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Janina Fisher, Ph.D. - Guest
Janina Fisher, Ph.D. is a licensed clinical psychologist and a former instructor at the Harvard Medical School and former instructor at The Trauma Center, a research and treatment center founded by Bessel van der Kolk. She is known as an expert on the treatment of trauma, and has also been treating individuals, couples and families since 1980. She is past president of the New England Society for the Treatment of Trauma and Dissociation, an EMDR International Association Credit Provider, and Assistant Educational Director of the Sensorimotor Psychotherapy Institute. Janina lectures and teaches nationally and internationally on topics related to the integration of the neurobiological research and newer trauma treatment paradigms into traditional therapeutic modalities. Janina is the author of Healing the Fragmented Selves of Trauma Survivors: Overcoming Self-Alienation (2017), Transforming the Living Legacy of Trauma: a Workbook for Survivors and Therapists (2021), and The Living Legacy Instructional Flip Chart (2022). She is best known for her work on integrating somatic interventions into trauma treatment, and the development of her approach Trauma Informed Stabilization Treatment (TIST), which one can be trained in by going to https://therapywisdom.com/healing-the-fragmented-selves/. You can learn more about Janina at her website, www.janinafisher.com. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:21)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. In today's episode, I'll be speaking with Janina Fisher, PhD, who is the licensed clinical psychologist and former instructor at the Harvard Medical School, and former instructor at the Trauma Center, a research and treatment center founded by Bessel van der Kolk. She is known as an expert on the treatment of trauma and has also been treating individuals, couples, and families. Since 1980, she's past president of the New England Society for the Treatment of Trauma and Dissociation, and EMDR International Association Credit provider and assistant educational director of the Sensorimotor Psychotherapy Institute. Janina lectures and teaches nationally and internationally on topics related to the integration of neurobiological research and newer trauma treatment paradigms into traditional therapeutic models. Janina is the author of Healing the Fragmented Cells of Trauma Survivors, overcoming Self Alienation, transforming the Living Legacy of Trauma, a workbook for survivors and therapists, and the Living Legacy instructional Flip chart. She's best known for her work on integrating somatic interventions into trauma treatment and the development of her approach, trauma-informed stabilization treatment tist, which one can be trained in by going to therapy wisdom.com. You can learn more about Jan at her website, jan fisher.com. Let's listen to the interview. Okay. Well, hi Janina. Thank you so much for joining us today.
Dr. Janina Fisher: (02:00)
Hello, Keith.
Dr. Keith Sutton: (02:02)
Great. I'm so glad you could join us. Um, so I've learned about your work through, I was taking a pessi, uh, workshop. I've been digging more into complex PTSD lately. Um, and, uh, I ended up taking your cer uh, certification course for a complex PTSD or a certificate, whatever it might have been, and just really loved your approach and your, the integration that you're doing and the different kind of modalities. And I've just learned so much that I wanted to see if I could have you on the podcast to hear about more about your work. Um, and I'd love to hear, you know, I always like to start off by finding out about, you know, kind of how folks kind of the, the evolution of their ideas to kind of getting to the work that they're doing now and kind of how they're putting that together. So maybe we could start off there.
Dr. Janina Fisher: (02:48)
Sure. I always take, that always takes me back to September, 1989 when I began my postdoctoral internship at Cambridge Hospital in Massachusetts, and I heard Judith Herman speak for the first time about trauma. And I remember, I remember exactly what she said. She said, doesn't it make more sense that people suffer because of what they've experienced rather than because of their infantile fantasies? Because, you know, in 1989 we were a Freud dominated field still.
Dr. Keith Sutton: (03:36)
Yeah. Wow.
Dr. Janina Fisher: (03:37)
And I remember thinking, oh my God, she's right! Of course it makes more sense. And at that moment, I just felt like, okay, there's my career path. I wanna work with trauma.
Dr. Janina Fisher: (03:53)
And it was very, very timely because the trauma field was just beginning to develop. Um, and of course, Judy Hermann and Bessel van der Kolk were the, the pioneers in the field. So I had this incredible stroke of luck to be on board as the first generation that the pioneers took forward. And we began to change how people thought about our clients. Especially the clients who were diagnosed borderline, and basically stigmatized and, and treated as if they were hopeless cases.
Dr. Keith Sutton: (04:44)
Yeah. Pathologized so much.
Dr. Janina Fisher: (04:46)
Yeah. Yeah. Exactly. Um, and so I had the chance to do a post-doctoral fellowship in Judy Hermann's clinic for two years, from 1991 to ‘93. And then Bessel VanDerKolk, who actually had, was an old family friend, I just happened to see him at a conference and I said, Hey, if you ever need supervisors at your clinic, I would love to jump ship and come work for you. And, and so in 1995, I became a supervisor and instructor at his trauma center. Just as the whole field of neuroscience research into trauma really started. Right, we didn't have the technology and suddenly we did, we could look at people's living brains. So it was a very exciting time. And as a supervisor in his clinic, um, I, I participated in the clinical team each week and they were such incredibly inspiring occasions because we were thinking not just about cases, we were thinking about how could we apply these new, this new information we're getting to how we treat people. How can we make our treatments work better?
Dr. Keith Sutton: (06:24)
Great.
Dr. Janina Fisher: (06:25)
Yeah. Yeah. And really at, uh, to give Bessel the credit he deserves. He, I would say he forced me to, but not really. He, he encouraged us all to get trained in EMDR, and then in, in a somatic psychotherapy. And the one I chose was sensorimotor psychotherapy, in part because it's a psychotherapy method. So it was much easier to integrate into, into what I call regular talking therapy. Because as I still say, two audiences, our clients come to us for help. They don't come to us for a particular method. You know, they come cuz they wanna feel better. And, and they don't wanna be sold a method. They want someone who will understand them and help them.
Dr. Keith Sutton: (07:31)
Yeah. Somebody that's gonna help and, and make change, but also feel like they, they feel safe.
Dr. Janina Fisher: (07:37)
Right. Right. Right, right, right. And to feel safe, you have to feel that the person understands. And we, we didn't understand because as a field, we still believed, even in the nineties, we still believed that if people just told the story of what happened, they would be set free. And it's a story that you still see on television. It enrages me because people have been telling their stories for 20, 30 years without feeling better.
Dr. Keith Sutton: (08:15)
Yeah. Yeah. That, I'm so glad that you mentioned this. Cause I think that was really just such a nice key piece in some of the teaching that you're doing about that. Cause I think that is sometimes where people go to like, oh, they just have to process that or tell the story or so, and that's what's gonna fix things.
Dr. Janina Fisher: (08:32)
Right. Which actually doesn't make sense. And I often use as an analogy, you know, if someone you knew had been in a plane crash and survived, what would be the first thing you'd ask them? Would you ask them, tell me what happened, blow by blow? Or would you say, are you okay? Right. How are you doing? How has this affected you? And somehow as a field, we never asked, how is this affecting you? We asked what happened? And, and so that's, I think that's part of what I set out to do. I mean, I had very modest expectations. I was 40 years old when I started my doctoral program. I had raised two kids. I had very modest aims. I thought, you know, I'm basically a middle-aged person starting a career. You know, if I'm lucky, I'll have a nice private practice. I had no ambition to, you know, to change the world. But because of my association with Bessel's Trauma Center, I had to do some teaching that was part of the deal.
Dr. Janina Fisher: (10:04)
You were a supervisor. You taught, you taught seminars in his training course. And, and when I taught my seminar, he stood up and started clapping. And said, he'd say, he said, you, you were made to do this. You have to, you have to come teach with me. This is, you know, this is what you do. That's what you're gonna do. And so I was like, but I'm scared of public speaking. I don't know if I want to do this. Uh, but I always say, Bessel is very good at throwing you in the deep end of the pool, assuming you'll be able to swim.
Dr. Keith Sutton: (10:52)
Figure it out. And you did it sounds like.
Dr. Janina Fisher: (10:55)
Yeah. Yeah. Yeah. And of course, I was particularly interested in how we take this idea of vessels. The body keeps the score, and how do we integrate it into the, into the average therapist talking therapy practice. Because in the end, very few people can find specialists, afford specialists, you know, especially in this day and age, it's so hard. And so I felt like I had to create a way for the average therapist to get a better understanding of trauma. And how to address it below the level of talking.
