Today on How We Can Heal Podcast, Lisa Danylchuk talks to Dr. Heather Hall about the different staggering studies that show the factors that affect trauma and dissociation and how some psychiatric practices disserve the treatment of trauma. Should trauma treatment be treated like checking boxes off a list? Dr. Heather helps us understand the ethnic density effect, how neighborhood environments affect dark-skinned immigrants in London, and how support systems can never be overlooked in treating trauma patients.
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How Attachment Works
By definition, Dr. Heather Hall describes attachment as 'the process by which trauma transcends' from one generation to another. For example, on parenting. If one is raised in an abusive and neglective environment, it'd be almost natural for that person to not have any substantial model of how a parent should adequately be to a child. In this type of situation, a disorganized attachment can develop.
If a person experiences this kind of attachment, insecurities can and may most definitely affect their approach to raising children. From being raised in trauma, this person will then be exposed to another phase of trauma wherein they will not be able to function ideally in the face of a child they can't connect with. In effect, the person with this kind of attachment will also expose the child to the same disorganized attachment.
About Dr. Heather Hall:
Dr. Hall is a board-certified adult psychiatrist. She has over thirty years of experience. She combines expertise in psychopharmacology and psychotherapy to develop treatment plans tailored to each patient. Before establishing her private practice, Dr. 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 of Trauma and Dissociation and specializes in treating complex trauma. In addition, she is the co-chair of the ISSTD's Public Health Committee and chair of the Annual Conference Committee. Dr. Hall is a graduate of Smith College in Northampton, MA.
She completed her medical training at Drexel University in Philadelphia, PA, and her psychiatric training at The Institute of Pennsylvania hospital.
Outline of the episode:
- [02:28] What drew Dr. Heather to becoming an MD Psychiatrist?
- [07:14] Some psychiatrists ignore a patient's trauma history
- [12:31] It's hard to be in a system that's not trauma-informed
- [18:02] A good portion of the homeless are trauma survivors
- [24:03] Voter turnout affects psychoses for darker-skinned immigrants in areas in London
- [31:46] With no trauma history, assessing symptoms may turn out like checking boxes off the list
- [37:09] The different factors that can affect a patient-psychiatrist connection and vice versa
- [43:07] From 'what's wrong with you?' to 'what happened to you?'
- [50:53] The importance of close contacts that are educated on how trauma history affects people
- [56:31] Dr. Heather Hall – on checking your patient's coping mechanisms
Resources:
Website: https://www.heatherhallmd.org/
Publications by Dr. Heather Hall:
Hall, H The Role of Discrimination and Social Defeat in Black Mental Health. Attachment, Volume 15, Number 1, June 2021, pp. 88-97(10):
Salter M, Hall H. Reducing Shame, Promoting Dignity: A Model for the Primary Prevention of Complex Post-Traumatic Stress Disorder. Trauma Violence Abuse. 2020 Dec:
https://pubmed.ncbi.nlm.nih.gov/33345743/
Shumway M, Alvidrez J, Leary M, Sherwood D, Woodard E, Lee EK, Hall H, Catalano RA, Dilley JW. Impact of capacity reductions in acute public-sector inpatient psychiatric services. Psychiatr Serv. 2012 Feb 1;63(2):135-41.:
https://pubmed.ncbi.nlm.nih.gov/22302330/
Hall, Heather Review of Buried in the Bitter Waters: The History of Racial Cleansing In America, Psychiatric Services, June 2008, p 700:
Articles Mentioned in Dr. Heather Hall ISSTD Presentation
Cantor-Graae, E., & Selten, J. P. (2005). Schizophrenia and migration: a meta-analysis and review. American Journal of Psychiatry, 162(1), 12-24
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.1.12
Kate, M. A., Hopwood, T., & Jamieson, G. (2020). The prevalence of dissociative disorders and dissociative experiences in college populations: A meta-analysis of 98 studies. Journal of Trauma & Dissociation, 21(1), 16-61.
https://www.tandfonline.com/doi/abs/10.1080/15299732.2019.1647915
Kirkbride, J. B. (2017). Migration and psychosis: our smoking lung?. World Psychiatry, 16(2), 119.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5428174/
Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A systematic review of the prevalence of schizophrenia. PLoS medicine, 2(5), e141.
https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020141
Full Transcript:
Lisa Danylchuk 0:00
Today my guest is Dr. Heather Hall. Dr. Hall is a board-certified adult psychiatrist with over 30 years of experience. She specializes in treating complex trauma and combines her expertise in psychopharmacology and psychotherapy to develop treatment plans tailored to each unique patient. Before establishing her private practice, Dr. Hall was an Associate Clinical Professor of Psychiatry at the University of California, San Francisco, and at UC Davis. She currently serves on the board of directors of the International Society for the Study of trauma and dissociation and is the co-chair of the ISSTD's public health committee. Along with chairing the annual conference committee. Dr. Hall is a graduate of Smith College in Northampton, Massachusetts. She completed her medical training at Drexel University in Philadelphia and her psychiatric training at the Institute of Pennsylvania Hospital. Heather and I have connected over years of serving on the ISSTD board together, I've always been impressed by her commitment to the organization, to clinical work, and to supporting populations that are all too often neglected and underserved. Heather is here to share some of her insights from working with the most complex psychiatric conditions. So you're in for a treat. Let's welcome Heather to the show. Hello, and welcome to the How We Can Heal podcast. My name is Lisa Danylchuk and I created this podcast to share deep conversations that encouraged us to move through life's toughest circumstances. Let's get talking about how we can heal. Alright, welcome, Heather Hall. I'm so happy to have you here on the How We Can Heal podcast. Thank you so much for joining me today.
Dr. Heather Hall 1:39
Thank you for asking me.
Lisa Danylchuk 1:40
Yes. So I'm curious. And I want people to know, I was, we were just at the ISSTD Conference. And you presented some really compelling presentations, and I want to share it with people. I want people to see dissociation, schizophrenia, some of the systemic betrayal, and racism through the lens that you see it. I think it's really compelling. And one of those things kind of like dissociation in my mind, where once you get it, you're kind of like, duh. Once you see it spelled out for you, it makes so much sense. So that was how I felt listening to you speak and I hope folks listening feel similarly. But I wanted to just start with a little bit about you. What made you want to become an MD psychiatrist?
