15
Dissociative Psychologies
When I first wrote this chapter in 1993, it was new to include attention to dissociative psychologies in a psychodynamically oriented book on personality. Since then, there has been an explosion of psychoanalytic attention to dissociative phenomena, especially among therapists identified with the relational movement (e.g., Boulanger, 2007; Bromberg, 1998, 2010; Davies & Frawley, 1994; Grand, 2000; Howell, 2005; D. B. Stern, 1997, 2009) and researchers in attachment (Liotti, 2004; Lyons-Ruth, Bronfman & Parsons, 1999) and cognitive and affective neuroscience (Panksepp, 1998; Schore, 2002; Teicher, Glod, Surrey, & Swett, 1993). Students of trauma and child development have generated new paradigms for understanding what was once called multiple personality and what recent editions of the DSM have labeled “dissociative identity disorder”—that is, dissociative reactions that are automatic, chronic, and repeated throughout the lifespan, the pattern that has struck me and some other writers as describable in terms of dissociative personality structure (cf. I. Brenner, 2001, 2004; Classen, Pain, Field, & Woods, 2006).
To update this chapter in the face of a flood of new data, I have collaborated closely with Richard Chefetz, who straddles the worlds of psychoanalysis and trauma studies, has extensive experience treating dissociative clients, and writes with particular poignancy about the topic, integrating attachment theory, affective and cognitive neuroscience, and relational psychoanalytic perspectives on multiple self-states with core work in traumatology (e.g., Chefetz, 2000a, 2000b, 2009, 2010a, 2010b). He is further along than I am in the paradigm shift that is in process; he rejects the concept of dissociative personality structure or personality disorder (Chefetz, 2004) and views my way of organizing diagnostic data as dependent on a flawed ego psychology model that has too often gotten in the way of therapists’ appreciating the dissociative process.
It may be true that organizing chronic and severe dissociative conditions under the rubric of traditional personality categories is not the best paradigm or metaphor for dissociative phenomena. I continue to feel, however, that dissociative identity disorder and other complex dissociative conditions should be represented in this book, given the crucial diagnostic importance of distinguishing the dissociative process from other patterns that may infuse character. In this chapter, I try to provide some fundamental knowledge to help readers with dissociative clients, while holding open the possibilities for different constructions of how to organize that information.
Until approximately the 1980s, multiple personality disorder and related psychologies based on severe dissociation were considered rare enough to preclude their incorporation into schemata of personality types and disorders. It has become clear, however, that many people engage dissociative processes quite actively as a first-line adaptation to deal with destabilizing situations such as emotional intensity. For many of them, their dissociative experience is ego syntonic and assumed to be normal. If dissociative identity disorder were not “a pathology of hiddenness” (Gutheil, in Kluft, 1985), in which the patient is often unaware of having dissociated self-states (alter personalities), and in which trust is so problematic that even those parts of the self that know about the dissociation are reluctant to divulge their secret, we might have known long ago how to begin identifying and helping dissociative clients.
In fact, some people did know long ago. A regrettable side effect of Freud’s ultimate privileging of maturational issues over traumatic ones, and of repression over dissociation, is that it distracted us from some fine scholarship on dissociation that was available at the end of the 19th century. Pierre Janet (1890), for example, explained many hysterical symptoms by reference to dissociative processes, explicitly disputing Freud’s favoring of repression as a primary explanatory principle (see van der Hart, Nijenhuis, & Steele, 2006, which builds upon Janet’s work). In the United States, William James and Alfred Binet were both interested in dissociation. Morton Prince (1906) published his detailed case of a dissociative woman around the time that The Interpretation of Dreams (Freud, 1900) was attracting notice (unfortunately, the eventual impact of the latter virtually eclipsed that of the former—see Putnam, 1989; C. A. Ross, 1989b). In mid-20th-century theorizing, Sullivan’s (1953) concept of “not-me” states as a normal variant of experience came closest to capturing the subjective experience of dissociation.
Therapists experienced with dissociative clients view multiplicity not as a bizarre aberration but as an understandable adaptation to a particular kind of history—specifically, as a chronic posttraumatic stress syndrome of childhood origin (D. Spiegel, 1984). Because of the extensively documented differences among the self-states of someone with dissociative identity disorder, the condition has been widely sensationalized. These differences (which may include subjective age, sexual identity and preference, systemic illnesses, allergies, eyeglass prescriptions, electroencephalogram [EEG] readings, handwriting, handedness, addictions, and language facility) are so impressive that lay people may consider multiple personality disorder the most exotic mental illness they have ever heard of. So do many therapists with little experience treating dissociation.
No other documented disorder has inspired comparable arguments about whether it exists at all independent of iatrogenesis. Dissociative phenomena can certainly strain credulity, but I find it no harder to accept that the mind has a method of segregating intolerable experience than I do to take seriously the fact that some people believe they are obese when they are in fact starving to death. George Atwood once remarked to me that the controversy over whether dissociative identity disorder “exists” eerily parallels the quandary of the dissociative patient (“Do I remember this, or am I making it up?” “Should I take my experience seriously, or dismiss it as attention seeking?”).
We now know (Solms & Turnbull, 2002) that glucocorticoids secreted during traumatic experience can shut down the hippocampus, making it impossible for episodic memory (the memory of being there) to be laid down in the first place. Semantic memory (third-person facts about the event), somatic–procedural memory (body experiences of it), and emotional learning (the amygdala’s storing of affect connected to triggers) remain operative, but the sense of “I was there and it happened to me” may never have been established in the brain and hence is not recoverable. Thus, because trauma damages memory, one frequently knows that a client has been traumatized, but not the details of how (J. H. Slavin, 2007). Along with many other therapists who have treated dissociative patients, I have found myself construing the controversy about “whether dissociative identity disorder exists” as a pervasive social countertransference to a condition that can be unbearable to imagine.
Considered in context, dissociation that results in “alter personalities” (Putnam, 1989) or experiences of “isolated subjectivity” (Chefetz, 2004) and the “elsewhere thought known” (Kluft, 2000) is not so incomprehensible. Researchers in cognitive psychology (e.g., Hilgard, 1986; LeDoux, 1996, 2002) have described simultaneous, coexisting trains of thought in both patient populations and “normals.” Investigations into dissociative states and hypnosis (people who dissociate are actually entering spontaneous hypnotic trances) have revealed some remarkable capacities of the human organism and have raised absorbing questions about consciousness, brain functioning, integrative and disintegrative mental processes, and latent potential. Still, clinicians know that each of their dissociative patients is in most respects an ordinary human being—a single person with the subjective experience of different selves—one whose suffering is only too real.