Dr. Keith Sutton: (11:54)
Definitely. And I, and I'm, I was wondering if you might be able to speak on your conceptualization of complex PTSD, because it's really just, I've been getting more and more deeper into this. And now as I'm learning some of, uh, Pete Walker's work and your work and, structural dissociation and internal family systems. I also do EMDR, you know, just trying to get, I'm just getting a much deeper understanding. I would love to, to hear how you describe it.
Dr. Janina Fisher: (12:22)
Well, you know, complex PTSD was something , it's sad to say something that was being discussed in the early nineties. So, Judy Herman and Bessel Van Der Kolk both had this, this idea that we, that the simple post-traumatic stress disorder diagnosis didn't fit people with histories of childhood trauma. It often even didn't fit people who were combat veterans. It didn't fit people who were victims of domestic violence. And so, um, and so the, what is now called complex PTSD was first conceptualized as DESNOS, disorders of extreme stress not otherwise specified. And what was interesting about this description of DESMOS is that trauma, you know, when you looked at the effects of long-term chronic traumatization, what what we see are symptoms, mood disorder symptoms, depression, anxiety. We see personality disorder symptoms. And we see symptoms of, I think what, what was then called disorders of meaning.
Dr. Janina Fisher: (13:57)
Right. A loss of a sense of, of who I am. You know, in today's language, we'd probably say, many negative cognitive distortions. Right. It was my fault. Um, something's wrong with me. I deserved it. I deserved to die. All kinds of, of, of cognitive effects of trauma. So really complex PTSD is a combination of a complex history coupled with these complex symptoms and not so much necessarily in the way of flashbacks and nightmares. The classic PTSD symptoms. Usually people are more troubled by their depression, their anxiety, their mood swings from anger to fear, and the negative cognitive distortions.
Dr. Keith Sutton: (15:08)
And the, in one way I've been conceptualizing it lately, I don't know if this is fitting, is kind of, you know, oftentimes when the person either grew up or for a prolonged period of time, were in an environment where they did not feel safe essentially, and that amygdala was firing off and that it, you know, they, they had to really kind of, figure out a way at living in survival mode for so long. Cause you know, sometimes some people say, well, I wasn't beaten or something like that, so I couldn't have complex PTSD or, you know, it's kind of more those unpredictable environments where the person, again, has to be kind of on guard and, and really the hyper vigilance and all those pieces for a long period of time and, and really having to shape their whole in way of interacting with the world around that sense of keeping oneself safe.
Dr. Janina Fisher: (15:58)
Well, I think the question to ask those clients is, when you were growing up, were either of your parents or was any adult in the household ever frightening. Cause those clients will say, yes, my father was frightening and, and my mother was depressed. That's the typical answer. And then I then the second question is, and when you were growing up, did either of your parents ever appear frightened? And then usually they say, well, you know, my mother couldn't say a word to my dad. You know, none of us could. So you get all, and then, then often people do disclose the physical abuse.
Dr. Janina Fisher: (16:57)
Or even the sexual abuse. Cause once they start talking about how scary their mother or father was, they talk in, start to talk in more detail about, you know, up there. You know, my father believed, you know, spare the rod and spoil the child. And, and now, even though five minutes ago they would've said no if you asked them if they were ever abused. But now they're telling you about what was abuse. And so then it's very easy to say, okay, so you grew up in a family that wasn't safe. You didn't feel safe. And it wasn't safe. And so no wonder you're struggling with complex PTSD.
Dr. Keith Sutton: (17:51)
Definitely. And even also too, in the neglect situation where again, just feeling unsafe cuz the parents weren't there to take care of needs or so on. Um, you know, sometimes I think those can also play in around again, that, that that kind of being in that survival mode.
Dr. Janina Fisher: (18:07)
But I think we have to make a distinction, which unfortunately is getting muddied these days. There's a distinction between traumatic neglect, and the emotional neglect that children experience when parents are very busy and preoccupied or when, you know, the parents', kind of emotional availability is limited, versus traumatic neglect in which you don't know if anybody will be home. You don't know if there'll be dinner on the table. You don't know if you are gonna be an eight year old trying to run a household by yourself.
Dr. Keith Sutton: (18:58)
That's unpredictable.
Dr. Janina Fisher: (19:00)
Right. That’s frightening. As opposed to being ignored by busy parents is distressing and painful, but it's not frightening.
Dr. Keith Sutton: (19:10)
Yes. Yes. Definitely.
Dr. Janina Fisher: (19:12)
And that's a very important distinction that I wanna keep because I'm part of the generation that fought to have trauma recognized as something different than distressing, a distressing childhood.
Dr. Keith Sutton: (19:30)
Yeah. Good. I like that. So kind of that central piece being the, whether, you know, the feeling frightened.
Dr. Janina Fisher: (19:41)
Right. Which is very easy, again, to ask people with histories of neglect, right, were either of your parents, did either of your parents appear frightened? Did either of them frighten you?
Dr. Keith Sutton: (19:58)
Definitely. Now, I'd love to hear your thoughts on, you know, kind of the, the aspects of dissociation and, and I know that, um, gosh, I'm blanking on the, the term you were using, um, like the hyperfunctional part, kind of, or the going about life normally part or so on, which I thought was really interesting. And I know there's, you know, I, I had, Dick Schwartz on the podcast and we were talking a little bit about his conceptualization of kind of like, we naturally kind of have parts and other perspectives where like parts are, are, are result from trauma. Um, yeah. I just would love to hear your thoughts on those kind of ideas. And I know you also work with a lot of, you know, uh, extreme dissociation, DID and and so on.
Dr. Janina Fisher: (20:46)
Yeah. Right. And I, you know, I like, I like the idea that we all have parts that we all have aspects of ourselves. I think that's a really helpful framework for understanding oneself. Regardless of trauma. But Dick and I have a fundamental difference in perspective that I think comes from the fact that I come from the trauma world. And he comes from the family therapy and Gestalt world. So, so we're really looking at it from two very different perspectives. Um, in, in the perspective that I use, which is the structural dissociation model, dissociation or fragmentation as I like to call it, occurs as a way of surviving in a traumatic environment. And so if you're a child living in a traumatic environment, you still have to get up in the morning and brush your teeth and go to school. Right? You still have spelling tests no matter how much abuse you're suffering at home. And you need to be able to respond quickly and adaptively to an array of different behaviors on the part of abusive or neglectful parents. And so the structural dissociation model proposes that we all have an instinct to keep, keep putting one foot in front of the other that is not a, that is not a false self. It's not, or as Dick calls it a manager.
Dr. Janina Fisher: (23:03)
It's a, it's an intact, very important instinct that human beings have had since the days of the cavemen and women. Right. Because the cavemen and women had to, had to still get up every morning and hunt for food and keep the fire going and fetch water and all those things as well as defend against enemies and predators. So, the structural dissociation theory proposes that in the context of extreme stress, there's a split between the left brain keeping on, keeping on part of the personality because it takes the left brain to remember, oh, we're running outta water here, right. And, and right brain subparts that are connected to or driven by the basic survival responses of fight, flight, fear submission, and cry for help.
Dr. Janina Fisher: (24:22)
And, uh, and so that's, you know, in my, I have model, a trauma informed parts model called trauma informed Stabilization Treatment or TIST, um, which integrates a lot of ideas and techniques from internal family systems, lot of ideas and techniques from sensorimotor psychotherapy ideas and techniques from clinical hypnosis ego state models. Um, it's actually, you know, it's got a little CBT in it. It's got lots of different, different, uh, elements. But basically what we try to do is to help people sort of create a different relationship to those complex PTSD symptoms by relating to them as parts of themselves.
Dr. Janina Fisher: (25:35)
So that what, and what that actually does, it generally is to give them more control over. So, you know, if something triggers me and I feel rage, I want a strong going on with normal life self to say, okay, you're just triggered. You don't have to, you don't have to fight, you know, pause, think about it and work with that angry part. To find the most effective way. Because, because you know, the primitive fight response starts yelling, hitting, throwing things. You know, attacking other people, attacking one's own body, um, and then people get labeled borderline. And, uh, the vicious circle begins as opposed to noticing whether it's fear, anger, shame, noticing those reactions as the reactions of parts. And, you know, again, a lot of this, a lot of the technique is, is borrowed or, or developed from internal family systems ideas. But the, but the kind of the theoretical part of it is a trauma related.
Dr. Keith Sutton: (27:21)
Yeah.
