think it's almost like they put themselves in a hypnotic trance in order to do this. And this rings so true with with patients.
Speaker 2:What would clinicians who are just starting to work with people who dissociate or have DID? What would you advise them to look out for or how to recognize that?
Speaker 1:I see it a lot in the the way the the patient presents. Patients who present with memory problems or confusion or even inattention and who also have PTSD symptoms, those are the patients that I look that that I I look for. And what I what I really don't I think many, many people dissociate who don't have DID. So patients most associated sort of patients do not have DID. They have some form of what would be called a detachment or compartmentalization.
Speaker 1:And so I really look for that in their presenting symptoms. And I begin to talk to them about, how they use this wave of detaching or compartmentalizing to cope.
Speaker 2:What is the difference between detachment and dissociation or how is it the same? I feel like that's a really specific word which I appreciate and like actually but but how is that fit in with the terminology of dissociation?
Speaker 1:Well, it's complex because a lot of people well, at least some people feel that the only way you can dissociate is into dissociative alters and that if it's and if it's not dissociative alters, then it's not dissociation. I don't know that I agree with that. As a matter of fact, I know I disagree with that. I I I like a more broader understanding understanding of dissociation. And I think the basic way to understand dissociation is that detachment versus compartmentalization where detachment is like this horizontal split where you split off from your world as a way of protecting yourself, creating a buffer.
Speaker 1:And then compartmentalization is when you take parts of yourself that you won't abide because usually because your your your caregivers force you to disown those parts like your anger or even your fear, and then you split that part of yourself away. That's what I would call compartmentalization. And those seem to me to be the two basic ways that people use association, and many people do both.
Speaker 2:Let me ask. How do you think or what do you think was the impact of 2020 on people who are already struggling with detachment or dissociation when we had the pandemic and we had the protests and we had the politics that were going on? What was the impact of all that external chaos and trauma on people who are already struggling?
Speaker 1:I saw it a lot in my patient population that they sort of deteriorated. They became more anxious. Their symptoms became more acute. And it seemed to me that the biggest factor was that they were once again trapped in their houses. Some were trapped in their in their houses alone because because of the virus.
Speaker 1:Others were trapped in their houses with their extended family. And they began to sort of relive that childhood experience of being stuck in a place with people who are hurting you, and they began to many of them began to have more problems with motivation and energy and memory loss and confusion. And I would talk to them about it. And in some ways, it it it gave us an opportunity to address these problems and to figure out what more effective coping strategies for the stress might be. So I found myself doing a lot of work with, Germer's mindful path to self compassion, talking with people about self compassion as a tool, to cope and to overcome complex trauma because so so because what child abuse does is it destroys your your ability to to to love yourself, actually.
Speaker 1:Actually. You're told that that you're worthless, and so many people buy into that. And it feels to me like self compassion, cultivating self compassion has been, in this past year, a really useful tool for people sort of stuck in painful environments.
Speaker 2:I think that's so powerful. I don't know if I've ever heard it phrased that way about trauma destroying your capacity to to love yourself. Yourself. And I feel like that rings so true as a survivor. It feels like you are made unlovable.
Speaker 2:But I think when you're in the midst of dissociation or detachment that you part of what you're detached from is yourself, right? And so so you don't think about because of trauma, I feel unlovable and so also I am not able to love myself. Like it's almost like you acknowledged the deepest part of the wound so that it can be brought to healing in a way that I had not previously connected.
Speaker 1:Yes. You know, I I think that that lack of self worth part of it, I say to patients that, you know, your childhood, by the time you're four or five, you have to go off to kindergarten, needs to give you three things. One is the the conviction that you're loved unconditionally. The other is that you're living a safe that you live in a safe place because your parents love you unconditionally even though you're the small helpless thing. And they so they create the self world safe world for you to be in.
Speaker 1:And because you're loved unconditionally and because you're in a safe world, you're gonna be able to go out and be successful in it. And so what happens to people when their childhoods don't give them that? Then they really struggle. They they struggle in grade school, and they struggle in college. They struggle in in in their work environments.