The first carefully documented case of multiple personality since M. Prince’s (1906) “Miss Beauchamps” was Eve (of The Three Faces of ... ), the pseudonym of Christine Costner Sizemore (Sizemore, 1989; Sizemore & Pittillo, 1977; Thigpen & Cleckley, 1957). Sizemore, a woman of impressive energy and achievement, is a good exemplar of a high-functioning dissociative person. It is notable that the first sufferer of characterological dissociation to “come out” to a therapist in this era was someone with considerable basic trust, ego strength, and object constancy. More disturbed individuals who are diagnosable with dissociative identity disorder, even when they suspect their multiplicity, are much too afraid of mistreatment to let a naive clinician in on their troubled inner life—especially early in therapy. A dissociative woman I treated for several years said that the deinstitutionalization of mental patients in the 1970s, which made it less likely that she would be locked up for life in some snake pit, contributed to her mustering the courage to admit to her hallucinatory experiences and “lost time.”
Josef Breuer’s famous patient “Anna O” (Bertha Pappenheim), a person who influenced psychoanalytic history in incalculable ways, is another example of a high-functioning multiple personality. Breuer and Freud (1883–1885) regarded her dissociated states as only one part of her hysterical illness, but most contemporary diagnosticians would consider her primarily dissociative. Consider the following description:
Two entirely distinct states of consciousness were present which alternated very frequently and without warning and which became more and more differentiated in the course of her illness. In one of these states she recognized her surroundings; she was melancholy and anxious, but relatively normal. In the other state she hallucinated and was “naughty”—that is to say, she was abusive, used to throw the cushions at people... . [I]f something had been moved in the room or someone had entered or left it (during her other state of consciousness) she would complain of having “lost” some time and would remark upon the gap in her train of conscious thoughts... . At moments when her mind was quite clear she would complain ... of having two selves, a real one and an evil one which forced her to behave badly. (p. 24)
This remarkable woman went on, after an abortive treatment with Breuer, to be a devoted and highly effective social worker (Karpe, 1961).
In contrast to Christine Sizemore and Bertha Pappenheim, who were able to function well through large parts of their lives, are the ruthlessly self-destructive and “polyfragmented” patients who dissociate so automatically and chaotically that they experience themselves as having hundreds of “personalities,” most of which consist of limited attributes that address some current issue. Truddi Chase (1987), whose many self-states the popular media touted during the resurgence of interest in dissociation, may be in this category, though it is arguable that if her therapist had been less invested in publicizing her dissociated condition, she might not look so splintered. Many dissociative people in the psychotic range may be in jails rather than mental hospitals; alter personalities who rape and kill, often in delusional states of mind, are possible outcomes of the traumatic abuse and neglect that create multiplicity (Lewis, Yaeger, Swica, Pincus, & Lewis, 1997).
Since the rediscovery of dissociation in the last three decades, there has been considerable mutual ambivalence between the psychoanalytic community and those who led the movement to gain and disseminate knowledge of dissociation. On the one hand, analysts appreciate the power of organized unconscious forces; consequently, the idea of traumatically created, out-of-consciousness alter personalities does not require from them a huge leap of imagination. And they tend to work with patients over months and years, during which the covert parts of a dissociative person may build up the courage to expose experiences that are unacknowledged in the self-state in which the client usually comes to therapy. Thus, analytic therapists are more likely than other professionals to have worked with people who have revealed their multiplicity, and many of them doubtless addressed such revelations respectfully, with a willingness to learn from the client about a condition that was not emphasized in their psychoanalytic training.
On the other hand, until recent developments in analytic theory, psychodynamic clinicians tended to accept the explanatory preferences of Freud, who eventually put less emphasis on trauma and molestation than on fantasy and its interaction with developmental challenges. Also, and curiously, Freud had little to say about multiple personality, a condition that was recognized in his day by several of the psychiatrists he revered (although he once made the off-hand comment, “Perhaps the secret of the cases of what is described as ‘multiple personality’ is that the different identifications seize hold of consciousness in turn” [1923, pp. 30–31]). His blind spots contributed to a tendency in some Freudians to regard reports of incest and molestation as fantasy. Intriguingly, Freud’s original “seduction theory” ran aground on a problem that later resurfaced in the form of the “false memory controversy” about reports of childhood sexual abuse: Trauma distorts perception, impairs memory, and creates a basis for later confusions of fact and fantasy (Dorahy, 2001). This is true for traumatized patients as well as for therapists with traumatic histories—people who have suffered trauma may be especially attracted to the profession of helping others or to the study of trauma—and so the possibilities for misunderstanding and confusion are vast.
In addition to habits of thought that derive from Freud, people trained in the psychodynamic tradition have sometimes misapplied developmental concepts to the switches in consciousness that signal the emergence of dissociated self-states. For example, they have been more inclined than other mental health professionals to interpret them not as alterations in consciousness but as nonamnesic regressive episodes or as evidence of defensive splitting. As a result, they have often failed to ask questions that would discriminate between the splitting off of what has once been integrated and the dissociation of what has always been held separately (D. B. Stern, 1997).
Some therapists who have distinguished themselves by their commitment to learning and teaching about trauma and dissociation have thus found it hard to forgive Freud and Freudians for minimizing both the prevalence and the destructiveness of the sexual abuse of children. Some also lament the influence of thinkers like Kernberg, on the grounds that they have conflated trauma-related dissociation with developmentally normative splitting and have thereby misdiagnosed many people with dissociative personalities as borderline or schizophrenic—a mistake that can cost such a patient years of misguided treatment. Specialists in dissociation (e.g., C. A. Ross, 1989a) rightly complain that legions of desperate people have been misunderstood and retraumatized for years by unnecessary medical procedures (e.g., major tranquilizers, electroshock). Critics of exponents of dissociation counter that when one is looking for them, one can find a multiple under every rock (cf. Brenneis, 1996; D. R. Ross, 1992). Fads in psychopathology are not unknown, especially in conditions in which suggestibility may play a large role.