Dr. Janina Fisher: (27:22)
Which is not true for IFS. IFS is not correct, is used for trauma, but it's not a trauma informed method.
Dr. Keith Sutton: (27:31)
Yeah. I like that idea of the appreciating the parts and, and having compassion and understanding, which, which I think is really nice. And what are, how do you think about it? Cuz I know, you know, with trauma, that's one of the hardest things is to recognize that it's this part. Cuz oftentimes, sometimes I think about it as like trauma mind sometimes when the person's triggered and they're tra in trauma mind, they have a hard time even accessing the part of them that knows that this is a separate part, but are are so, you know, and then one's kind of out of that fight or flight or deescalated or feeling safe again, then being able to access those other parts. How do you think about the process of helping a client moving from that, that kind of, that reactivity or that emotional flashback to that ability to have that kind of metacognition or that kind of psychological distance or cognitive diffusion to Oh wait a second. This is that part.
Dr. Janina Fisher: (28:27)
Well, it has to start, it has to start with something very simple. I mean, it was really Bessel VanDerKolk's brain research, brain scan research that first showed that when an individual is traumatically activated, the prefrontal cortex, the thinking brain shuts down. So of course, you know when people are triggered when they're threatened, and the thinking brain shuts down, they react, they don't think. So the first thing I do is to teach clients that they're triggered, and how to recognize being triggered. Which is also usually a relief once people get it, it's a huge relief because otherwise they feel enraged with themselves, enraged at other people. They feel hopeless, they feel ashamed. I've made a mess of my life.
Dr. Keith Sutton: (29:39)
I remember in the training too, you had talked about a client who, you know, was kinda like, I don't know, I just woke up feeling this way. Or very, and then you, like, when you both traced it back, you realized it was like a, it was gonna rain that day and he realized on the rainy days he was stuck inside with his mother. And that there's, it's almost always, you know, some, some trigger that sometimes we're not aware of. And so I imagine that also helps things feel less out of control out of the blue if, if the clients are understanding that there's something that's triggering that and that we might decipher it or maybe not sometimes, but yeah.
Dr. Janina Fisher: (30:13)
I mean, I think that the key is to understand why rain is triggering rather than go back into the event memories. Because, because that usually is more triggering. I mean, we know that telling the blow by blow story of something that's happened evokes the emotional responses associated with the event. That's why therapists keep trying to get people to talk about their events. Because they want them to feel the feelings. Um, but it doesn't work if they start to talk about the event and the prefrontal cortex shuts down and they're overwhelmed.
Dr. Keith Sutton: (31:06)
Yeah.
Dr. Janina Fisher: (31:08)
So, what I teach clients to do is to keep the prefrontal cortex online to learn how to notice these signs that they're triggered. Whether they're somatic signs like my body tenses or braces or start, I start to shake. Or whether it's what I call suddenness intensity and duration, the feeling hits you like a ton of bricks. Um, to me that's a triggered feeling.
Dr. Janina Fisher: (31:50)
Unless, you know, unless I have a mugger at the door, I'm not gonna suddenly be hit by a feeling like a ton of bricks. And so, so just, that's usually the best place I've found to start to help people keep that prefrontal cortex online. Mindfulness, helping them to notice, rather than interpret the experience. Because, you know, the truth is that most of us, I have to say as a human condition, we tend toward negative interpretations, not positive. If you think about the average person on the average day, we're much more likely to interpret things negatively. And that doesn't usually help.
Dr. Janina Fisher: (32:56)
So learning to notice and be interested in what we experience, how we react, what feelings come up, what thoughts come up, it's calming for the nervous system and it keeps us out of trouble. Keeps us out of making things worse for ourselves.
Dr. Keith Sutton: (33:19)
Being curious about it rather than just interpreting.
Dr. Janina Fisher: (33:22)
Right. Cause in, in my, the mindfulness world, people are taught to notice with interest, to be interested in what they notice, good, bad, and ugly. Without attachment or aversion. Meaning without trying to push away a feeling or without getting too attached to this is how I really feel.
Dr. Keith Sutton: (33:53)
Yeah. And that's, yeah. That's great. And then, and so kind of bringing in that prefrontal cortex and then, what kind of bottom up processing are you doing? Are you still doing EMDR or is it mostly with the sensory motor or, how, yeah, how are you kind of doing those aspects?
Dr. Janina Fisher: (34:15)
Um, you know, um, that's, that's harder to say because I've been trying to retire from practice for the last five years. So I'm not doing much of anything anymore. I'm doing a lot of consulting to therapists and to clients, and a lot of teaching. Mostly what I do is teaching. So if I were in practice, I, you know, I probably still would use an eclectic approach because most people that I get referred are extremely high functioning and very, very, very traumatized. So they function professionally at a high level, and they're tortured inside. And usually, what the kind of, the intensity of their symptoms and their limited ability to regulate the symptoms, makes them poor EMDR clients candidates because they're at the highest risk for to be overwhelmed by EMDR treatment. Even though they're so super high functioning. That you would think, I always include the body in whatever I'm doing.
Dr. Janina Fisher: (35:57)
And so that's, you know, even, even a consultation because you know, the body is where it all starts, right. Emotions start in the body. Images start in the body. Even cognitions, I would forget the brain is part of the body. So, I tend, I suppose, not to use any one approach, but to use the combination of approaches that work for the client. And particularly I use my trauma-informed stabilization treatment or TIST. Because that's, that's probably what I'm most passionate about these days. Why, I'm just in the process of finishing up my first online TIST training and we started out with a group of 500 clinicians from all over the world in the level one training. And now we have a hundred of that original 500 who are doing a certification training. Wonderful. And, uh, so then we'll have, we'll have certified TIST therapists that we can recommend or that clients can look up online. It's very exciting. And what's lovely about TIST is it's such a good treatment for complex PTSD, because it's, you can work with all of the complications from suicidality to addiction, to over-functioning, under-functioning.
Dr. Keith Sutton: (37:58)
Well I'm glad that you mentioned the suicidality cuz I was also struck by some of the, what you discussed regarding suicidality in your work. And I really liked, I don't know if you could speak to some of the ways you're conceptualizing that, cause I thought that was really helpful. Um, particularly in clients that might be, have a diagnosis, borderline personality disorder or you know, again, that, that are having this complex PTSD. Can you talk a little bit about that? I thought that was really interesting.
Dr. Janina Fisher: (38:24)
Right. And, and I'm reminded of a, uh, of a client who, whom I interviewed. I did a video interview with her and she talked about how absolutely useless and actually harmful it was to be given the borderline diagnosis and to be told she was attention seeking and manipulative. And there's this wonderful moment where she says, this is a 23 year old young woman, many suicide attempts in hospitalizations. And she said, didn't they understand that if they called us manipulative and attention seeking, we'd wanna kill ourselves even more. Right? So, um, so what, what I believe what I, the belief I've developed, which really comes from having a somatic perspective and a structural dissociation perspective, is that suicide is just the other side of the coin from homicide, right. That we all have a fight response. We're born with that basic instinct to fight or flee or submit or cry for help.
Dr. Janina Fisher: (39:56)
And that that fight response can be turned against others or against one's own body. And the trauma survivors often learned as children to turn those fight responses against their own bodies because it wasn't safe to turn them against a parent's body. Right. I mean, I'm sure any parents who are listening have had experiences of small children hitting them, kicking them, otherwise fighting them. You know, I often ask people when they say, you know, I'm afraid, I don't want my child to feel unsafe. And I say, well, does your child ask for what he wants? And they say, oh yes. Does your child protest when you say no? Absolutely. Does your child persist in asking for what you just said? No. And, and they say yes. And then I say, well that's the good news is your child feels safe. Because if we don't feel safe, we don't fight the parent.
Dr. Keith Sutton: (41:26)
Yeah. I appreciate you saying this cuz it's just making me think of, I've got some of my clients that, cause I also work with children, families and oftentimes end up working with the parents after kind of getting things going with the children. And one of the parents I was working with, which is so incensed that the child is asking for what they want, you know, and, and that just felt, was feeling so frustrating. So kind of like unappreciative or so on. And then we, yeah. We had to look at that because again, that they didn't get to do that in their family. And so seeing there was, there was, they had such mixed feelings about their children asking for what they want. Cuz there was a system in their own mind of like, don't do that. That's bad. So it's helpful to understand in that context.