Speaker 1:They just struggle for the rest of their lives until unless they can sort of find a therapeutic environment to to to get that sense of self love, that that sense of safety, and that sense of self confidence.
Speaker 2:All of that seems so foreign to me and yet at the same time, I feel like with those three things, you've given a structure, a framework on which I can sort of hold my understanding to it so that it doesn't slip through my fingers, if that makes sense, both for my and both and and both for myself and for what I want to give my own children as as they grow.
Speaker 1:Yes. I've I have found talking with patients like this to be very important. I try to help them understand what's wrong. And then once they understand what's wrong and figure out what happened that went wrong, then they can sort of go back and figure out what kind of changes they wanna make. I help them look at how the past colors the present, how assumptions that they made in childhood about their worth that were wrong, that they never reevaluated, could be reevaluated now.
Speaker 1:And then if you can see in your in your actual day to day life just how those unproblematic assumptions play out, then you can say, oh, this is one of those moments. Can I do something different in this moment than I've always done before?
Speaker 2:What does that look like in the context of historical or generational trauma? I know that you spoke last fall with the ISSTD on the conference for the societal impact of historical and generational trauma with margin communities. Can you tell more about that?
Speaker 1:I'll talk about it first from a patient who's not particularly from a marginalized community and, a man that I've treated for a number of years now, who very early on in our treatment, he sort of told me his earliest memory. And his earliest memory was being a child maybe four or five, watching Frosty the Snowman with his parents and sisters. And Frosty dies at the end of the show, and he begins to tear up over the loss of Frosty, but he cannot let himself cry in front of his parents, cry about frosty at any rate. So he has to throw himself down on the ground to pretend to hit his head, and that then will give him some cover and being able to cry. And this man struggled with his self worth that he was not good enough as a human being, that he struggled with his spirituality.
Speaker 1:He couldn't feel comfortable within his relationship with God because he was just not good enough for God's love. And it took a cup a couple of years into treatment, he came across a clipping about his father's death. And he had kind of his grandfather's death. He kind of knew the story, but but not in such detail where his grandfather had gone to his mother's house, the family home with a gun after a divorce and ended up being, you know, tackled by the male members of the family. He was arrested and jailed, and he was she committed suicide in prison that night.
Speaker 1:And one of the things about my patient was that he was always suicidal, but at least in the beginning, he would say, I'm not suicidal. Some other outside force is gonna come along and and get cause me to jump. And I helped him to see that, yes, that was his feeling. And one of the things he worked with for a long time was him to understand that his mother could not tolerate his normal emotional life and childhood, most likely because what she had experienced in her own childhood with her father. And most likely, her parents didn't allow her a space to talk about how she felt about what happened when with her father.
Speaker 1:So she grew up in a in a in a household where emotion was taboo. And my patient comes along as sort of a intuitive, intelligent, emotional kid, and he gets the brunt of his mother's experience with her own father. And it's been eye opening for him to look at it that way and make sense of why he feels the way he does now.
Speaker 2:It makes it it not only makes meaning of their experience but connects to that original meaning where that experience came from.
Speaker 1:Right. And so now when he finds himself feeling very self critical, he can say, this is this is the self criticism we're talking about in therapy. And it isn't because I really am worthless. It's because I've had these experiences. And can I can I change what I say to myself at a moment like this?
Speaker 1:I feel like
Speaker 2:that is something that I have even just personally in the last year learned on a very small scale where I like I was fighting against, I don't know, I guess in my own therapeutic process recognizing how much of my experience was ignored or dismissed. And so in acknowledging that, I became very sensitive to that being ignored or dismissed in others and sort of found myself fighting or advocating. It it took some time before and practice before it became more finesse. So it was it was more fighting originally. It became more advocating.