Dr. Heather Hall 2:25
Um, I think it was because I was always sort of drawn to learning about the human body, I was very interested in that and as a child, and it just made sense that I want to be a doctor. And I never thought I wanted to be a psychiatrist, though. But it's interesting that when I was in college, I took this course on Beethoven. And we had to write a paper on some aspect of Beethoven's life. And way, way back then, I chose to write a paper on Beethoven's nephew, who had made a suicide attempt or something like this. So it was fascinating to me how Beethoven's nephew should have done that. Right? And so it's interesting that I was in. So it's interesting. It's, it's interesting that even back then before I even knew what a psychiatrist was, I was kind of interested in those kinds of questions. And so that when I went to med school and was interested in many different aspects of medicine, but then when I did my first rotation in psychiatry, I just felt this incredible affinity for it. I just felt like I understood the patients, so that almost naturally, so it was just an interesting thing. And I just loved it for my very first rotation in it, and decided to be a psychiatrist right there on the spot.
Lisa Danylchuk 3:48
You just had the feeling? Like this is, this is it. There's something interesting happening here.
Dr. Heather Hall 3:52
More interesting, right. Yeah.
Lisa Danylchuk 3:55
And when in that path, did you learn about dissociation?
Dr. Heather Hall 4:00
I was a psychiatric resident. The second year of my training, I had a patient who was admitted to the inpatient unit that was working on who happened to have DID. It was a male patient of all things. And Rick Kluft was an attending at that hospital and read to supervise me with this case.
Lisa Danylchuk 4:23
I did not know that.
Dr. Heather Hall 4:24
Yeah, it was just, that's why I just learned some really basic things about. He had a really short stay, but I just learned a lot about the idea of dissociation. What dissociation was. And it was kind of interesting to me that this patient died actually maybe five or six years later, and he was, and he was found someplace. He was an alcoholic. A lot of bad things were going on with him. And he had my cards still in his wallet.
Lisa Danylchuk 4:53
Oh, wow.
Dr. Heather Hall 4:56
I got a call and, you know, saying that he had deceased and they didn't know where any of his family members were. So I was able to remember which town he was from and give them some information about how they would find his family. But it was just interesting to me that all those years later, he still had my card. It meant that we had made this connection, which was, it was moving in many ways.
Lisa Danylchuk 5:21
Yeah, I bet. I mean, I can imagine that. I mean, I'm projecting a little bit here. But I can imagine someone like feeling really understood for what's going on with that.
Dr. Heather Hall 5:33
It was probably the first time anyone paid attention to his trauma history. What that meant for him.
Lisa Danylchuk 5:40
Right. Wow, that's really powerful. It's really sad and really moving at the same time, right like that. Here you are five years later, in his wallet. Exactly. So is that how you found the ISSTD, then through Kluft?
Dr. Heather Hall 5:56
No, actually, I didn't keep up with Kluft after that. But many, many years later, when I was moved to San Francisco by then. I was working on the inpatient unit, and seeing patients who were clearly in a dissociated state. And just looking for more information about it. Looking to see if there was any support for people treating dissociation. But I came upon the ISSDD. So it was even it was, even later than that, that I actually decided to join, not till 2012. But I was just out in the field, like I was out in the wilderness, trying to figure it out myself, looking for more information.
Lisa Danylchuk 6:44
I hear that from a lot of people in terms of finding that ISSTD and going, "okay, I'm working with trauma, I'm seeing this thing, I'm not really sure how to work with it." You know, I've heard of people trying to refer out and then clients or patients saying, like, "no, I want to work with you." And so they're like, okay, I gotta find this training somewhere. But it's not something that's really made it into, you know, most training programs, whether they're Masters level, or Doctorate or MD programs. It's not something you..
Dr. Heather Hall 7:14
You know most psychiatrists are actually trained to ignore a patient's trauma history. It's just not something to talk to them about. It's actually something to change the subject on when it comes up.
Lisa Danylchuk 7:25
That's really interesting. So it's more about the symptomology, with the symptoms that are showing up, and what medication can respond to those symptoms?
Dr. Heather Hall 7:33
Exactly
Lisa Danylchuk 7:34
So let's like go out of the narrative, and come back to how can I help your body get the medication it needs.
Dr. Heather Hall 7:39
Right, you know, I even had a colleague who once admitted to me that he never gave anyone a diagnosis that he couldn't treat with medication. So if there wasn't a medication to treat it, he never, never considered it in the diagnostic.
Lisa Danylchuk 7:57
That's so interesting. So it just takes out anything where we don't have a medical answer or a prescription answer for?
Dr. Heather Hall 8:07
Yeah
Lisa Danylchuk 8:08
Oh, wow, that there's a lot in that. There's a lot in that in terms of diagnostics, in terms of the field of psychiatry, and, you know, communication between fields. Like how do we, if we don't have a diagnosis for something, well, then what do we do with it? Right. And I think that's, you know, a lot of what I learned from your talk, too, is how trying to filter things into certain diagnoses without that context of the trauma history, which is something that you know, is a big N, in my own mind and world as well, like, if we, if we're not paying attention to that, then we just see these pieces, right? We don't really see the whole picture.
Dr. Heather Hall 8:46
Exactly.
Lisa Danylchuk 8:46
I'm curious because you've helped a lot of people directly that are working with complex trauma, working with dissociation. What are some of the really common symptoms or diagnoses or experiences you see what are the challenges that people come to you with?