I review all of this because it remains true that, even though dissociative identity disorder and other dissociative conditions have attained respectability by inclusion in the DSM, a certain polemicism infuses the work of both explicators and critics of dissociative concepts. This is to be expected in any field when there has been a paradigm shift (Kuhn, 1970; R. J. Loewenstein, 1988; Loewenstein & Ross, 1992). I urge readers, whatever your biases, to try to comprehend the phenomenon of dissociation with an “experience-near” sensibility; that is, from the standpoint of empathy with the internal experience of the person who feels and behaves like a composite of many different selves. My own understanding of dissociation is still developing, and I suspect that much of what I say here will eventually be revised. It is less important to decide which experts to believe than to try to comprehend what patients experience.
DRIVE, AFFECT, AND TEMPERAMENT
IN DISSOCIATIVE CONDITIONS
People who use dissociation as their primary defense mechanism are essentially virtuosos in self-hypnosis. Movement into an altered state of consciousness when one is distressed is not possible for everybody; you have to have the talent. Just as people differ in their basic levels of hypnotizability (Spiegel & Spiegel, 1978), they differ in their capacities for autohypnosis. To learn to dissociate automatically, one has to have the constitutional potential to go into trance; otherwise, trauma may be handled in other ways (e.g., repression, acting out, substance use).
Some have suggested that people who develop dissociative identity disorder are innately more resourceful and interpersonally sensitive than the norm. A child with a complex, rich inner life (imaginary friends, fantasy identities, internal dramas, and a penchant for imaginative play) may be more able to retreat to a secret inner world when terrorized or emotionally traumatized than a less gifted youngster. Clinical lore suggests that people who struggle with dissociation are as a group brighter and more creative than average. Such observations may be artifactual; those who come for help may not be typical of the whole dissociative spectrum. It was once thought that Eve and Sybil (Schreiber, 1973) were paradigmatic multiples, but their more hysteroid presentations are now seen as characteristic of only a small percentage of those who dissociate (Kluft, 1991).
To my knowledge, no drive constructs have been put forward to account for dissociative phenomena, probably because by the time the mental health community attended seriously to dissociation, the hegemony of psychoanalytic drive theory was over. With respect to affect, however, the picture is clear: Dissociative people have been overwhelmed with it and have gotten virtually no help processing it. Their affect is consequently in a state of chronic dysregulation (Chefetz, 2000a). Primordial terror, horror, and shame are foremost among the emotions that provoke dissociation in any traumatic situation; rage, excitement, and guilt may also be involved. The more numerous and conflicting the emotional states activated, the harder it is to assimilate an experience without dissociation.
Bodily states that may instigate trance include intolerable pain and confusing sexual arousal. While it is possible to develop a dissociative identity in the absence of early sexual trauma and abuse by caregivers, empirical studies have established this relationship in the vast majority of cases in hospital settings severe enough to be diagnosed as dissociative identity disorder (Braun & Sacks, 1985; Putnam, 1989). More and more, neglect is emerging as equally pathogenic (Brunner, Parzer, Schuld, & Resch, 2000; Teicher et al., 2004); the child who is sexually used by a parent and otherwise ignored (by both the exploitive parent and other caregivers) suffers unbearably and must resort to dissociative solutions. Bullying and peer aggression (Teicher, Samson, Sheu, Polcari, & McGreenery, 2010), emotional abuse, and—probably most pathogenic of all—witnessing of domestic violence (Wolf, Gales, Shane, & Shane, 2000) are found in the histories of people with severe enough dissociation to meet DSM criteria for dissociative identity disorder.
DEFENSIVE AND ADAPTIVE PROCESSES
IN DISSOCIATIVE CONDITIONS
Dissociative defenses that become relied on as a first-order strategy are like any others in that they begin as the best possible adaptation of an immature organism to a particular situation, then become automatic and hence maladaptive in later circumstances. Some adults with dissociative personalities have merely continued to use simple and sophisticated “below-the-radar” dissociative processes to regulate affect ever since the time of their original traumas; others, once the abusive practices ceased, have achieved for significant periods either a tenuous cooperation of alter personalities or the consistent domination of their subjective world by one self-state.
One common clinical presentation is the person whose observable dissociation stopped when he or she left the family in which it originated, only to surface again when a son or daughter reached the age at which the parent was first abused. (This identificatory connection is usually completely out of consciousness.) Another frequent trigger for dissociation in an adult whose autohypnotic tendencies have been dormant is an experience that unconsciously recalls childhood trauma. One woman in my practice suffered a household fall that injured her in the same places where she had been mutilated during childhood ritual abuse, and for the first time in years she suddenly became someone else. In taking a careful history, one often finds many minor instances of dissociation throughout the patient’s adult life, but what usually brings the person to treatment is some dramatic and disabling dissociative reaction (losing significant amounts of time, being told of things one cannot remember, suffering interruption of the daily routines of living that have allowed the person to avoid feeling through doing). It is phenomena like these that prompted Kluft (1987) to talk about “windows of diagnosability” in dissociative conditions (see R. J. Loewenstein, 1991).
Dissociation is an oddly invisible defense. When one self-state or system of alters is running things smoothly, no one outside the client can see the dissociative process. Many clinicians believe they have never treated someone with dissociative identity disorder—perhaps because they expect such a client to announce his or her multiplicity or to generate a dramatically alien alter personality. Sometimes this happens, but more commonly, indications of dissociation are subtle. Frequently, only one alter personality goes to therapy in a particular session. Even when a fairly identifiable alter emerges in treatment (e.g., a frightened child), an unenlightened therapist will tend to read the change in the patient in nondissociative terms (e.g., as a passing regressive phenomenon).
My first experience with a severely dissociative client—knowingly, that is—was at one remove. In the early 1970s, a close friend and colleague at Rutgers was conferring with me about treating a student who had exposed her multiplicity in the second year of her therapy with him. I found his account riveting. Sybil had just been published, and I remember thinking that this woman must be one of only a dozen or so extant multiples. Then he mentioned that she was in a course that I taught and, with her permission, told me her name. I was stunned. I would never have guessed that this young woman was dissociative; from the outside, the shifts that indicated “switching” looked like minor changes of mood. Since I knew from my friend how painfully she struggled with amnesia, it was an unforgettable lesson in how opaque the condition is to observers, even credulous ones. I began to wonder how many other hidden dissociative people there might be.