Dr. Janina Fisher: (42:09)
Absolutely. Yes. Yeah. And often parents I think are triggered when their children engage in behavior that would've been dangerous in their world. And, and so I've had many clients who were triggered by their children's asking for what they want persisting when they've been told no. I remember actually one of my few remaining clients, complained to me recently that her, she was disciplining her five-year-old son, and she said to her son, go to your room right now. And he turned around and said to her, no, you go to your room. And and of course she was triggered and incensed because she would've been, she would've been killed. For saying something like that to a parent.
Dr. Keith Sutton: (43:08)
Wow. Now back to the suicide piece, I think, you know, one of the things that, that I think, you had talked about also is that, you know, you know, especially for someone experiencing childhood trauma, sometimes there was this, you know, fantasy of dying and that was a way of, of helping to dissociate, helping to decrease the distress and, and you know, kind of seeing some of the suicidal ideation, you know, uh, also as a means of coping.
Dr. Janina Fisher: (43:38)
Oh, absolutely. Yeah. Yes. And particularly, you know, when clients, when clients express suicidal ideation, or they are self-harming or they're restricting or binging and purging, I asked them, how old were you the first time you thought about dying as a way to get out? And it's amazing. People say eight, seven, you know, 10, I mean so young. Because, you know, often for children trapped in a dangerous situation that seems like the only possible hope. So I think, so what I, the way I conceptualize and try to help clients conceptualize suicidality is that it's a suicidal part trying to help them, trying to say, look, give it up. You know, just, just see, here's the exit, here's the parachute, take it and go. And, and that, and which is ironic because most of these individuals have fought so hard to survive.
Dr. Janina Fisher: (45:18)
You know, it's been often a life's work just to fight to survive. And then the suicidal part says, ah, why are you fighting so hard? Working so hard? Right. Look, there's the exit sign right over there. And so I, I really get people to notice the suicidal feelings as a suicidal part. And I teach my students to do the same and to be very, um, persistent that, you know, because many times clients say, you know, every cell in my body wants to die. It's not just a part, it's all of me. And, and I have to say, I know it feels like it's all of you. And I'm sure that every cell in your body wants relief, but they don't necessarily wanna be killed. And that's, that's really the, the difference in perspective that seems to help.
Dr. Janina Fisher: (46:34)
I mean, the young lady who told me, you know, why didn't the doctors realize that calling us manipulative would make us wanna die more, she again had been chronically suicidal since age 13. Many, many hospitalizations. And when, when I taught her the structural dissociation model And I, and I said, this, your suicidal part is your fight part. That's the part of you that, that sees suicide as the only fight that you can win. And this young lady was also substance abusing. And so we talked about how her flight part would say, her flight part would say, Hey, have some drugs. Her, her suicidal part would say, oh, why don't you cut yourself, or even better die. And so she was able to actually, in just a couple sessions, she was able to change her perspective so that when she had the suicidal ideation or impulses, she would, she recognized those as the fight part. She would say, you seem to be having a bad day, how can I help you? And it totally changed. I think I met her, I'm gonna say I met her in 2015. I know her therapist, her, her therapist is a colleague of mine. And to this day, she has never been hospitalized.
Dr. Keith Sutton: (48:27)
Wow.
Dr. Janina Fisher: (48:28)
Because she got it and she learned every time she had the suicidal thoughts and feelings, she knew, okay, that's not me. That's my fight part.
Dr. Keith Sutton: (48:40)
That's great. Yeah. Having that shift in that kinda understanding and changing that relationship to the symptoms.
Dr. Janina Fisher: (48:46)
Right. And I can, I can think of so many clients who were chronically suicidal for years and years, and once they could relate to the suicidal ideation as a part, it totally, it changed. Doesn't mean, it doesn't mean the suicidal part doesn't get triggered again. But it's a totally different experience to notice those feelings and impulses as, as being a part on a mission.
Dr. Keith Sutton: (49:20)
Yeah. And we're almost outta time, there's one last piece that I think was really that, that was really striking from the, the workshop that I took was, you know, also talking about kind of that, you know, you know, of course many clients are, especially with trauma, are not gonna, are gonna have a hard time trusting the therapist, but also being able to just make space for that. I think you gave an example of a therapist who you're consulting with who is asking the client, why don't you trust me? And kind of feeling like there was a therapeutic issue or so on, rather than kind of understanding that the client may never trust them, especially, you know, earlier in, in the treatment and so on. And, and just kind of even speaking that to the client allowing that to be there.
Dr. Janina Fisher: (50:02)
Right, right, right. As I think, you know, that all goes back to the issue of do we communicate to the client that we get it, that we understand, because that's what creates safety. If we don't understand, we could be the nicest, gentlest, most mild mannered, non-judgmental person in the world, but if we don't understand them, if we're not getting it, we're not gonna feel entirely safe. And so, I really feel quite genuinely that that trust is not a prerequisite for therapy. Therapy is a collaboration and, and you know, we can collaborate with people we trust completely, but we can also collaborate with people that we don't fully trust. It's all about the willingness to work together. So, I really try to take the monkey off the back of the client. Because, because it's an unreasonable expectation. It's like saying you'll never get better unless you can trust, but they can't trust until they're, they're doing and feeling better.
Dr. Keith Sutton: (51:30)
Yeah, exactly. Right. Yeah. And putting it in that context, I think is relieving, you know, for the, and, and not making it an area where the, the therapist and the client could get stuck and, and again, just honoring their experience and that not feeling safe.
Dr. Janina Fisher: (51:49)
Right. Absolutely. And you know, I think for all of us, if it feels so much safer, if we're not under pressure to believe people, trust people, you know, do what we're told.
Dr. Keith Sutton: (52:08)
Yeah, definitely.
Dr. Janina Fisher: (52:09)
And, and so often as therapists, we kind of expect clients to buy what we're offering.
Dr. Keith Sutton: (52:18)
To get on board and go along rather than working together and deciding to, to get on board together and go somewhere.
Dr. Janina Fisher: (52:25)
Right. Right. Yeah, I mean, one of the things I used to do, which might have been going a little overboard, but I would say to clients, you know, maybe third, fourth this session, after I'd gotten to know them a little bit, I would say, you know, we have a choice in how we can work. And I, I used to have an easel in my office, so I'd actually write it out on the easel. I'd say, you know, we could do regular talking therapy, otherwise known as psychodynamic therapy. And then I would list, and here's, here's what that entails. Here are the pros, here are the cons. We could do EMDR, here are the pros, here are the cons. We could do sensorimotor psychotherapy, or we could do parts therapy. And uh, and, and then the client has made a choice, right. If they say
Dr. Keith Sutton: (53:31)
-they've got the agency.
Dr. Janina Fisher: (53:33)
Right. And they've also made a commitment. So it's much harder to, you know, because if they kind of, if they're, what I, I hate to use the word resistant. But if they're resistant,
Dr. Keith Sutton: (53:50)
Yeah, yeah.
Dr. Janina Fisher: (53:51)
Then I can say, well, let's go back to our choices. We could do psycho. Right.
Dr. Keith Sutton: (53:58)
I have to, I have a similar thing. Yeah. Cuz sometimes the clients almost feel like the therapy gets away from them and they're like, Ooh, I don't want, and say like, Hey, you know what? You're the captain of the ship here. I know you wanted to work on this trauma because you wanted to be closer to your husband and you felt like this was so, but we don't have to do that. We can do this. And then oftentimes when the person feels like, no, actually no, that is what I want to do. And really again, them taking the lead again, filling that agency and filling, cuz it, it sometimes shifts to feeling out of control. So kinda going back to that.
Dr. Janina Fisher: (54:30)
And the other thing, your example is a great one because it reminds me that often, whatever the treatment we're using, it's triggering. So your client comes in wanting to work on the marriage by working on the trauma, but then working on the trauma is triggering. And so then there's like, oh, I don't know about this. And so it also really helps to say, you know, is this maybe a little triggering for you? Cuz we could slow it down. We don't have to do, go full bore. We can slow it down. We can do, you know, again, I don't ever focus on the events ever. Ever, ever, ever, ever. Because my mission besides teaching TIST is to help people to see, it's the effects of what happened that we have to address.
Dr. Keith Sutton: (55:42)
Well thank you so much. This has been so wonderful today and I really appreciate getting to know more of your work. And, and I, I know this will be very helpful for our listeners and I'll link to the, to your TIST model and that training. I think that sounds great. It's so wonderful to hear that's available. I'm gonna check that out myself. And we'll also link to, I know you've also done a lot of writing and, and, all these kind of resources, which I think will really be great for therapist's interest in learning more and, and getting more training. So thank you so much for taking the time to be here with us today.