Dr. Heather Hall 9:00
Well, you know, it's in my office, it's quite different from the inpatient unit. On the inpatient unit, we saw, I saw a lot of people present with a sort of agitation and sort of like some sort of trance-like state, responding to internal stimuli, being very disorganized. And one of the most striking cases was a woman who came in with very disorganized speech. And as, as I began to talk to her, it seemed to me that she was in a dose dissociative trance. So I kind of gave her permission to tell me her story. And as she told me her story, a significant trauma history, she began to organize, right. And I realized what she was doing, she was speaking in metaphor. And so, as she told her story, she began to organize and became completely lucid, and had this horrific story of childhood trauma. And about spending many, many years sitting on her back porch lost in a fantasy that she was in this place called Angels Landing. Shocked at having had an angel above her bed, as a child, and how she would just start praying to that Angel, and, and she, I think she's even gone to Harvard or something had to drop out because her illness got really bad. And it was interesting because I was working with a resident at the time, and there were other residents on the unit. And so one of the residents brought her attending to interview the patient towards the end, someone who was a skeptic, without a doubt. And again, the patient was totally disorganized. Wow. And for in talking to her, what was really important for her was permission to speak because her main abuser had been her brother, who her parents had put up on a pedestal, and never allowed her to tell them what he was doing to her. So she didn't have permission to speak. And so in my giving her permission to speak, she was able to organize herself. And then just before discharge, when she was very lucid again and ready to go, and her husband came up thanking us for giving his wife back to him. Speaking to this other clinician with who she didn't feel she had permission to speak, she was, again, a total disorganized word,
Lisa Danylchuk 11:51
That speaks so many volumes, even with what you just said, of psychiatrists being trained to divert from the narrative, and how powerful it was for this, how self-organizing it was for this person to have that permission to speak. And, and I'd imagine, this isn't the only person who's had experiences like that, where there's the silencing, and, you know, not a safe space to just kind of let it flow through and express and have someone witness that and have someone believe and support it, or even just be there.
Dr. Heather Hall 12:31
So I saw a lot of that on the inpatient unit, people who would get better. And then I would be trying to talk to their outpatient team about the fact that they were trauma survivors. And it was so frustrating because no one ever took that, that seriously, and so they would come back over and over again, you know, and, and it was really tragic. That was very painful.
Lisa Danylchuk 12:59
It can be hard to be in a system that's not trauma-informed or not trauma aware, and to be aware, and to see all these impacts, and to not necessarily be in a position to change that systemically, right? To say, hey, can we, you know, make this care a little.
Dr. Heather Hall 13:17
Even just one on one, even just with one? What we know, a really, really, um, I had so many those experiences. And I did feel that in many cases, just the one experience of being listened to made enough of a difference. So they could go out in a new way. Yeah.
Lisa Danylchuk 13:43
Yeah. It makes me think just about your recent talk and how you are outlining how many people are diagnosed with schizophrenia and psychosis. They're actually experiencing reactions, probably common reactions to trauma and dissociation. Can you talk a little bit more about what you've seen there? And how maybe in your mind, you would differentiate, oh, this person is presenting more with schizophrenia, this person's presenting more with dissociative symptoms?
Dr. Heather Hall 14:15
Well, I actually feel that you almost can't know at the beginning, right? Yeah. And so you meet so on the inpatient unit. It was sort of allowing them their story to unfold. Because that's what I found once you gave them the permission to tell their story. They would tell their story, and you would see them organize around it. So these were very, very disorganized people and very, very chaotic situations. Very, very acutely ill. To see them get better in like a couple of weeks. You'd be astounded at how they could organize around telling your story. And when you're working with outpatients, it's usually people who are not as sick, right? So you don't do that level of pathology in the outpatient setting. What I see as an outpatient psychiatrist, more often than people with a diagnosis of schizophrenia, what I see is people with the diagnosis of bipolar disorder who have a lot of rage. And psychiatrists very often see rage as mania. And they can't see it as anything other than mania. So the diagnosis of mania, I have so many patients who have bipolar disorder, who, and it takes a while to tease these symptoms out, right? Sometimes it takes years, I never tell them that they don't have bipolar disorder, or that they shouldn't take their meds, I just start talking to them about the story. And it's not uncommon to find over time, sometimes over years, you get the sense that there's dissociation and there's trauma in this, whether it takes a while for it all to come together.
Lisa Danylchuk 16:16
And that's been my experience working with clients individually too is that it takes a long time for these things to come together. And sometimes it takes a long time to tell different parts of the story or different aspects, whether that's that they're available in memory are that they just, quote-unquote, don't feel important in the moment. And then, at some point, later on, there's, you know, a level of trust or vulnerability or a level of they become more central, and sort of naturally integrate. I'm curious, about the inpatient work. Did you ever see the storytelling or the narrative? Did that ever? Did you ever see that be too triggering for people? I'm kind of thinking about EMDR. And when people go into processing, and sometimes it impacts too much? Did that happen? Or did it just seem to be more that you were such a need?
Dr. Heather Hall 17:03
These were people who were already disorganized, right? Already completely, they'd already fallen apart,
Lisa Danylchuk 17:12
It was all unpacked already.
Dr. Heather Hall 17:14
Right. Cause they had already broken them down. Right. And so um, so you might think that asking them about their trauma history might make things worse, but not with that particular population. Yeah, I worked without patients, I worked for a while an outpatient homeless facility where they did case management, and housing case management for the homeless. And that was a population that was very sort of put together in this way of being homeless, right. And so they took up in the be one of the reasons I went to work for with that population was because I had to stop for my impatient work that a good portion of the homeless were actually trauma survivors. And I thought it might be 40, 50%, or something. I worked with that population for several years. And by the end of my time working with them, I came to believe it was probably 90%. And people who wouldn't report a trauma history, when you first knew them, as they began to trust, you would begin to acknowledge it. And I didn't see myself as doing trauma work with them, really, because that just really wasn't possible and a situation where they were so unsafe, and had so few supports, really. Um, so it was another frustrating time where you had these really sick patients who really needed a lot, but they were just not in the position to be able to provide that for them. Although, I did manage to put together a group therapy with a small handful of them, who were at the place where they could sort of talk a little bit with each other and process the meaning mainly, of the trauma, not the specific details of the trauma, but how they can come to terms with what it means about who they are, and, and what is their self worth and in the context of what's happened to them. And can they pull a sense of worth for themselves to be able to create a life for themselves? That's the kind of work I tended to do with those patients, but many of them were quite fragile, to tell you the truth.