Accurate appraisal of the demographics of dissociation is hampered by its invisibility. I have sometimes consulted with spouses of people with dissociative psychologies, who, despite full awareness of their partner’s diagnosis, have made comments like, “But yesterday, she said the opposite!” Cerebral knowledge that one was talking to a different alter yesterday pales against the data provided by one’s senses: I was speaking to the same physical person on both days. If intimate partners of those with admitted, diagnosed dissociative identity disorder miss signs of dissociation, it is not hard to see how professionals can be even blinder, especially if they have been advised to view the topic skeptically. People who dissociate learn to “cover” for their lapses. They develop techniques of evasion and fabrication in childhood, as they find themselves repeatedly accused of “lying” about things they do not remember. Because they have suffered grievously at the hands of people who were supposed to protect them, they do not trust authorities, and they do not come to treatment with the expectation that full disclosure is in their interest.
The estimation of how many of us rely heavily on a dissociative adaptation to living also depends on how the term is defined. In addition to “classic” multiple personality, there is the condition currently labeled dissociative disorder not otherwise specified (DDNOS), in which alter personalities exist but do not take executive control of the body or who do so but with no demonstrable amnesia. There are also other dissociative phenomena such as depersonalization—after depression and anxiety the third most commonly reported psychiatric symptom (Cattell & Cattell, 1974; Steinberg, 1991)—that can be frequent and longstanding enough to be considered characterological.
In 1988, Bennett Braun suggested a conceptualization that has come to be known by the acronym BASK (behavior, affect, sensation, knowledge). With it, he elevated the concept of dissociation to the status of a superordinate category rather than, as Freud had conceived it, a more peripheral defense. Braun’s model subsumes many processes that often occur together but have not always been seen as related. One can dissociate behavior, as in a paralysis or a trance-driven self-mutilation; or affect, as in acting with la belle indifférence or remembering trauma without feeling; or sensation, as in conversion anesthesias and body memories of abuse; or knowledge, as in fugue states and amnesia. The BASK model views repression as a subsidiary of dissociation (dissociation of knowledge) and puts a number of phenomena that were previously regarded as hysterical into the dissociative domain. It also links to trauma many issues that have tended to be understood in terms of intrapsychic conflict. Some contemporary psychoanalysts (Bromberg, 1998; D. B. Stern, 1997) have similarly relocated defensive processes under the umbrella of dissociation. Therapists working with diagnosed dissociative patients have found such formulations useful; those working with others may find that it sensitizes them to the dissociative processes that occur in all of us.
RELATIONAL PATTERNS IN DISSOCIATIVE CONDITIONS
The outstanding feature of the childhood relationships of someone who becomes regularly dissociative is abuse, including but not limited to sexual abuse. The caregivers of people with dissociative identity disorder are frequently themselves dissociative, either directly, as a result of their own traumatic histories, or indirectly, via altered self-states created by alcohol and other drugs. Because the parents often have amnesia for what they do—whether it is psychogenic amnesia or substance abuse-related blackouts—they both traumatize their children and fail to help them understand what has happened to them.
Severely dissociative clients show “Type D” attachment, the disorganized–disoriented type associated with infantile experience in which the object of safety is also the object of fear (Blizard, 2001; Fonagy, 2001; Liotti, 1999; Lyons-Ruth et al., 1999; Main & Hesse, 1990; Solomon & George, 1999). Disorganized attachment may increase susceptibility to traumatic experiences even when its source lies not in overt abuse but in a mother’s emotional unavailability (Pasquini, Liotti, Mazzotti, Fassone, & Picardi, 2002). Avoidant attachment may also predict dissociation (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). Traumatic experience early in life has devastating effects on psychic structure (Schore, 2002), distorting the development of the limbic system (Teicher et al., 1993), causing abnormalities in the corpus callosum (Teicher et al., 2004), and interfering with the development of the cerebellar vermis (Anderson, Teicher, Polcari, & Renshaw, 2002). Chronic hyperarousal floods the brain with glucocorticoids that damage the hippocampus (Solms & Turnbull, 2002). Severe trauma can override any constitutional, environmental, genetic, or psychological resilience factor (de Bellis, 2001).
Herman (1992) and Liotti (1999, 2004) have elaborated on the internal presence in traumatized people of perpetrator, victim, and rescuer images—the “drama triangle” originally noted by Karpman in 1968. Others have noted witness and bystander roles as well (Davies & Frawley, 1994; R. Prince, 2007). Therapists can expect to find themselves cast in such roles, and to face dramatic eruptions of traumatic themes. Sudden, intense experiences of danger, affective deluge, and emotional pressure to enact one of these positions tend to repeat in treatment the overwhelming and formative life experiences that created this psychology.
Many have wondered whether dissociative identity disorder is more common now than it was generations ago, or whether the current increase in diagnosing it derives entirely from our increased ability to identify it. It is not impossible that severe child abuse has been on the rise over the past decades and that a greater portion of humanity has resulting dissociative problems. Sociological factors that might contribute to more child abuse include the nature of modern warfare (in which whole civilizations rather than small groups of warriors are traumatized, and more people may reenact their horror with their children); destabilization of families; increases in addiction made possible by modern capacities for distribution (an intoxicated parent will do things that he or she would not even conceive of doing sober); increased violent imagery in the media (such that trance states are more often stimulated in a susceptible person); and the mobility, anonymity, and privacy of contemporary life (I have no idea how my next-door neighbors treat their kids, and I have no personal influence on their behavior).
On the other hand, children have been traumatized since antiquity. When one treats a patient for dissociative problems, one frequently finds that that person’s parent was also abused, as was the parent’s parent, and so on. Coontz’s (1992) indictment of nostalgia in sociological theorizing should give pause to anyone inclined to postulate easier times for children in prior generations. It seems likely, though, that more people in our era are talking about their childhood abuse and seeking help for its dissociative legacy. In the United States, this conversation was fueled by both the feminist movement and the reports of soldiers traumatized in Vietnam. Dissociation is not just a Western phenomenon, however; recent studies in Turkey (Sar, Akyuz, & Dogan, 2006; Sar, Dogan, Yargic, & Tutkun, 1999) found roughly the same proportion of dissociative patients there as Latz, Kramer, and Hughes (1995) found in a North Carolina hospital.
Kluft (1984) has offered a four-factor theory of the etiology of multiple personality disorder and severe dissociation. First, the individual is talented hypnotically. Second, he or she is severely traumatized. Third, the patient’s dissociative responses are shaped by particular childhood influences; that is, dissociation is adaptive and to some extent rewarded by the family. Fourth, there is no comfort during and after traumatic episodes. I have already discussed aspects of Kluft’s first three prerequisites; the last is equally critical, and it never fails to move therapists. No one seems ever to have held the dissociative child, or wiped away a tear, or explained an upsetting experience. Typically, emotional responses to trauma elicited more abuse (“Now I’ll really give you something to cry about!”). There is often a kind of systemic family collusion to deny feeling, to forget pain, to act as if the horrors of the preceding night were all imaginary.