Speaker 2:But not just in social justice issues but that even in conversations or with other people who were meaning to do well but but not recognizing the harm that they were doing the way they said things or how they said things or when they would offer a solution instead of being present or different scenarios like that and it taking some time for me to realize that part of what mattered is that my voice mattered and part of what I was learning was that not just my own voice mattered but that people's complicit silence around me had actually been harmful. And so when opportunities to speak up came to me, it was so critical to my healing that I also spoke up for them in healthy and appropriate ways which took practice because no one had ever done that for me. And so in different experiences, have children adopted from foster care and so in experiences with them, with their families, or we were out in a farmer's market and someone spit on my daughter who had brown skin and dealing with that or with a friend who who was gaslighted in just a normal political conversation and not arguing about the differences of opinions but about the way that that was presented and the way it unfolded, the dynamic of it, and being able to stand up for those things was empowering somehow to not my own history but as if small tiny change in the world around me of I have the power to help make the world a safer place by doing these tiny things that make it safer for other people in ways it had not been for myself.
Speaker 1:I think that that one of the things it does is it validates your own sense of your own worth, your own sense of your agency, your own sense of being able to be a a force in your own world. And I think that that is one of the aspects of self worth that are really important to sort of tease out. There's a paper by Robin Dillon from 1999 that talks about basal self worth, which is this basic self sense worth that you get from just from being from your parents loving you. And there are there are other kinds of self worth, such as self worth based on what you achieve or self worth based on which group you belong to. And we try to use those types of self worth to our basal self worth when we don't have it, but it doesn't work.
Speaker 1:So we really have to focus on on the actual, I am a human being, and I am worthy of love as I am. Not because I'm gonna become who someone else wants me to come to become, but I'm gonna be me, and I can be loved as me. And so standing up for other people who's who are suffering like you is one of the ways that Robin Dillon talks about working to overcome overcome this low basal self worth.
Speaker 2:How have you seen clinical practice with dissociation or trauma? How have you seen that change over the years? I think that
Speaker 1:the emergence of of some of the different types of therapies that are somatic therapy and even some of the work that people are are are developing for working with trauma have been very important in like, I was I was just taught psychodynamic psychotherapy, and what I found was that that was not enough. And so going out and learning more about somatic treatments, learning more about things such as SEMDR and begin to incorporate those things into into my practice has helped me be a better therapist for my DID and complex trauma patients.
Speaker 2:How did you find the ISSTD?
Speaker 1:I I think I was doing a Google search one day and came upon it. And that was pretty late. I was like maybe twenty twelve. And I immediately joined. And that was, you know, began an important learning experience for me.
Speaker 2:You've done so much for the ISSTD and I know the podcast isn't about the ISSTD but what are some of the ways that you've been able to or or that other clinicians are able to get involved if they join?
Speaker 1:So there are lots and lots of volunteer opportunities. Myself and a colleague, we have started the public health task force, Michael Sulzer and I. And what we're interested in is how trauma and dissociation plays out, not necessarily in families because families definitely play a huge role in it. But how the social environment, the political environment impacts families and then how that then that impact of the world that the families live in make it more likely that the children are gonna be traumatized. So we're interested in stepping back from the mother child, father child relationship and looking at it at a bigger picture because we both think that we're not gonna be able to treat our way out of complex trauma because it's such an expensive, such an intense treatment that what we have to do is work on ways to to prevent it.
Speaker 1:And so we're we've just written a paper that's gonna be published in 2020, and we're looking to move the ISSTD a little bit away from the from the dyadic relationship and more in sort of the the environmental community relationships such as refugee populations, such as inner city minority populations, maybe even such as rural populations. How societies fail families and how that failure increases the likely the children will suffer complex trauma.
Speaker 2:What does that look like? Can you talk about that some more? Some examples or or or what you're noticing or learning about how society is impacting children and and trauma in people.
Speaker 1:I can. I have a patient whom I'm treating right now who was born in African country, a country that had been under colonial rule until not that long ago. And she'd also had a series of traumatic events and that started when she was intense in her in her country, Tanzania, and then has have continued since she's been here in The United States. And so I met her because she she was referred to me because she had been diagnosed with bipolar disorder and started on antipsychotics and then made a suicide attempt. She was drinking heavily, and then she ended up getting ECP, which then I think it actually helps her, but but it it led to more dissociation.
Speaker 1:So they stopped it, and they sent her to me. And she was in a incredibly bad state when I first met her. And she has three altars, and these are three women. They started out as girls when she was a girl. And she always seen saw them as superior to her, more beautiful than she was, smarter, more talented.