Lisa Danylchuk 19:45
Yeah. Yeah. And you go in thinking, Oh, 40, 50% trauma history, and then you go maybe 90 plus. I had that experience in working in juvenile halls to where you know, if you look at the case files, oh, there's maybe 60% reported history of sexual abuse, and then you start working and you're like, maybe it's 70, maybe 80, maybe let's just assume it's 100 just to be safe so that we're not.
Dr. Heather Hall 20:14
In really bad situations, where this person didn't have a chance from the start, right? Look at the situation to which they were born. There was just no escaping it, knowing that they were going to escape.
Lisa Danylchuk 20:31
Yeah, and that's, that's something big to be up against, you know, as one clinician coming in, and it sounds like what you could do in that circumstance was to tap into that sense of worth, right, like, Okay, well, let's connect. Okay, maybe there were these things that happened, but what about how you think and feel about yourself? And where's the sense of self-worth? And can we connect and maybe create some narrative around that.
Dr. Heather Hall 20:54
Because that's what I find myself talking about with patients more than anything else. How a history of childhood trauma leaves them feeling as if they don't have worth. The message they get from the way they're treated is that they don't have any worth whatsoever. And so how can we help them build a sense of that worth. They've never had a relationship with anybody who's made them feel like they have worth and so quite often, that becomes the therapeutic relationship.
Lisa Danylchuk 21:26
Yep. And a lot of what you're speaking to, I can think of, you know, and I think we're gonna go there in a moment in a larger systemic sense too, where if you're brought up in a culture that's not valuing any group that you're a part of, or any way that you identify or present. Well, then how does that pass down this message of, I'm not worthy, or I'm less than or what, however, those words show up some kind of feeling, I think of disempowerment or something along those lines. Right.
Dr. Heather Hall 21:55
So so, you know, my work with the inpatients got me trying to understand how there could be a relationship between the severe symptoms of psychosis that I've seen, that seem to be trauma-related. And, and I was working at that time at San Francisco General Hospital, which had cultural focused units. So at that time, I was on the black focus unit. And the black folk focusing unit was sort of interested in black and African American and black issues. But it certainly wasn't a unit that was just black patients. It was all patients of all kinds. And all the units were like that. But I just began to think, how is it that all these black patients coming onto the unit with such symptoms of psychosis? What am I seeing? And that's when I came upon a paper out of London, where they, they actually said he found this incredibly elevated rate of quote-unquote, schizophrenia, the poor immigrant populations around London. And to my amazement, they found that, that the darker your skin, the more likely you were to be psychotic. And that dark-skinned immigrants from places like the Caribbean have had 10 times the rate of schizophrenia than white native-born Londoners. And that was just mind-boggling to me. I'm like, How could that be? Right? So I started to research. And so the interesting thing about the papers is they came to the conclusion that it was not genetic, that it had something to do with the neighborhood environment. And this particular paper looked at social capital and they used voter turnout to be a proxy for social capital, and found that the best predictor of psychosis in these London neighborhoods was vote was voter turnout. We'll lower the voter turnout. We'll lower the social capital in the neighborhood, the more likely the darker-skinned immigrants were to be psychotic. Wow. And they found things like, if you live in a neighborhood where there are fewer people like you, you are more or less likely to be psychotic. You call that the Ethnic Density Effect. The less-dense your people were in your neighborhood, the more likely you were to be psychotic, right. And, and all kinds of information like this really pointed to the fact that it was the social conditions in the neighborhoods that were driving the rate of schizophrenia, rather than some sort of genetic loading. And they found that when those immigrant groups, there was no increase, for instance, in the rates of psychosis in their native countries. And they also found that when they immigrated to countries that were not dominated by a white power structure, they also had no elevated rates of testing. Right. And they didn't just find this in London, they are finding this in all over the world in the United States and other parts of Europe, there will be just an avalanche of studies looking at immigration, and they would call it a Social Defeat. Yeah. And psychosis.
Lisa Danylchuk 25:55
Yeah. And I want to pull one or more of those studies and put them in the show notes because I pulled them from your presentation. Dissociative disorders are 10 times more prevalent in the general population, so 11.4?
Dr. Heather Hall 26:15
Then schizophrenia
Lisa Danylchuk 26:16
And schizophrenia. And then in some dark-skinned minority populations, it was 10 times the rate, then schizophrenia as compared to white populations. So that really speaks, speaks volumes. And then and then what you just said to that the rates of schizophrenia actually increase as the person skin.
Dr. Heather Hall 26:42
Right. And you can say, Oh, is there some sort of genetic loading for dark skin. And I actually went on, that's what I learned, I learned schizophrenia was a genetic illness. And that. And, for instance, the fact that more black people were diagnosed with schizophrenia, for a lot of people just meant that more black people were genetically predisposed to schizophrenia. A lot of the colleagues particularly on the black focus unit, and I was working with, the idea was that maybe it was some sort of missed diagnosis based on racial bias that was causing it. And as I began to look at this new data, I began to think that the reason this disparity existed was because of the high rates of discrimination and social defeat in dark skin populations that were being, and because psychiatrists had no, pay no attention to trauma, or dissociation. They're just completely missing it. And seeing those, those that deal with disorganization, those responding to internal stimuli, they're seeing that as equal to schizophrenia, and saying these people all have schizophrenia without even really thinking beyond because they had no they would not include any dissociative disorders in the differential diagnosis.
Lisa Danylchuk 28:11
So if we're talking about differential diagnosis, or even someone listening, that's not a mental health clinician, that's like trying to help a family member or a friend or something. How do you see it? What are some of the symptoms you see show up that initially look like schizophrenia, but then when you go a layer deeper, actually relate to trauma? And can you kind of make that connection for us?