One fascinating aspect of dissociative identity disorder is how lovable many dissociative people are—at least many who seek treatment. Despite all the devastations to their basic emotional security and all the corruptions of parental care that one would expect to have destroyed the capacity to attach, clinicians almost universally report that dissociative patients evoke in them deep feelings of concern and tenderness. Although they often get involved with abusive people (via the repetition compulsion, as in masochism), they also attract some generous, understanding friends. In the histories of dissociative individuals, there is often one person after another—a childhood friend who stayed in touch for years, a nurse who felt this patient was different from the “other” schizophrenics on the ward, a beloved teacher, an indulgent cop—who saw something special in the dissociative person and tried to act as a force for good.
Readers may recall that I have sequenced these typological chapters according to the degree of object-relatedness I have attributed to the overall psychology under consideration. Even more than the hysterical person, the dissociative patient may be object seeking, hungry for relationship, and appreciative of care. I have not seen any explanation for this widely noted phenomenon in the literature on dissociation, but perhaps the unresolved nature of the dissociative person’s attachment style leads him or her to keep trying to connect. Whatever the reasons, many people with multiple personality disorder tend to attach powerfully and with hope. With others, one feels the conflicted pull of “please help me but don’t come near me,” a communication that has often been considered paradigmatic of borderline psychology (Masterson, 1976), especially when it is accompanied, as it often is in dissociation, by high levels of suicidal and parasuicidal behavior.
THE DISSOCIATIVE SELF
The most striking feature of the self of a chronically traumatized person is, of course, that it is fractured into numerous split-off partial selves, each of which performs certain functions. Often, an infancy characterized by neglect and maltreatment prevented the self from integrating in the first place. The discrete self-states typically include one that traumatologists originally dubbed the “host personality” (the one most often in evidence, usually the seeker of treatment, who may present as anxious, dysthymic, and overwhelmed), infant and child components, internal persecutors, victims, protectors and helpers, and special-purpose alters (see Putnam, 1989). The host may know all, some, or none of the alters, and each alter may likewise know all, some, or none.
It can be hard for inexperienced or skeptical people to appreciate how discrete and “real” the dissociated selves can seem, both to the dissociative individual and to knowledgeable others. One evening I picked up my phone when my answering machine was beginning to record and found myself talking to a petulant child, an alter personality of a patient. She was calling to tell me about an early trauma whose existence I had suspected and to ask why the treatment-seeking part of the self needed to know about it. The next day when I told my client about the message, she asked to hear it. After listening together to my conversation with this dissociated aspect of herself, she was amused to note that she had not been feeling at all identified with the childish voice recounting her own history but was instead feeling sympathy with me, the voice of parental reason (she was a mother), trying to persuade a peevish little girl that I knew what was good for her.
Running through all the identities of a dissociative person, like the themes in a complex musical composition, are core beliefs engendered by childhood abuse. Colin Ross, discussing the “cognitive map” of multiple personality disorder, summarizes them as follows:
1. Different parts of the self are separate selves.
2. The victim is responsible for the abuse.
3. It is wrong to show anger (or frustration, defiance, a critical attitude ... ).
4. The past is present.
5. The primary personality can’t handle the memories.
6. I love my parents but she hates them.
7. The primary personality must be punished.
8. I can’t trust myself or others. (1989b, p. 126)
Ross then dissects each of these convictions, exposing its component beliefs and inevitable extrapolations. For example:
2. The victim is responsible for the abuse.
2a. I must have been bad otherwise it wouldn’t have happened.
2b. If I had been perfect, it wouldn’t have happened.
2c. I deserve to be punished for being angry.
2d. If I were perfect, I would not get angry.
2e. I never feel angry—she is the angry one.
2f. She deserves to be punished for allowing the abuse to happen.
2g. She deserves to be punished for showing anger. (p. 127)
Recent literature by traumatologists contains extensive information on how to access alter personalities and how to reduce amnesic barriers so that they may eventually become integrated into one person with all the memories, feelings, and assets that were previously sequestered and inaccessible. The therapist must keep in mind is that “everyone” is the patient. Even the most unsavory persecutory personality is a valuable, potentially adaptive part of the person. When alters are not in evidence, one should assume they are listening and address their concerns by “talking through” the available personality (Putnam, 1989).
People who have not worked closely with dissociative patients can be unsettled by the idea of joining the patient in reifying alter personalities, but to do anything else seems to be ineffective (Kluft, 2006). Refusal to acknowledge personified self-states could cause much of the client’s mental life to be kept out of the therapeutic relationship. If my experience is normative, it would also be false to one’s natural empathic response to the patient’s experience. Some clinicians talk about “parts,” whereas others refer to “different ways of being you,” a commonsense use of language that holds the experience of being one while feeling like many (Chefetz, 2010a). Treatment may seem a bit like family therapy—with one person who has constructed an internal family system.
TRANSFERENCE AND COUNTERTRANSFERENCE
WITH DISSOCIATIVE PATIENTS
The most impressive feature of transference in dissociative clients is that there is so much of it. A person who has been severely mistreated lives in constant readiness to see the abuser in anyone on whom he or she comes to depend. Especially when child self-states are in ascendance, the present can feel so much like the past that hallucinatory convictions (e.g., the therapist is about to rape me, to torture me, to desert me) are not uncommon. These transferences, which may strike the therapist as psychotic but are better understood as traumatic transferences (Kluft, 1994; R. J. Loewenstein, 1993), do not indicate psychotic or schizophrenic disorders, though professionals untrained in dissociation have frequently made that inference. Rather, they are posttraumatic perceptions, sensations, and affects that were severed from awareness at the time of the original abuse and that remain unintegrated into the client’s personal narrative. They can perhaps be best conceptualized as conditioned emotional responses to a class of stimuli associated with abuse.
A common sequence with people with undiagnosed dissociation is for the therapist to feel a vague, benign positive transference from the person in the self-state that seeks therapy, who is treated as the whole patient for several weeks, months, or years. Then there is a sudden crisis driven by the patient’s emerging recollection of trauma and its activation of alter personalities, somatic memories, and/or reenactments of abuse. Such developments can be deeply disturbing and can invite counterphobic responses from the naive clinician, who may assume a schizophrenic break. The histories of dissociative patients are littered with referrals for unwarranted pharmacological treatment (including major tranquilizers, which may aggravate dissociation), invasive medical procedures, electroshock, and infantilizing “management” approaches. But for a therapist who can see what has really happened, this crisis can signal the beginning of a reparative collaboration.