Dr. Janina Fisher: (56:13)
My pleasure, Keith. Take care.
Dr. Keith Sutton: (56:16)
Thank you. Bye-bye.
Dr. Janina Fisher: (56:19)
Bye.
Dr. Keith Sutton: (56:20)
Thank you for joining us. If you're wanting to use this podcast, earn continuing education credits, please go to our website at therapy on the cutting edge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to SfIAP.com or call (415)617-5932. Also, we really appreciate feedback and if you have something you're interested in, something that's on the cutting edge of the field of therapy and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. In today's episode, I'll be speaking with Janina Fisher, PhD, who is the licensed clinical psychologist and former instructor at the Harvard Medical School, and former instructor at the Trauma Center, a research and treatment center founded by Bessel van der Kolk. She is known as an expert on the treatment of trauma and has also been treating individuals, couples, and families. Since 1980, she's past president of the New England Society for the Treatment of Trauma and Dissociation, and EMDR International Association Credit provider and assistant educational director of the Sensorimotor Psychotherapy Institute. Janina lectures and teaches nationally and internationally on topics related to the integration of neurobiological research and newer trauma treatment paradigms into traditional therapeutic models. Janina is the author of Healing the Fragmented Cells of Trauma Survivors, overcoming Self Alienation, transforming the Living Legacy of Trauma, a workbook for survivors and therapists, and the Living Legacy instructional Flip chart. She's best known for her work on integrating somatic interventions into trauma treatment and the development of her approach, trauma-informed stabilization treatment tist, which one can be trained in by going to therapy wisdom.com. You can learn more about Jan at her website, jan fisher.com. Let's listen to the interview. Okay. Well, hi Janina. Thank you so much for joining us today.
Dr. Janina Fisher: (02:00)
Hello, Keith.
Dr. Keith Sutton: (02:02)
Great. I'm so glad you could join us. Um, so I've learned about your work through, I was taking a pessi, uh, workshop. I've been digging more into complex PTSD lately. Um, and, uh, I ended up taking your cer uh, certification course for a complex PTSD or a certificate, whatever it might have been, and just really loved your approach and your, the integration that you're doing and the different kind of modalities. And I've just learned so much that I wanted to see if I could have you on the podcast to hear about more about your work. Um, and I'd love to hear, you know, I always like to start off by finding out about, you know, kind of how folks kind of the, the evolution of their ideas to kind of getting to the work that they're doing now and kind of how they're putting that together. So maybe we could start off there.
Dr. Janina Fisher: (02:48)
Sure. I always take, that always takes me back to September, 1989 when I began my postdoctoral internship at Cambridge Hospital in Massachusetts, and I heard Judith Herman speak for the first time about trauma. And I remember, I remember exactly what she said. She said, doesn't it make more sense that people suffer because of what they've experienced rather than because of their infantile fantasies? Because, you know, in 1989 we were a Freud dominated field still.
Dr. Keith Sutton: (03:36)
Yeah. Wow.
Dr. Janina Fisher: (03:37)
And I remember thinking, oh my God, she's right! Of course it makes more sense. And at that moment, I just felt like, okay, there's my career path. I wanna work with trauma.
Dr. Janina Fisher: (03:53)
And it was very, very timely because the trauma field was just beginning to develop. Um, and of course, Judy Hermann and Bessel van der Kolk were the, the pioneers in the field. So I had this incredible stroke of luck to be on board as the first generation that the pioneers took forward. And we began to change how people thought about our clients. Especially the clients who were diagnosed borderline, and basically stigmatized and, and treated as if they were hopeless cases.
Dr. Keith Sutton: (04:44)
Yeah. Pathologized so much.
Dr. Janina Fisher: (04:46)
Yeah. Yeah. Exactly. Um, and so I had the chance to do a post-doctoral fellowship in Judy Hermann's clinic for two years, from 1991 to ‘93. And then Bessel VanDerKolk, who actually had, was an old family friend, I just happened to see him at a conference and I said, Hey, if you ever need supervisors at your clinic, I would love to jump ship and come work for you. And, and so in 1995, I became a supervisor and instructor at his trauma center. Just as the whole field of neuroscience research into trauma really started. Right, we didn't have the technology and suddenly we did, we could look at people's living brains. So it was a very exciting time. And as a supervisor in his clinic, um, I, I participated in the clinical team each week and they were such incredibly inspiring occasions because we were thinking not just about cases, we were thinking about how could we apply these new, this new information we're getting to how we treat people. How can we make our treatments work better?
Dr. Keith Sutton: (06:24)
Great.
Dr. Janina Fisher: (06:25)
Yeah. Yeah. And really at, uh, to give Bessel the credit he deserves. He, I would say he forced me to, but not really. He, he encouraged us all to get trained in EMDR, and then in, in a somatic psychotherapy. And the one I chose was sensorimotor psychotherapy, in part because it's a psychotherapy method. So it was much easier to integrate into, into what I call regular talking therapy. Because as I still say, two audiences, our clients come to us for help. They don't come to us for a particular method. You know, they come cuz they wanna feel better. And, and they don't wanna be sold a method. They want someone who will understand them and help them.
Dr. Keith Sutton: (07:31)
Yeah. Somebody that's gonna help and, and make change, but also feel like they, they feel safe.
Dr. Janina Fisher: (07:37)
Right. Right. Right, right, right. And to feel safe, you have to feel that the person understands. And we, we didn't understand because as a field, we still believed, even in the nineties, we still believed that if people just told the story of what happened, they would be set free. And it's a story that you still see on television. It enrages me because people have been telling their stories for 20, 30 years without feeling better.
Dr. Keith Sutton: (08:15)
Yeah. Yeah. That, I'm so glad that you mentioned this. Cause I think that was really just such a nice key piece in some of the teaching that you're doing about that. Cause I think that is sometimes where people go to like, oh, they just have to process that or tell the story or so, and that's what's gonna fix things.
Dr. Janina Fisher: (08:32)
Right. Which actually doesn't make sense. And I often use as an analogy, you know, if someone you knew had been in a plane crash and survived, what would be the first thing you'd ask them? Would you ask them, tell me what happened, blow by blow? Or would you say, are you okay? Right. How are you doing? How has this affected you? And somehow as a field, we never asked, how is this affecting you? We asked what happened? And, and so that's, I think that's part of what I set out to do. I mean, I had very modest expectations. I was 40 years old when I started my doctoral program. I had raised two kids. I had very modest aims. I thought, you know, I'm basically a middle-aged person starting a career. You know, if I'm lucky, I'll have a nice private practice. I had no ambition to, you know, to change the world. But because of my association with Bessel's Trauma Center, I had to do some teaching that was part of the deal.
Dr. Janina Fisher: (10:04)
You were a supervisor. You taught, you taught seminars in his training course. And, and when I taught my seminar, he stood up and started clapping. And said, he'd say, he said, you, you were made to do this. You have to, you have to come teach with me. This is, you know, this is what you do. That's what you're gonna do. And so I was like, but I'm scared of public speaking. I don't know if I want to do this. Uh, but I always say, Bessel is very good at throwing you in the deep end of the pool, assuming you'll be able to swim.
Dr. Keith Sutton: (10:52)
Figure it out. And you did it sounds like.
Dr. Janina Fisher: (10:55)
Yeah. Yeah. Yeah. And of course, I was particularly interested in how we take this idea of vessels. The body keeps the score, and how do we integrate it into the, into the average therapist talking therapy practice. Because in the end, very few people can find specialists, afford specialists, you know, especially in this day and age, it's so hard. And so I felt like I had to create a way for the average therapist to get a better understanding of trauma. And how to address it below the level of talking.
Dr. Keith Sutton: (11:54)
Definitely. And I, and I'm, I was wondering if you might be able to speak on your conceptualization of complex PTSD, because it's really just, I've been getting more and more deeper into this. And now as I'm learning some of, uh, Pete Walker's work and your work and, structural dissociation and internal family systems. I also do EMDR, you know, just trying to get, I'm just getting a much deeper understanding. I would love to, to hear how you describe it.