Dr. Heather Hall 28:35
Well, they may be hearing voices, right. And quite often, these patients will be hearing voices, and a variety of different kinds of voices and maybe an overwhelming number of voices in their head, that many times they will deny hearing because I've had patients say, I thought everybody heard voices, right? So that they or they'll be fearful of being diagnosed as crazy, quote, unquote. So they'll deny it, so many patients will deny it. So you might see some behavior that looks bizarre to you. And, and, and they might be disorganized. But I would say the number one symptom is hearing voices. But I also see people who develop what seems like a delusional system. Like this lady who, you know, in her mind, she was in this place called Angel's Landing, where they spent all day scanning the globe looking for people who were in distress and saving them, right. That was she spent her day doing. I had another patient who came in after the suicide of his father, believing that he was in a he was the center. He was like in a Truman Show type of thing where everyone was watching it? And, you know, he talked about this initially being a fantasy that he would indulge in because it was, it was sort of comforting to be the center of attention like that in his mind. And he talks about in childhood, how he used to lie in the grass, and pretend that he was just one of the many blades of grass. And that was comforting. So we sort of went from this fantasy place where he was one of many blades of grass to being the center, the center from one of many to the, to the center. And then in the aftermath of his father's suicide, it took on a kind of a sinister rule where people were, where it wasn't, it was now a frightening thing for him. And when you ask him, well, what is the frightening thing? And he says, Well, they're all trying to give me a message right there on sending you this message. And what is the message that they're sending him? That he shouldn't eat sugar. And why shouldn't he eat sugar? He shouldn't eat sugar, because he'll get diabetes like his father. And again, he was someone who, um, it just went away. Right? He's concerned that he was in The Truman Show, he was the center of attention just sort of evaporated as he talked about his life. And he and his father had had a disagreement just before his father's death. And so I mean, it was just clear how. And you know, this whole idea of this, and they call it Maladaptive Daydreaming. Yeah. Because I do think that Maladaptive Daydreaming as a dissociative spectrum issue, can itself morph into what seems like a delusional system.
Lisa Danylchuk 32:06
And so a psychiatrist who's told don't listen to the trauma history is just going to hear oh, you're hearing voices. Checkbox. Oh, sounds like you're delusional. Check. And so I can see how it'd be really easy for someone who's presenting with some kind of dissociative experience, even if it's not, I mean, it could be DID or
Dr. Heather Hall 32:28
It could be like just Dissociative Disorder NOS.
Lisa Danylchuk 32:32
It could be not otherwise specified. It could be specified DID. It could be some dissociative experience. And then it just shows up in this way, where if you don't have that context of complex trauma and dissociation, and you just hear the symptoms, and you're just looking at these diagnoses, you go, oh, check, check, check.
Dr. Heather Hall 32:54
Because they say, you know, there's evidence that people with DID have more first-rank symptoms, which are considered symptoms of psychosis, and people with schizophrenia, by far by maybe, maybe the averages of two or three with people with schizophrenia, you might be five or six people with dissociative identity disorder.
Lisa Danylchuk 33:24
So that's a really important differential diagnosis. And I know, some of the folks listening or in the mental health world are in a place where they can say, okay, let's really look at this in our, you know, our intakes are for our community-based services or for the clinic or for the hospital. Let's start to look at this a little bit more. And I think, you know, education on dissociation, like we were saying earlier, is lacking in a lot of places. So, do you have, is there anywhere I remember seeing maybe it was at another conference? I don't remember where or when, but I remember seeing some plenary talking about this, at some point, just differentiating dissociation and psychosis,
Dr. Heather Hall 34:04
There's an explosion in the literature. In the past few years, when I was in San Francisco, general-raised people say, you know, five or 10 years from now, no one is going to be disputing this fact. Because I was beginning to see these studies coming out in the literature. And now there's been this huge explosion of studies looking at this issue. And so I mean, I think this is like the thing that swelling up from the ground becoming obvious to everybody that there's a definite link between childhood trauma, childhood sexual abuse, and particularly neglect where the child has no one to go to. And dissociative symptoms. Well and psychosis, right. My theory is that it is the dissociative spectrum illness that is the thing that mediates the symptoms that appear to be schizophrenia.
Lisa Danylchuk 35:10
Have you worked with anyone where you feel like maybe it's not disclosed or you don't find out about it, where it just feels different, like, oh, this feels like a different presentation of psychosis or schizophrenia? Where, like, these feel very dissociative, but these feel different somehow, like, there might be some other pathway?
Dr. Heather Hall 35:27
I do think and I wouldn't. What I would see a lot is a type of a schizoid person who, rather than actually having a wealth of emotions, seems to actually be the void of emotions, a void of the desire to connect, when you talk to them, there's a kind of an emptiness. And the emptiness is different from a trance state, not a trance state type emptiness, but a qualitatively different kind of not there. Not interested in, I guess, the sort of schizoid personality that they talked about. It's hard to describe it exactly. But you can easily see a person who's in a dissociative trance state to be in that state. But if you understand what a dissociative trance is, then they actually do look quite different.
Lisa Danylchuk 36:32
Yeah. And it sounds like it's that qualitative, it feels different too. Being in the presence of it, you're like this. There's another flavor happening here.
Dr. Heather Hall 36:41
If the person is very foreign to you, if there's someone who you don't connect with their skin color, their nationality, their sexual orientation, their religious background is very different from yours, then you don't reach out to them in the way that you would someone who's familiar. And you can pick up on that qualitative difference.
Lisa Danylchuk 37:08
So that's another way. I mean, when you talk about structural racism and social defeat, and you look at, you know, who has more access to education here in the States, or maybe probably in the UK, in many places in the world, or, you know, if someone's looking for psychological support, or treatment, or even an inpatient setting, like, are they going to get someone who already feels connected to them based on these, you know, those factors that you just went through these and factors of identity or culture or skin color or assumption, like, is there going to be that sense, like, oh, as a, as a provider, I feel like I get this person? Whereas a patient, I feel like this person gets me.
Dr. Heather Hall 37:52
I have empathy for this person, here's a person whose schizophrenia is a really bad diagnosis, and I would really prefer this person not to have schizophrenia. So I'm gonna withhold that diagnosis until I get to know them a little better. Other than that, I don't understand this person at all, and they're scary to me. Right? I'm sure this person has schizophrenia, and I don't have the same need to give them the benefit of the doubt, and to rule out everything else, before I just end there, you know.