Because transference inundates dissociative patients, the therapist needs to be somewhat more “real” than some analytic therapists customarily behave. Many clinicians find that they do this naturally—albeit with guilt if their training emphasized an invariant, “orthodox” technique. It is true that relatively healthy nondissociative people can be so grounded in reality that for their underlying projections to become evident, the therapist must be relatively reserved. In the classical psychoanalytic paradigm, transferences become analyzable because the client discovers a tendency to make attributions in the absence of evidence and then discovers that the sources of such assumptions are historical. In contrast, people struggling with dissociation, even those who are high functioning, tend to assume that current reality is only a distraction from a more ominous real reality: exploitation, abandonment, torment.
To explore a dissociative person’s transference, the therapist must first establish that he or she is someone different from the expected abuser—someone respectful, devoted, modest, and scrupulously professional. The dissociative person’s world is so infused with unexamined transferences that the active contradiction of them, especially early in treatment or in reorienting during or after a flashback (“I’m Nancy McWilliams, and we’re here in my office in Flemington”), may be critical to eventually understanding the intense reactions that confuse past and present.
The most disturbing experiences for both therapists and clients addressing dissociation include erotic (erotized) (Blum, 1973; Wrye & Welles, 1994) and traumatic transferences (Chefetz, 1997). The patient may exert intense pressure to be treated as “special,” including as a lover, which can interact with the therapist’s narcissistic needs to be seen as generous, benevolent, and altruistic. The temptation to act out the role of rescuer or idealized object of desire, while not acknowledging to oneself coexisting feelings of hatred and resentment, can produce enactments that infantilize and harm the client and exacerbate dissociative responses. The suffering of traumatized individuals is so profound and undeserved, their responsiveness to simple consideration so touching, that one yearns to put them on one’s lap (especially the child alters) or take them home. But however intensely they evoke this reaction, they are also petrified by any violation of normal boundaries; it smacks of incestuous exploitation.
Pathfinders in the rediscovery of multiplicity in the second half of the 20th century, who lacked the benefit of prior work by trauma therapists who could have helped them manage their countertransferences, had a tendency toward excessive nurturance: Cornelia Wilbur was very motherly toward Sybil, and David Caul seems to have been overinvolved with Billy Milligan (Keyes, 1982). Like their intrepid predecessors, many clinicians seeing their first dissociative client tend to overextend themselves. Traumatized patients are notoriously hard to contain; at the end of each session they may linger and chat, evidently seeking a few extra shreds of moral support in facing the horrors that therapy has unearthed. Even experienced practitioners report that sessions with such clients tend to creep past the scheduled end of sessions. Dissociative patients use time boundaries to gauge when the assumed re-abuse, the abuse that is seen as an inevitable part of relating, will likely occur. Being warmer and more emotionally expressive than one usually is with clients, while at the same time being fastidiously observant of limits, gets easier with practice. And when one inevitably blunders, some alter will usually be happy to provide corrective instruction.
One rather amusing countertransference to dissociative people is dissociation. Like other psychologies, dissociation is catching. Not only is it easy to get into trance states while working with an autohypnotist, one also gets oddly forgetful. When I began to work with my first known multiple, I enrolled twice in the International Society for the Study of Multiple Personality and Dissociation (now the International Society for the Study of Trauma and Dissociation), having forgotten that I had already joined.
THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF A DISSOCIATIVE CONDITION
New therapists can be intimidated by the prospect of working with someone with severe or chronic dissociation, and many training programs consider such clients too daunting for a beginner. This is unfortunate. Dissociation is common, and severe dissociation and its challenges are faced by any therapist sooner or later, whether or not it is seen for what it is. Putnam (1989) says that there is nothing fancy, no special wizardry, required to help a dissociative client. In the first edition of this book, I echoed this assessment, but as my experience with this population has increased, I want to qualify his assertion. The emotional demands of working with patients with dissociative identity disorder and other complex posttraumatic conditions are great. Because inductions into traumatic enactments are a risk with this group, one needs both a deep level of self-knowledge, preferably from one’s own therapy, and a lot of support from dissociation-savvy supervisors and colleagues.
In distilling the essence of effective therapy with this population, I could not do better than Kluft (1991), who has derived the following principles:
1. MPD [multiple personality disorder] is a condition that was created by broken boundaries. Therefore, a successful treatment will have a secure treatment frame and firm, consistent boundaries.
2. MPD is a condition of subjective dyscontrol and passively endured assaults and changes. Therefore, there must be a focus on mastery and the patient’s active participation... .
3. MPD is a condition of involuntariness. Its sufferers did not elect to be traumatized and find their symptoms are often beyond their control. Therefore, the therapy must be based on a strong therapeutic alliance, and efforts to establish this must be undertaken throughout the process.
4. MPD is a condition of buried traumata and sequestered affect. Therefore, what has been hidden away must be uncovered, and what feeling has been buried must be abreacted.
5. MPD is a condition of perceived separateness and conflict among the alters. Therefore, the therapy must emphasize their collaboration, cooperation, empathy, and identification... .
6. MPD is a condition of hypnotic alternate realities. Therefore, the therapist’s communications must be clear and straight... .
7. MPD is a condition related to the inconsistency of important others. Therefore, the therapist must be evenhanded to all the alters, avoiding “playing favorites” or dramatically altering his or her behavior toward the different personalities. The therapist’s consistency across all of the alters is one of the most powerful assaults on the patient’s dissociative defenses.
8. MPD is a condition of shattered security, self-esteem, and future orientation. Therefore, the therapy must make efforts to restore morale and inculcate realistic hope.
9. MPD is a condition stemming from overwhelming experiences. Therefore, the pacing of the therapy is essential. Most treatment failures occur when the pace of the therapy outstrips the patient’s capacity to tolerate the material... . [I]f one cannot get into the difficult material one planned to address in the first third of the session, to work on it in the second, and process it and restabilize the patient in the third [one should not approach] the material, lest the patient leave the session in an overwhelmed state....
10. MPD is a condition that results from the irresponsibility of others. Therefore, the therapist must be very responsible, and hold the patient to a high standard of responsibility once the therapist is confident that the patient, across alters, actually grasps what reasonable responsibility entails.