Speaker 1:And she sort of used these authors, I guess, as her way of being in the world in this sort of colonialized environment that she came from. And it's interesting that she saw them as she saw herself as inferior to them and wasn't particularly interested in in trying to figure out a way to live to for her to be in charge rather than than them to be in charge. And then one day, I was having a conversation with the main main alter, and it was clear that this alter also saw herself as superior to my patient. My patient was inferior. My patient was black.
Speaker 1:These ulcers were white. And it was interesting that it was in hearing this conversation between me and her main ulcer realizing that not only did she think the ulcer was superior to her, but the author agreed that she was superior to her because she was white and my patient was black. That was a changing point for her. And she started to work to be the one who was in charge because these ulcers were actually ruining her life. They had no respect for her, so they were causing all kinds of havoc in in her life.
Speaker 1:And she's done so well in such a short time after coming to that realization. That's so powerful. I agree. It's very it's a very interesting patient who's and she talks about something that we don't address that often.
Speaker 2:How can people do better at paying attention to that or hearing that or listening to that or talking about that more often?
Speaker 1:I think the biggest impediment is fear and guilt, not wanting to address it. Not because we we we we were all raised in an environment where we're we're exposed to information that makes prejudice or embrace prejudice against others. And those prejudices gets so deeply embedded in our sense of who we are and who other people are. And we've we've had to justify those for so long that it and it's so deeply embedded. So to to to understand that it's happening means that you have to look at something really painful.
Speaker 1:Look at how you have been part of a system that that oppresses others who are different. And I think that's just too painful for a lot of people.
Speaker 2:It's interesting to me because when it's painful to do the work of that, then the the almost the natural response is to dissociate or detach from it. Yeah. But that eats the wound there instead of addressing it. Right?
Speaker 1:I agree. And so I've been recently reading this book called called Caste by an author, Wilkerson, and it's about the caste system in America, in The United States, And The United States, and what actually how it was developed and what are all the things that went into it. And it is so pain as an African American, it is so painful. I probably will not get to the end of the book because it is way too painful. This is all I sort of knew all of this, but this and but to see it written down and to see the sources and to see the detail of how destructive racism has been in The United States for black people, for Native Americans, and for other races too.
Speaker 1:The rule race plays in dividing and conquering and allowing the wealthy, powerful elite to remain that way and how they use regular ordinary people as tools in that. It's so painful that it's I recommend anyone with a sort of strong stomach to to read the book because you it will be eye open.
Speaker 2:Thank you so much for sharing that. Is there anything else that you wanted to share or that we've not gotten to discuss or address that you wanted to? No.
Speaker 1:I think this has been a pretty in-depth conversation that has covered many of the topics that I feel are important.
Speaker 2:Well, I so appreciate your voice. I we met actually in San Francisco briefly before it was canceled and had dinner. And I I remember getting to sit across from you and thinking I really wanted to talk to you but I have cochlear implants and I couldn't hear in that restaurant setting in the in the wine cellar wall kind of setting. The sound was not good for me hearing. And so I apologize for not getting to speak to you more then.
Speaker 2:But I am excited to have gotten to know you better a little bit since then through the listservs and your your sharing in conferences and being able to talk with you on the podcast. Your voice is so important. The things that you have to share and the podcast and the the perspective that you have with survivors and clinicians and I feel this momentum sort of building behind you of where things really could go and bring healing to the world in a whole new way.
Speaker 1:Well, I'm I'm I'm somewhat hopeful. I think the work is hard and painful, though. So the question will detach me and dissociate and win out. I hope not.
Speaker 2:Thank you so much.
Speaker 1:Thank you. I I appreciate that. I appreciate knowing that. Alright. Thanks a lot.
Speaker 2:Bye. Thank you so much.
Speaker 3:Thank you for listening. Your support of the podcast, the workbooks, and the community means so much to us as we try to create something together that's never been done before, not like this. Connection brings healing, and you can join us on the community at www.systemsspeak.com. We'll see you there.