Lisa Danylchuk 38:29
So that's where implicit bias comes in. That's where, you know, assumption and just sort of lack of, I don't know, cross-cultural connection or lack of, you know, whatever, you know, I'm thinking even when I picture as I've generally been in there a few times with different clients and things. And there's also like the potential for socio-economic kind of.
Dr. Heather Hall 38:55
Right, the poverty-stricken very often, they're homeless. Also, because San Francisco has this huge immigrant population. They might not even speak the language. They come from totally different cultures. So all of these things play, playing a role in someone who's just different. So if they're too different, you have difficulty having empathy. Unless you decided that what you want to be is empathic to people who are different, right? You almost have to decide that you're going to do that.
Lisa Danylchuk 39:36
It's so interesting because what you're describing is making me think too of you know when I used to work in a wraparound school for kids right after they were getting off probation, so they were juveniles. They had been incarcerated. They were kind of going back out and into a wraparound therapeutic school. And I remember there were all these adults there and we would always just say, like, whoever has a connection with this person roll with it, like we've got the psychiatrist. We've got the counselors, we got the youth support, the enrichment, the activities, the parenting specialists, we've got all these people, we've got the substance abuse counselors, all these people in the building the probation officers, and we're all as adults just trying to be like, Oh, they're talking to you great, for whatever reason, and I feel like some of those connections, they would hear you like playing a song while you were driving up to work. And they liked that song. And so, you know, the kid would just say, hey, and start talking to you and start opening up, it could be this, like, seemingly random connection, but there just had to be, we didn't even always know what it was. But there would be something like, oh, you always have the type of gum that I like to choose. So I'm going to come to your office and ask her for a stick of gum, or, you know, your last name is the same as my cousin's. And so it could be almost anything you really like, I don't really like the shirt to wear. But once there was like, this little thread, and thinking of that, in this, you know, picturing someone in the hospital, you know, sort of interviewing someone trying to get a diagnosis going, it's like, any little connection like, oh, you liked The X Files, I liked The X Files, whatever it is. That then sort of shifts things. Right.
Dr. Heather Hall 41:12
Right. But the connection could be, I'm interested in hearing what you have to say, rather than I have this checklist of questions that I'm wanting you to answer. And I'm not really I don't have time for you to say more than that. So please don't go on. Just enter these questions. And then I assess you based on how you answer questions on my timeframe.
Lisa Danylchuk 41:38
So that brings up a word that I think circles around again, again, just curiosity like this, this curiosity of like, who are you and tell? Tell me about yourself. And it's so powerful to hear you tell the stories of how self-organizing it was for people who are showing up with these really, you know, severe behaviors and presentations, and maybe even seeming scary to some people, I don't know exactly how they're ending up in the hospital.
Dr. Heather Hall 42:05
It's usually because they're acting out, right? They get brought in on a 5150. Because someone, either the family member, or the police, or someone who has them as being strange, or scary, or crazy, or any number of things.
Lisa Danylchuk 42:22
They called out some attention, right? And so but then if you kind of get curious about that, like, what's going on here? And who are you and tell me about yourself, or keep talking with whatever's on your mind? I mean, I can even think in, you know, walking around, sometimes I've walked by people. I'm assuming them to be homeless, who are just talking about something, you know, and there's no one really there directly listening. But I have the immediate thought, like, who are you saying that to, in your mind? And what happened to you? And what are you what memory are you responding to in this moment? Right. And I think if, and that's, you know, someone who's the daughter of a trauma therapist, and has had a lot of trauma training. So it's like, I think if we come with that.
Dr. Heather Hall 43:07
You know, I think one of the most important when people say, what's trauma-informed care? And I think the most important aspect of trauma-informed care, is instead of asking what's wrong with you, it asked what's happened to you? Right? And that's a hugely different way of approaching diagnosis.
Lisa Danylchuk 43:26
Absolutely. You know, if we ask what happened, and we can even add on to that, like, what's right about this? How does this fit? Like, even dissociation, it's keeping you alive? You know what I mean? There's something right about that. There's some strength in that as well.
Dr. Heather Hall 43:42
The more I think about people, let's say you come from a terrible childhood and you run away from home. And you dissociate. The streets, okay, for you, because you can dissociate and go live under a bridge. And then you're in this dissociative role then you can tolerate it. You can stay there for years.
Lisa Danylchuk 44:04
Yeah. So how does attachment connect to all of this? We talked a little bit about that in your presentation.
Dr. Heather Hall 44:14
I think that the way attachment. Attachment almost becomes the process by which trauma is trends, goes across the generations is transgenerational because if you are raised in abuse and neglect, right, then you have no idea how to parent. And parenting is overwhelming. So then you have an insecure disorganized attachment. And then you're going out into this world that's traumatizing you further, and then you have a child that you have no idea how to connect with. So then now you're starting a second generation with an insecure, disorganized attachment that is going to then go out into the world themselves, and experience all different kinds of social defeat based on discrimination based on what their circumstances are, right. And then it'll just go on to the next generation. So it is this attachment disruption, that makes it so that a person cannot parent. Right? And then that's how it gets transmitted to the next generation and the next generation.
Lisa Danylchuk 45:46
And it's not just, you know, verbal, physical, emotional, sexual abuse, it's also neglect,
Dr. Heather Hall 45:54
Neglect is a huge part of it. Because if you are not neglected, then you don't need to rely on your innate sense of dissociation to cope in childhood. It is that child who's being abused, and then there's no one there to help them that then is forced to rely on whatever innate dissociative abilities they have, as a way to cope. Many people will say, well, why isn't everybody who gets abused have dissociative get a dissociative disorder? Because just being abused is not enough. It's being it's the abuse in the context of neglect.
Lisa Danylchuk 46:43
Yeah, and not having those social supports. Not having, you know, a parent who has learned how to parent or has had that experience, being able to pass that down or not having a parent who's, you know, having a parent who's not present for economic reasons, or whatever other things, right? Just the absence has as much of an impact as the presence of these other right negative things. So I'm curious then if people maybe in the hospital setting or maybe this is more so related to your, your private practice now, but how does it show up? Like, what are people what kind of healing are people asking for or looking for when they come and find you?