11. MPD is a condition that often results because people who could have protected a child did nothing. The therapist can anticipate that technical neutrality will be interpreted as uncaring and rejecting and is best served by taking a warmer stance that allows for a latitude of affective expression.
12. MPD is a condition in which the patient has developed many cognitive errors. The therapy must address and correct them on an ongoing basis. (pp. 177–178)
It also helps to know a little hypnosis. Since dissociative people by definition go into trance states spontaneously, it is not possible to work with them without hypnosis—either they are doing it alone, or you and they are doing it cooperatively. A therapist who can help the patient learn how to get the hypnotic process under control and use it autonomously and therapeutically rather than traumatically and defensively is providing a critical service. Trance-inducing techniques are extremely easy to use with this population of hypnotic prodigies, and they are especially effective in building a sense of safety, containing surplus anxiety, and handling emergencies. Help in this area can be found from the American Society for Clinical Hypnosis at www.asch.net and the International Society of Hypnosis at www.ish-web.org.
I say this as someone who came to hypnosis kicking and screaming. My colleague Jeffrey Rutstein calls this the “If-it-wasn’t-good-enough-for-Freud-it-isn’t-good-enough-for-me!” reaction. My resistance to learning hypnotic techniques came from my misgivings about any intervention I regarded as authoritarian; I did not want to tell clients they were getting sleepy if that was actually my directive rather than their natural experience. This prejudice remitted when I learned to hypnotize in an egalitarian, collaborative way (having the patient direct me as to induction images and other particulars), and when I saw how much calmer it made my dissociative clients in managing the emotional maelstrom created by going in and out of traumatic memories. For therapists who have no background in it, a weekend workshop in hypnosis is enough to provide adequate skill for work with most dissociative clients. The training also helps one to appreciate the full range of dissociative phenomena. Similarly, eye movement desensitization and reprocessing (EMDR) has shown promise as an adjunctive treatment (Chemtob, Tolin, van der Kolk, & Pitman, 2004), although it can be disorganizing to people with complex dissociation.
Because of the power of the traumatic transferences, one must tolerate being used by the patient in ways that feel “distorting.” This requires swallowing one’s defensiveness and engaging in what Sandler (1976) called “role responsiveness” and Lichtenberg (2001) has called “wearing the attributions” of the client. Chefetz (personal communication, October 11, 2010) offers an example of this kind of response: “So, you’re feeling like you’re at risk of being hurt by me? Tell me about what you imagine might happen. What comes to mind as you consider this? Does that match any scenes from the past? Are there other ways of being you in the background, close by, who are really engaged in a lot of this thinking and feeling? Why do you think they are so present?”
Chu’s (1998) description of the stages of treatment for complex dissociation is pertinent here. Chu divides therapy into three phases: (1) the early work (which may last a long time), focusing on self-care, symptom control, acknowledgment of early trauma, support for normal functioning, expression of feelings, and constant negotiation of the therapeutic alliance; (2) the middle part of treatment, involving abreation and reconstruction at a pace tolerable to the patient; and (3) late-stage work, consisting of consolidation of gains and increasing skills needed to live one’s life. Chefetz (personal communication, October 11, 2010) summarizes phase-oriented treatment of the dissociative disorders as stabilization, working through trauma, integration, and termination. The stabilization period, which may be long and should not be rushed, may require teaching techniques for self-soothing, self-care, grounding, and affect tolerance.
In practice, as is true of any therapy, the treatment phases often occur out of order. Some trauma work might intrude into the stabilization period; some may recur during integration and termination as old issues are reworked or come to light for the first time. In a 10-year follow-up study of patients diagnosed with dissociative identity disorder, Coons and Bowman (2001) found that following the general treatment guidelines of the International Society for the Study of Trauma and Dissociation (www.isst-d.org/education/treatmentguidelines-index.htm) brought improvements in both dissociative and nondissociative symptoms.
Working with dissociative clients requires some flexibility. Deviations from standard care may occur in the form of apparently innocent boundary crossings or in the therapist’s occasional deliberate decision to “throw away the book” (cf. Hoffman, 1998). In either case, it is critical to negotiate the boundary in an open, thoughtful manner that attends to potential meanings (Gabbard & Lester, 2002). I have occasionally attended a client’s wedding, accepted a gift, or walked around the block with a person whose anxiety was too high to stay in one place, and sometimes such boundary crossings have been taken in as healing. When one has traversed the normal boundaries of treatment, intentionally or not, it is especially important to process mutually what has happened and what it means to the client. Because dissociative people are even more concerned than others about boundary infractions, attention to their responses to departures from standard operating procedure is particularly vital.
Especially with dissociative patients, it is wise to remember the old psychoanalytic chestnut, “The slower you go, the faster you get there.” When multiplicity was rediscovered in the 1980s, some clinics and researchers experimented with ways to cut down on treatment time with exposure and planned abreaction, but they found that these techniques tended to retraumatize complexly dissociative clients. We have no business, especially in the name of mental health, hurting someone who has already had more than an ordinary share of injury. For readers who want more education in this area, I recommend the psychotherapy program for the dissociative disorders and chronic complex trauma in children, adolescents, and adults that Richard Chefetz and Elizabeth Bowman started in 2001. Information is available at www.isst-d.org.
DIFFERENTIAL DIAGNOSIS
Because so much of the misunderstanding and mistreatment of dissociative patients derives from diagnostic errors, this section is more thorough than in other chapters. The typical profile for someone with chronic and complex dissociation includes having been in the mental health system for years, with different serious diagnoses (e.g., bipolar, schizophrenic, schizoaffective, and major depression), none of which has been effectively treated with medication. Often the patient is also diagnosed with BPD. There may be periods when the person is off all medication and somehow functions well. Dissociative clients leave in their wake numerous failed medication regimens and multiple therapists, and yet no one has asked them about being abused or hurt or has questioned them about depersonalization, derealization, and amnesia. In 1988, Coons, Bowman, and Milstein found that an average of 7 years elapses between a dissociative client’s initial search for treatment and an accurate diagnosis. This lag may be shrinking, but it is still true that one factor that should alert a diagnostician to a possible dissociative identity problem is the presence of several prior, serious, and/or mutually exclusive diagnostic labels in a person’s treatment history.