Dr. Janina Fisher: (12:22)
Well, you know, complex PTSD was something , it's sad to say something that was being discussed in the early nineties. So, Judy Herman and Bessel Van Der Kolk both had this, this idea that we, that the simple post-traumatic stress disorder diagnosis didn't fit people with histories of childhood trauma. It often even didn't fit people who were combat veterans. It didn't fit people who were victims of domestic violence. And so, um, and so the, what is now called complex PTSD was first conceptualized as DESNOS, disorders of extreme stress not otherwise specified. And what was interesting about this description of DESMOS is that trauma, you know, when you looked at the effects of long-term chronic traumatization, what what we see are symptoms, mood disorder symptoms, depression, anxiety. We see personality disorder symptoms. And we see symptoms of, I think what, what was then called disorders of meaning.
Dr. Janina Fisher: (13:57)
Right. A loss of a sense of, of who I am. You know, in today's language, we'd probably say, many negative cognitive distortions. Right. It was my fault. Um, something's wrong with me. I deserved it. I deserved to die. All kinds of, of, of cognitive effects of trauma. So really complex PTSD is a combination of a complex history coupled with these complex symptoms and not so much necessarily in the way of flashbacks and nightmares. The classic PTSD symptoms. Usually people are more troubled by their depression, their anxiety, their mood swings from anger to fear, and the negative cognitive distortions.
Dr. Keith Sutton: (15:08)
And the, in one way I've been conceptualizing it lately, I don't know if this is fitting, is kind of, you know, oftentimes when the person either grew up or for a prolonged period of time, were in an environment where they did not feel safe essentially, and that amygdala was firing off and that it, you know, they, they had to really kind of, figure out a way at living in survival mode for so long. Cause you know, sometimes some people say, well, I wasn't beaten or something like that, so I couldn't have complex PTSD or, you know, it's kind of more those unpredictable environments where the person, again, has to be kind of on guard and, and really the hyper vigilance and all those pieces for a long period of time and, and really having to shape their whole in way of interacting with the world around that sense of keeping oneself safe.
Dr. Janina Fisher: (15:58)
Well, I think the question to ask those clients is, when you were growing up, were either of your parents or was any adult in the household ever frightening. Cause those clients will say, yes, my father was frightening and, and my mother was depressed. That's the typical answer. And then I then the second question is, and when you were growing up, did either of your parents ever appear frightened? And then usually they say, well, you know, my mother couldn't say a word to my dad. You know, none of us could. So you get all, and then, then often people do disclose the physical abuse.
Dr. Janina Fisher: (16:57)
Or even the sexual abuse. Cause once they start talking about how scary their mother or father was, they talk in, start to talk in more detail about, you know, up there. You know, my father believed, you know, spare the rod and spoil the child. And, and now, even though five minutes ago they would've said no if you asked them if they were ever abused. But now they're telling you about what was abuse. And so then it's very easy to say, okay, so you grew up in a family that wasn't safe. You didn't feel safe. And it wasn't safe. And so no wonder you're struggling with complex PTSD.
Dr. Keith Sutton: (17:51)
Definitely. And even also too, in the neglect situation where again, just feeling unsafe cuz the parents weren't there to take care of needs or so on. Um, you know, sometimes I think those can also play in around again, that, that that kind of being in that survival mode.
Dr. Janina Fisher: (18:07)
But I think we have to make a distinction, which unfortunately is getting muddied these days. There's a distinction between traumatic neglect, and the emotional neglect that children experience when parents are very busy and preoccupied or when, you know, the parents', kind of emotional availability is limited, versus traumatic neglect in which you don't know if anybody will be home. You don't know if there'll be dinner on the table. You don't know if you are gonna be an eight year old trying to run a household by yourself.
Dr. Keith Sutton: (18:58)
That's unpredictable.
Dr. Janina Fisher: (19:00)
Right. That’s frightening. As opposed to being ignored by busy parents is distressing and painful, but it's not frightening.
Dr. Keith Sutton: (19:10)
Yes. Yes. Definitely.
Dr. Janina Fisher: (19:12)
And that's a very important distinction that I wanna keep because I'm part of the generation that fought to have trauma recognized as something different than distressing, a distressing childhood.
Dr. Keith Sutton: (19:30)
Yeah. Good. I like that. So kind of that central piece being the, whether, you know, the feeling frightened.
Dr. Janina Fisher: (19:41)
Right. Which is very easy, again, to ask people with histories of neglect, right, were either of your parents, did either of your parents appear frightened? Did either of them frighten you?
Dr. Keith Sutton: (19:58)
Definitely. Now, I'd love to hear your thoughts on, you know, kind of the, the aspects of dissociation and, and I know that, um, gosh, I'm blanking on the, the term you were using, um, like the hyperfunctional part, kind of, or the going about life normally part or so on, which I thought was really interesting. And I know there's, you know, I, I had, Dick Schwartz on the podcast and we were talking a little bit about his conceptualization of kind of like, we naturally kind of have parts and other perspectives where like parts are, are, are result from trauma. Um, yeah. I just would love to hear your thoughts on those kind of ideas. And I know you also work with a lot of, you know, uh, extreme dissociation, DID and and so on.
Dr. Janina Fisher: (20:46)
Yeah. Right. And I, you know, I like, I like the idea that we all have parts that we all have aspects of ourselves. I think that's a really helpful framework for understanding oneself. Regardless of trauma. But Dick and I have a fundamental difference in perspective that I think comes from the fact that I come from the trauma world. And he comes from the family therapy and Gestalt world. So, so we're really looking at it from two very different perspectives. Um, in, in the perspective that I use, which is the structural dissociation model, dissociation or fragmentation as I like to call it, occurs as a way of surviving in a traumatic environment. And so if you're a child living in a traumatic environment, you still have to get up in the morning and brush your teeth and go to school. Right? You still have spelling tests no matter how much abuse you're suffering at home. And you need to be able to respond quickly and adaptively to an array of different behaviors on the part of abusive or neglectful parents. And so the structural dissociation model proposes that we all have an instinct to keep, keep putting one foot in front of the other that is not a, that is not a false self. It's not, or as Dick calls it a manager.
Dr. Janina Fisher: (23:03)
It's a, it's an intact, very important instinct that human beings have had since the days of the cavemen and women. Right. Because the cavemen and women had to, had to still get up every morning and hunt for food and keep the fire going and fetch water and all those things as well as defend against enemies and predators. So, the structural dissociation theory proposes that in the context of extreme stress, there's a split between the left brain keeping on, keeping on part of the personality because it takes the left brain to remember, oh, we're running outta water here, right. And, and right brain subparts that are connected to or driven by the basic survival responses of fight, flight, fear submission, and cry for help.
Dr. Janina Fisher: (24:22)
And, uh, and so that's, you know, in my, I have model, a trauma informed parts model called trauma informed Stabilization Treatment or TIST, um, which integrates a lot of ideas and techniques from internal family systems, lot of ideas and techniques from sensorimotor psychotherapy ideas and techniques from clinical hypnosis ego state models. Um, it's actually, you know, it's got a little CBT in it. It's got lots of different, different, uh, elements. But basically what we try to do is to help people sort of create a different relationship to those complex PTSD symptoms by relating to them as parts of themselves.
Dr. Janina Fisher: (25:35)
So that what, and what that actually does, it generally is to give them more control over. So, you know, if something triggers me and I feel rage, I want a strong going on with normal life self to say, okay, you're just triggered. You don't have to, you don't have to fight, you know, pause, think about it and work with that angry part. To find the most effective way. Because, because you know, the primitive fight response starts yelling, hitting, throwing things. You know, attacking other people, attacking one's own body, um, and then people get labeled borderline. And, uh, the vicious circle begins as opposed to noticing whether it's fear, anger, shame, noticing those reactions as the reactions of parts. And, you know, again, a lot of this, a lot of the technique is, is borrowed or, or developed from internal family systems ideas. But the, but the kind of the theoretical part of it is a trauma related.
Dr. Keith Sutton: (27:21)
Yeah.
Dr. Janina Fisher: (27:22)
Which is not true for IFS. IFS is not correct, is used for trauma, but it's not a trauma informed method.