Dr. Heather Hall 47:25
So often, people want a psychiatrist who will listen to them right? Not just rushed to the prescription. Because I get a lot of patients who've been cheated with every single medication under the sun over the past 10 years, right. And they knew better. And the psychiatrists who were treating them said, literally, I don't know what to offer you anymore. I don't know what to do for you, and they start looking for someone else. Or maybe the psychiatrist gets, gets frustrated because you're not getting better. You must not be compliant. It must be, what are you doing to not be compliant? Or to not get better, so they so that they leave and find somebody new. So usually when I get, I get patients who've been through many different treatment providers, and they're still looking for help, and then they stumble upon me.
Lisa Danylchuk 48:27
And then what do you feel like you, I think you've already started to describe this, but what do you feel like you provide that's different?
Dr. Heather Hall 48:32
I provide them, someone, who listens to what they feel is wrong, right? I don't say, what are your symptoms, and take this medication and come back in three months or one month. I say, come back and see me in two weeks. We can talk further. You know, sometimes they want medication, and I tried to figure out what they've been on. What could possibly help them. And sometimes I have to say, you know what, not all symptoms get better with medications and you might just have symptoms that don't get better with medications. We're gonna have to figure out some nonmedication ways to help you.
Lisa Danylchuk 49:18
I bet that's surprising for some people to hear.
Dr. Heather Hall 49:23
And so, sometimes the people are new to treatment. And it seems to me that they might have a social disorder as part of what's going on. But they want medication. That's what they want. And so I go that route with them. And sometimes it might take a couple of years, right? Of saying, of talking to them. Saying well, what's going on at home? What's happening? Developing a relationship with them while medications aren't working. Sometimes I send them to TMS because depression hasn't responded to medication. Let's try TMS or something and see if that'll help because I I don't want to send someone down, who's reluctant to talk about their childhood history. I don't want to start them down that road at all if we don't have to. If we can find something that's going to treat the depression and anxiety, let's try it first. Some people really still want medication. Other people, I don't want medication. I just want someone who will listen to me, you know, it depends on the person.
Lisa Danylchuk 50:25
So when you say TMS is the Transcranial Magnetic Stimulation?
Dr. Heather Hall 50:29
Yeah. And you know sometimes, I'm surprised that helps.
Lisa Danylchuk 50:35
And so you're really listening not just to the story, but to what your patient, your client wants.
Dr. Heather Hall 50:41
What kind of treatments they've already had.
Lisa Danylchuk 50:46
Yeah. Has it been helpful? Has it not been helpful? What makes it better? What makes it worse? So what would you say to someone who's struggling right now? Or even someone who knows someone who's struggling with psychosis or schizophrenia, and maybe they're wondering, what happened to this person? And they're starting to go down that path? What would? How maybe could they explore this a little bit more?
Dr. Heather Hall 51:09
Well, um, you know, lots of times having someone to listen to helps, right? And so one of the things I quite often do with some success is if there's a family member, right, that you can educate in how a trauma history affects the person and how being able to listen to them might also help. I've always thought that the recovery from trauma requires safety, right. You can't let go of your dissociative coping strategies if you're in an unsafe environment. Yeah. And so helping them figure out how to provide a safe environment for themselves, or supporting them through to the point where they can find get their own safe environment, or helping the family members that are interested in helping them provide a safe environment do so. So much of what you do in the beginning is helping that person be in a safe space so that they can begin to question the need for these dissociative coping strategies.
Dr. Heather Hall 51:32
And then, what do you wish just for the field of mental health along these lines? What do you hope?
Dr. Heather Hall 52:36
I think it's already beginning to happen, but it's, but it's being becoming increasingly clear that we can't ignore dissociation, can't ignore dissociative symptoms. And just the paper, I mean, you know, the work that's being done by researchers to sort of point to point out how you can see the association in the brain. And how you can understand it as a brain process is really, really helping, right? Developing biomarkers for dissociation. So that those people who are skeptical of it can feel more comfortable that it actually exists. And they can feel more comfortable than, again, giving people that diagnosis, right? And I also think that various psychiatrists had abandoned psychotherapy. Everyone thought we were gonna get the medication, and we don't have to do it anymore. It's sinking in that is not the case. It might not ever be the case. And that psychiatrists need to have other tools in their arsenal. So these things are all happening. As I sort of 10 years ago, when I was in the wilderness, looking at the fledgling studies that were coming out, it just seemed to me that we're going to eventually get there.
Lisa Danylchuk 54:01
Yeah. And what stands out to me too, from everything you're saying is how important it is to be listened to. And how important it is to recognize the impact of being socially excluded, or put down, or looked down upon.
Dr. Heather Hall 54:22
Because a lifetime of social defeat can force a person into dissociative coping strategies.
Lisa Danylchuk 54:33
Right, because they're trying to find a way just like in a family if there is abuse and no one to turn to, in a larger system, if there is abuse and exploitation and no one to turn to. Well, what's that, you know, trickle down the line of coping skills? Eventually, it gets to dissociation, which then presents as schizophrenia or psychosis.
Dr. Heather Hall 54:54
And the other thing I also just want to say really briefly, is I see a lot of attention deficit disorder. That is also a dissociative process. People who just people who have attention deficit disorder and they dissociate. And when they're under stress, and their in this sort of, their dissociation is heightened. Suddenly their ADHD medication doesn't work.
Lisa Danylchuk 55:19
It doesn't work anymore?
Dr. Heather Hall 55:20
It stops working.
Lisa Danylchuk 55:22
Wow, that is so interesting. How do you understand that
Dr. Heather Hall 55:30
I sort of imagined that there's, the place in the brain that sort of hypoactive in attention deficit disorder, which might be a similar place where people who dissociate used to distance themselves from their surroundings. And so it's involving the same brain mechanisms, but maybe from a different pathway.
Lisa Danylchuk 55:58
I love this other Heather. This is like what Lauren Lavoie was presenting to a little bit, some of the fMRI and neuroimaging studies with dissociation with it actually being, you know, really, hyper frontal activity like that the lid is really tight on the can, instead of it being something you can turn when you want. It's like, sealed in there. And so it would be that that focus that would come with it, that's really interesting. I hope we get some more research.
Dr. Heather Hall 56:28
I have not seen this in the literature, but I have had 5 or 6 clients now. And I would try to increase their attention-deficit medication to no benefit. And so then it began to dawn on me to start talking to them about how they were coping. And I would find that is at those times when they're feeling overwhelmed. Those days, when they're overwhelmed by their like the children or the work stress or something like that gets particularly hot. Suddenly their medication doesn't work. So helping them figure that out and figuring out coping strategies to organize their day better, so they're under less stress. Like I have a patient who's the mother of 3 children, and she thinks that she's supposed to multitask, but she thinks that it's normal. That everyone else can multitask. Why can't she? I'm like, no one can like be cooking on the stove, your child in the highchair, and your other three children. You shouldn't expect that you should build a focus on all those things the same. So give yourself a break. Step outside. When I do step outside and calm down, then I do feel like my medication is working again.
Lisa Danylchuk 57:43
Interesting. Yeah, that is really fascinating in terms of like level of arousal, in terms of your nervous system. In terms of what your brains doing. In terms of just that sense, even like you were talking about a little bit earlier, of like, self-confidence. I mean, you were talking about self-worth earlier, but it's almost like. Is there something I can do in this moment? And what are my expectations of myself? If the expectation is for you to be able to respond to three kids at once while cooking dinner. There's a little bit of that supermom mentality out there, like I'm supposed to be able to super parents are supposed to be able to do it all. It's like no. Do one thing at a time.
Dr. Heather Hall 58:24
Just do that. Just try that tactic. It was very helpful for her.
Lisa Danylchuk 58:30
Yeah. So in terms of changing this pattern and changing the outcomes for these patients, it's about listening to people. It's about being attuned to symptoms of dissociation. It's about understanding how trauma impacts people.
Dr. Heather Hall 58:46
And also racial trauma, discrimination, and social defeat. Yes, that is actually traumatic. Yeah, what that does. Imagine a dissociative process where you need to separate yourself from a lifetime.
Lisa Danylchuk 59:02
Because it's so painful to be continuously mistreated. Exactly. And I would hope that most people, I mean, I'm assuming a lot of people listening to this have that empathy, but I would hope that most people could get it's really painful to be continuously mistreated. And then from there, we can kind of make the next step too well, how do we respond to trauma, and what's kind of the last line of defense? And this is where it just Heather makes so much sense. And when you're presenting the other day, I was just like, you just lay it out. Just like ABCDEFG.
Dr. Heather Hall 59:37
That's what I try to do.
Lisa Danylchuk 59:40
You didn't really well, and I mean, even just in conversation now it makes a ton of sense to me. And I'm really glad you're writing about this. I know you've published stuff recently.
Dr. Heather Hall 59:51
This presentation I gave at the ISSTD. I have actually submitted a version of that to a publication, so I'm hoping to get that published.
Lisa Danylchuk 1:00:01
Good, well keep me posted. I would love to read that and share that. And I'm curious as we wrap up, I mean, a lot of this stuff can be just really challenging. Like being in the inpatient unit as of general, you know, seeing and working with people who've just experienced a lot of abuse down the line, and across generations had that neglect and abuse. So what, what gives you a sense of hope with all this work that you're doing?
Dr. Heather Hall 1:00:30
That it's treatable. And then the more we, the more we can recognize it. And the more we can put our efforts into developing effective treatments, we're going to find that we can help people. But you know, Michael Salter, and I wrote a paper on it. And the reason we wrote it was because it was on the sort of prevention strategies, because, you know, wouldn't it be nice to prevent discrimination and social defeat from childhood trauma? So you don't even have to treat it later on? Right?
Lisa Danylchuk 1:01:06
Yes. Yes, it would. It makes a lot more sense. And I know in a lot of conversations around prevention, people are like, well, you can't measure it if it didn't happen yet. You're like, but you can measure how much, how hard it is. To try to respond. It's possible. The treatment is there, and it's possible. But it's so much easier if we can just get in there a little sooner with a preventative lens
Dr. Heather Hall 1:01:33
Provide sort of the social safety net needed to minimize this transgenerational reoccurrence of trauma.
Lisa Danylchuk 1:01:47
I know you're writing about this. Definitely keep me posted. I know you've written and published some amazing work. So we'll put that in the show notes. Is there any other way that you know, people might connect with you or your work?
Dr. Heather Hall 1:01:59
Well, yeah, I'm not I'm old, soo my social media. But you know, my work is on, like academia or research it. So if you look for me, you will find the different things I've written. And, you know, as I write more, I would put them up.
Lisa Danylchuk 1:02:26
Okay. Dr. Heather Hall. Thank you so much, Heather. I really appreciate you taking the time and spelling all this out. And you know, all the work that you've done for the ISSTD and, you know, for the community, in San Francisco and in Sacramento and beyond. I just, I really appreciate your work. So thank you for being here and for sharing yourself with us today.
Dr. Heather Hall 1:02:48
Well, thank you for inviting me.
Lisa Danylchuk 1:02:50
Thanks so much for listening. My hope is that you walk away from these episodes feeling supported, and like you have a place to come to find the hope and inspiration you need to take your next small step forward. I do you want to make sure it's clear that this podcast isn't offering any prescriptions. It's not advice or any kind of diagnosis. Your decisions are in your hands, and we encourage you to consult with any relevant health care professionals you may need to support you through your unique path of healing. For more information and resources, please visit my website howwecanheal.com. There you'll find tons of helpful resources in the full transcript of each show. You can also click the podcast menu to submit requests for upcoming topics and guests. Before we wrap up, I want to send thanks to our guest today to Christine O'Donnell and Celine Baumgartner of Bright Sighted Podcasting, and to everyone who helps support this podcast directly and indirectly. Alex, thanks for taking the dogs out while I record. I'd also like to give a shoutout to my brother Matt. He passed away in 2002. He wrote this music and recorded it and it makes my heart so happy to share it with you now.
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