Dr. Keith Sutton: (27:31)
Yeah. I like that idea of the appreciating the parts and, and having compassion and understanding, which, which I think is really nice. And what are, how do you think about it? Cuz I know, you know, with trauma, that's one of the hardest things is to recognize that it's this part. Cuz oftentimes, sometimes I think about it as like trauma mind sometimes when the person's triggered and they're tra in trauma mind, they have a hard time even accessing the part of them that knows that this is a separate part, but are are so, you know, and then one's kind of out of that fight or flight or deescalated or feeling safe again, then being able to access those other parts. How do you think about the process of helping a client moving from that, that kind of, that reactivity or that emotional flashback to that ability to have that kind of metacognition or that kind of psychological distance or cognitive diffusion to Oh wait a second. This is that part.
Dr. Janina Fisher: (28:27)
Well, it has to start, it has to start with something very simple. I mean, it was really Bessel VanDerKolk's brain research, brain scan research that first showed that when an individual is traumatically activated, the prefrontal cortex, the thinking brain shuts down. So of course, you know when people are triggered when they're threatened, and the thinking brain shuts down, they react, they don't think. So the first thing I do is to teach clients that they're triggered, and how to recognize being triggered. Which is also usually a relief once people get it, it's a huge relief because otherwise they feel enraged with themselves, enraged at other people. They feel hopeless, they feel ashamed. I've made a mess of my life.
Dr. Keith Sutton: (29:39)
I remember in the training too, you had talked about a client who, you know, was kinda like, I don't know, I just woke up feeling this way. Or very, and then you, like, when you both traced it back, you realized it was like a, it was gonna rain that day and he realized on the rainy days he was stuck inside with his mother. And that there's, it's almost always, you know, some, some trigger that sometimes we're not aware of. And so I imagine that also helps things feel less out of control out of the blue if, if the clients are understanding that there's something that's triggering that and that we might decipher it or maybe not sometimes, but yeah.
Dr. Janina Fisher: (30:13)
I mean, I think that the key is to understand why rain is triggering rather than go back into the event memories. Because, because that usually is more triggering. I mean, we know that telling the blow by blow story of something that's happened evokes the emotional responses associated with the event. That's why therapists keep trying to get people to talk about their events. Because they want them to feel the feelings. Um, but it doesn't work if they start to talk about the event and the prefrontal cortex shuts down and they're overwhelmed.
Dr. Keith Sutton: (31:06)
Yeah.
Dr. Janina Fisher: (31:08)
So, what I teach clients to do is to keep the prefrontal cortex online to learn how to notice these signs that they're triggered. Whether they're somatic signs like my body tenses or braces or start, I start to shake. Or whether it's what I call suddenness intensity and duration, the feeling hits you like a ton of bricks. Um, to me that's a triggered feeling.
Dr. Janina Fisher: (31:50)
Unless, you know, unless I have a mugger at the door, I'm not gonna suddenly be hit by a feeling like a ton of bricks. And so, so just, that's usually the best place I've found to start to help people keep that prefrontal cortex online. Mindfulness, helping them to notice, rather than interpret the experience. Because, you know, the truth is that most of us, I have to say as a human condition, we tend toward negative interpretations, not positive. If you think about the average person on the average day, we're much more likely to interpret things negatively. And that doesn't usually help.
Dr. Janina Fisher: (32:56)
So learning to notice and be interested in what we experience, how we react, what feelings come up, what thoughts come up, it's calming for the nervous system and it keeps us out of trouble. Keeps us out of making things worse for ourselves.
Dr. Keith Sutton: (33:19)
Being curious about it rather than just interpreting.
Dr. Janina Fisher: (33:22)
Right. Cause in, in my, the mindfulness world, people are taught to notice with interest, to be interested in what they notice, good, bad, and ugly. Without attachment or aversion. Meaning without trying to push away a feeling or without getting too attached to this is how I really feel.
Dr. Keith Sutton: (33:53)
Yeah. And that's, yeah. That's great. And then, and so kind of bringing in that prefrontal cortex and then, what kind of bottom up processing are you doing? Are you still doing EMDR or is it mostly with the sensory motor or, how, yeah, how are you kind of doing those aspects?
Dr. Janina Fisher: (34:15)
Um, you know, um, that's, that's harder to say because I've been trying to retire from practice for the last five years. So I'm not doing much of anything anymore. I'm doing a lot of consulting to therapists and to clients, and a lot of teaching. Mostly what I do is teaching. So if I were in practice, I, you know, I probably still would use an eclectic approach because most people that I get referred are extremely high functioning and very, very, very traumatized. So they function professionally at a high level, and they're tortured inside. And usually, what the kind of, the intensity of their symptoms and their limited ability to regulate the symptoms, makes them poor EMDR clients candidates because they're at the highest risk for to be overwhelmed by EMDR treatment. Even though they're so super high functioning. That you would think, I always include the body in whatever I'm doing.
Dr. Janina Fisher: (35:57)
And so that's, you know, even, even a consultation because you know, the body is where it all starts, right. Emotions start in the body. Images start in the body. Even cognitions, I would forget the brain is part of the body. So, I tend, I suppose, not to use any one approach, but to use the combination of approaches that work for the client. And particularly I use my trauma-informed stabilization treatment or TIST. Because that's, that's probably what I'm most passionate about these days. Why, I'm just in the process of finishing up my first online TIST training and we started out with a group of 500 clinicians from all over the world in the level one training. And now we have a hundred of that original 500 who are doing a certification training. Wonderful. And, uh, so then we'll have, we'll have certified TIST therapists that we can recommend or that clients can look up online. It's very exciting. And what's lovely about TIST is it's such a good treatment for complex PTSD, because it's, you can work with all of the complications from suicidality to addiction, to over-functioning, under-functioning.
Dr. Keith Sutton: (37:58)
Well I'm glad that you mentioned the suicidality cuz I was also struck by some of the, what you discussed regarding suicidality in your work. And I really liked, I don't know if you could speak to some of the ways you're conceptualizing that, cause I thought that was really helpful. Um, particularly in clients that might be, have a diagnosis, borderline personality disorder or you know, again, that, that are having this complex PTSD. Can you talk a little bit about that? I thought that was really interesting.
Dr. Janina Fisher: (38:24)
Right. And, and I'm reminded of a, uh, of a client who, whom I interviewed. I did a video interview with her and she talked about how absolutely useless and actually harmful it was to be given the borderline diagnosis and to be told she was attention seeking and manipulative. And there's this wonderful moment where she says, this is a 23 year old young woman, many suicide attempts in hospitalizations. And she said, didn't they understand that if they called us manipulative and attention seeking, we'd wanna kill ourselves even more. Right? So, um, so what, what I believe what I, the belief I've developed, which really comes from having a somatic perspective and a structural dissociation perspective, is that suicide is just the other side of the coin from homicide, right. That we all have a fight response. We're born with that basic instinct to fight or flee or submit or cry for help.
Dr. Janina Fisher: (39:56)
And that that fight response can be turned against others or against one's own body. And the trauma survivors often learned as children to turn those fight responses against their own bodies because it wasn't safe to turn them against a parent's body. Right. I mean, I'm sure any parents who are listening have had experiences of small children hitting them, kicking them, otherwise fighting them. You know, I often ask people when they say, you know, I'm afraid, I don't want my child to feel unsafe. And I say, well, does your child ask for what he wants? And they say, oh yes. Does your child protest when you say no? Absolutely. Does your child persist in asking for what you just said? No. And, and they say yes. And then I say, well that's the good news is your child feels safe. Because if we don't feel safe, we don't fight the parent.
Dr. Keith Sutton: (41:26)
Yeah. I appreciate you saying this cuz it's just making me think of, I've got some of my clients that, cause I also work with children, families and oftentimes end up working with the parents after kind of getting things going with the children. And one of the parents I was working with, which is so incensed that the child is asking for what they want, you know, and, and that just felt, was feeling so frustrating. So kind of like unappreciative or so on. And then we, yeah. We had to look at that because again, that they didn't get to do that in their family. And so seeing there was, there was, they had such mixed feelings about their children asking for what they want. Cuz there was a system in their own mind of like, don't do that. That's bad. So it's helpful to understand in that context.
Dr. Janina Fisher: (42:09)
Absolutely. Yes. Yeah. And often parents I think are triggered when their children engage in behavior that would've been dangerous in their world. And, and so I've had many clients who were triggered by their children's asking for what they want persisting when they've been told no. I remember actually one of my few remaining clients, complained to me recently that her, she was disciplining her five-year-old son, and she said to her son, go to your room right now. And he turned around and said to her, no, you go to your room. And and of course she was triggered and incensed because she would've been, she would've been killed. For saying something like that to a parent.
Dr. Keith Sutton: (43:08)
Wow. Now back to the suicide piece, I think, you know, one of the things that, that I think, you had talked about also is that, you know, you know, especially for someone experiencing childhood trauma, sometimes there was this, you know, fantasy of dying and that was a way of, of helping to dissociate, helping to decrease the distress and, and you know, kind of seeing some of the suicidal ideation, you know, uh, also as a means of coping.
Dr. Janina Fisher: (43:38)
Oh, absolutely. Yeah. Yes. And particularly, you know, when clients, when clients express suicidal ideation, or they are self-harming or they're restricting or binging and purging, I asked them, how old were you the first time you thought about dying as a way to get out? And it's amazing. People say eight, seven, you know, 10, I mean so young. Because, you know, often for children trapped in a dangerous situation that seems like the only possible hope. So I think, so what I, the way I conceptualize and try to help clients conceptualize suicidality is that it's a suicidal part trying to help them, trying to say, look, give it up. You know, just, just see, here's the exit, here's the parachute, take it and go. And, and that, and which is ironic because most of these individuals have fought so hard to survive.
Dr. Janina Fisher: (45:18)
You know, it's been often a life's work just to fight to survive. And then the suicidal part says, ah, why are you fighting so hard? Working so hard? Right. Look, there's the exit sign right over there. And so I, I really get people to notice the suicidal feelings as a suicidal part. And I teach my students to do the same and to be very, um, persistent that, you know, because many times clients say, you know, every cell in my body wants to die. It's not just a part, it's all of me. And, and I have to say, I know it feels like it's all of you. And I'm sure that every cell in your body wants relief, but they don't necessarily wanna be killed. And that's, that's really the, the difference in perspective that seems to help.
Dr. Janina Fisher: (46:34)
I mean, the young lady who told me, you know, why didn't the doctors realize that calling us manipulative would make us wanna die more, she again had been chronically suicidal since age 13. Many, many hospitalizations. And when, when I taught her the structural dissociation model And I, and I said, this, your suicidal part is your fight part. That's the part of you that, that sees suicide as the only fight that you can win. And this young lady was also substance abusing. And so we talked about how her flight part would say, her flight part would say, Hey, have some drugs. Her, her suicidal part would say, oh, why don't you cut yourself, or even better die. And so she was able to actually, in just a couple sessions, she was able to change her perspective so that when she had the suicidal ideation or impulses, she would, she recognized those as the fight part. She would say, you seem to be having a bad day, how can I help you? And it totally changed. I think I met her, I'm gonna say I met her in 2015. I know her therapist, her, her therapist is a colleague of mine. And to this day, she has never been hospitalized.
Dr. Keith Sutton: (48:27)
Wow.
Dr. Janina Fisher: (48:28)
Because she got it and she learned every time she had the suicidal thoughts and feelings, she knew, okay, that's not me. That's my fight part.
Dr. Keith Sutton: (48:40)
That's great. Yeah. Having that shift in that kinda understanding and changing that relationship to the symptoms.
Dr. Janina Fisher: (48:46)
Right. And I can, I can think of so many clients who were chronically suicidal for years and years, and once they could relate to the suicidal ideation as a part, it totally, it changed. Doesn't mean, it doesn't mean the suicidal part doesn't get triggered again. But it's a totally different experience to notice those feelings and impulses as, as being a part on a mission.
Dr. Keith Sutton: (49:20)
Yeah. And we're almost outta time, there's one last piece that I think was really that, that was really striking from the, the workshop that I took was, you know, also talking about kind of that, you know, you know, of course many clients are, especially with trauma, are not gonna, are gonna have a hard time trusting the therapist, but also being able to just make space for that. I think you gave an example of a therapist who you're consulting with who is asking the client, why don't you trust me? And kind of feeling like there was a therapeutic issue or so on, rather than kind of understanding that the client may never trust them, especially, you know, earlier in, in the treatment and so on. And, and just kind of even speaking that to the client allowing that to be there.
Dr. Janina Fisher: (50:02)
Right, right, right. As I think, you know, that all goes back to the issue of do we communicate to the client that we get it, that we understand, because that's what creates safety. If we don't understand, we could be the nicest, gentlest, most mild mannered, non-judgmental person in the world, but if we don't understand them, if we're not getting it, we're not gonna feel entirely safe. And so, I really feel quite genuinely that that trust is not a prerequisite for therapy. Therapy is a collaboration and, and you know, we can collaborate with people we trust completely, but we can also collaborate with people that we don't fully trust. It's all about the willingness to work together. So, I really try to take the monkey off the back of the client. Because, because it's an unreasonable expectation. It's like saying you'll never get better unless you can trust, but they can't trust until they're, they're doing and feeling better.
Dr. Keith Sutton: (51:30)
Yeah, exactly. Right. Yeah. And putting it in that context, I think is relieving, you know, for the, and, and not making it an area where the, the therapist and the client could get stuck and, and again, just honoring their experience and that not feeling safe.
Dr. Janina Fisher: (51:49)
Right. Absolutely. And you know, I think for all of us, if it feels so much safer, if we're not under pressure to believe people, trust people, you know, do what we're told.
Dr. Keith Sutton: (52:08)
Yeah, definitely.
Dr. Janina Fisher: (52:09)
And, and so often as therapists, we kind of expect clients to buy what we're offering.
Dr. Keith Sutton: (52:18)
To get on board and go along rather than working together and deciding to, to get on board together and go somewhere.
Dr. Janina Fisher: (52:25)
Right. Right. Yeah, I mean, one of the things I used to do, which might have been going a little overboard, but I would say to clients, you know, maybe third, fourth this session, after I'd gotten to know them a little bit, I would say, you know, we have a choice in how we can work. And I, I used to have an easel in my office, so I'd actually write it out on the easel. I'd say, you know, we could do regular talking therapy, otherwise known as psychodynamic therapy. And then I would list, and here's, here's what that entails. Here are the pros, here are the cons. We could do EMDR, here are the pros, here are the cons. We could do sensorimotor psychotherapy, or we could do parts therapy. And uh, and, and then the client has made a choice, right. If they say
Dr. Keith Sutton: (53:31)
-they've got the agency.
Dr. Janina Fisher: (53:33)
Right. And they've also made a commitment. So it's much harder to, you know, because if they kind of, if they're, what I, I hate to use the word resistant. But if they're resistant,
Dr. Keith Sutton: (53:50)
Yeah, yeah.
Dr. Janina Fisher: (53:51)
Then I can say, well, let's go back to our choices. We could do psycho. Right.
Dr. Keith Sutton: (53:58)
I have to, I have a similar thing. Yeah. Cuz sometimes the clients almost feel like the therapy gets away from them and they're like, Ooh, I don't want, and say like, Hey, you know what? You're the captain of the ship here. I know you wanted to work on this trauma because you wanted to be closer to your husband and you felt like this was so, but we don't have to do that. We can do this. And then oftentimes when the person feels like, no, actually no, that is what I want to do. And really again, them taking the lead again, filling that agency and filling, cuz it, it sometimes shifts to feeling out of control. So kinda going back to that.
Dr. Janina Fisher: (54:30)
And the other thing, your example is a great one because it reminds me that often, whatever the treatment we're using, it's triggering. So your client comes in wanting to work on the marriage by working on the trauma, but then working on the trauma is triggering. And so then there's like, oh, I don't know about this. And so it also really helps to say, you know, is this maybe a little triggering for you? Cuz we could slow it down. We don't have to do, go full bore. We can slow it down. We can do, you know, again, I don't ever focus on the events ever. Ever, ever, ever, ever. Because my mission besides teaching TIST is to help people to see, it's the effects of what happened that we have to address.
Dr. Keith Sutton: (55:42)
Well thank you so much. This has been so wonderful today and I really appreciate getting to know more of your work. And, and I, I know this will be very helpful for our listeners and I'll link to the, to your TIST model and that training. I think that sounds great. It's so wonderful to hear that's available. I'm gonna check that out myself. And we'll also link to, I know you've also done a lot of writing and, and, all these kind of resources, which I think will really be great for therapist's interest in learning more and, and getting more training. So thank you so much for taking the time to be here with us today.
Dr. Janina Fisher: (56:13)
My pleasure, Keith. Take care.
Dr. Keith Sutton: (56:16)
Thank you. Bye-bye.
Dr. Janina Fisher: (56:19)
Bye.
Dr. Keith Sutton: (56:20)
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