Unless a client has a known history of trauma, most beginning therapists are not encouraged to look for dissociation. In my training in the 1970s I was never taught to “rule out” dissociative possibilities. I was told, for example, that a client who reports hearing voices is presumptively psychotic, organically or functionally, probably some variety of schizophrenic. I was not told to ask whether the voices seemed to be inside or outside the person’s head. This quick-and-dirty way of discriminating posttraumatic hallucinatory states from psychotic decompensation was not even known in the 1970s, and despite research that has since then established its value (Kluft, 1991; C. A. Ross, 1989a), it is still taught only rarely. It is my impression that even now, most graduate programs teach students, at best, only how to recognize classic PTSD.
I cannot stress enough that most people with dissociative psychologies do not come to therapy announcing that their problem is dissociation. It must be inferred. Data suggesting the possibility of a dissociative process include a known history of trauma; a family background of severe alcoholism or drug abuse; a personal background of unexplained serious accidents; amnesia for the elementary school years; a pattern of self-destructive behavior for which the client can offer no rationale; complaints of lost time, blank spells, or time distortion; headaches (common during switching); referral to the self in the third person or the first-person plural; eye-rolling and trance-like behaviors; voices or noises in the head; and prior treatment failures.
Individuals born with anomalous genitals (for whatever reason: chromosomal, hormonal, prenatal injury) who have had early surgeries and invasive medical treatments intended to make them look unambiguously like one gender are at serious risk of dissociation. This is a particular risk if, as pediatric protocols dictated until just a few years ago (Lee et al., 2006), the affected child was lied to about his or her condition and the reason for the painful, traumatically exposing medical interventions. As 1 in every 2,000 births involves anomalous genital presentation (“intersex” condition, “disorder of sexual development,” or “atypical genitals”), there is a substantial group of people who have been deeply traumatized for this reason—over 100,000 in the United States alone have been subjected to the older medical protocol (Blackless et al., 2000).
Depersonalization and derealization are regularly features of the dissociative disorders, but patients are unlikely to volunteer this information and must be asked about them in a manner that does not make them feel that their basic sanity is being impugned. One may have to ask questions in several different ways; for example, “Do you ever have an experience of somehow, in a not really understandable way, not quite being in your body? Do you ever find yourself feeling unreal in ways you can’t describe? Do you have other experiences that are hard to describe in the words I’ve used?”) Because people often think they are crazy if they suffer depersonalization or derealization, a wise clinician is alert to the sad reality that shame is often at the core of dissociative dynamics.
Dissociative problems range from mild depersonalization to polyfragmented multiple personality disorder. Many of us have occasional dissociative symptoms, and neither they nor the dissociative strategies that may pervade personality can be addressed by a therapist who is not open to seeing them. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1993) is the current gold standard for diagnosis, but it can take 2 to 3 hours to complete. Other inventories by C. A. Ross (1989b: Dissociative Disorder Interview Schedule), Briere (1992; Trauma Symptom Inventory: www.johnbriere.com/tsi.htm), and Dell (2006: Multidimentional Inventory of Dissociation) may be helpful.
Dissociative Conditions versus the Psychoses
Because dissociative patients in crisis or under stress show most of Schneider’s (1959) “first-rank” symptoms (Hoenig, 1983; Kluft, 1987, 2000), they are easily construed as schizophrenic. If an interviewer regards dissociative switching as lability of mood, the client may be seen as schizoaffective or bipolar at the psychotic level. Hallucinations and delusions in dissociative people tend to be flashback phenomena rather than dominantly projective operations. Their relationships with therapists often have an intensity from the beginning, whereas schizophrenic clients have a flat, deadened quality and do not tend to draw the therapist into an intense attachment. Schizophrenic withdrawal from reality and relatedness tends to start in the teens and progress insidiously toward further isolation in adulthood. Individuals with dissociative identity disorder, in contrast, live compartmentalized lives, functioning well in some areas and poorly in others.
Bipolar and schizoaffective people have shifts of mood but no disorders of memory. In a manic state the person with bipolar illness is much more grandiose than the agitated dissociative person. Whereas rapid cycling in bipolar disorders is defined as four times yearly, a dissociative patient may switch consciousness many times in 1 day or even in 1 hour.
Complicating the diagnostic challenge is the fact that dissociative symptoms can coexist with schizophrenia and with the affective psychoses. To assess whether dissociation is a major part of a psychotic picture when voices are reported, one can ask to speak with “the part of you that is saying these things.” If dissociation predominates, an alter may answer back. The first time one does this it feels ludicrous, but after that it seems a rather prosaic question. Beginners should remember that the worst that can happen is for the patient to stare blankly and ascribe the request to some weird professional rite of intake.
Dissociative versus Borderline Conditions
From the psychoanalytic developmental perspective I have represented here, the diagnoses of borderline and dissociative conditions are not mutually exclusive. Dissociation can pervade personality at any level of severity. Referring to DSM-III-R definitions of multiple personality disorder and borderline personality disorder, Kluft (1991) reported that “of treatment-adherent patients who appear to have both MPD and BPD, one-third rapidly ceased to show BPD features once they settled into treatment, one-third lost their apparent BPD as their MPD resolved, and one-third retained BPD features even after integration” (p. 175). Presumably, once patients in this last group had stopped dissociating, their borderline status could be addressed in further treatment.
Even though some dissociative clients are legitimately regarded as in the borderline range, where separation–individuation issues prevail, it is common for high-functioning dissociative people to be misconstrued as borderline when their dissociation becomes problematic. Dissociation resembles splitting, and switches of self-state can be easily mistaken for non-amnesic outbreaks of hostility, dependency, shame, and other attitudes. Thus, one must be sensitive to the presence or absence of amnesia. Because traumatized people do not trust in the benevolence of authorities, they may offer critical information only if it is expressly and respectfully welcomed, and so phrasing matters. Saying “Last Monday you were furious at me and thought I was worthless, but today you’re saying I’m wonderful” may evoke defensiveness in either a dissociative or a generically borderline person. But saying “I’m noticing that today you are clear that I am really on your side. Do you recall how you felt about me in last Monday’s session?” may permit the dissociative client to admit to having forgotten the Monday session. The person with borderline dynamics is more likely to rationalize moving back and forth from love to hatred, idealization to devaluation.
Dissociative versus Hysterical Psychology
As I have mentioned, there is considerable overlap between hysterical and dissociative psychologies; many of us have both, and many contemporary traumatologists regard the terms as synonymous. Neurotic-level hysterical personality (Kernberg, 1984), however, as opposed to the more serious histrionic personality disorder of the DSM or the severe conversion symptoms, does not in my experience necessarily result from trauma and may have more to do with temperamental sensitivity than with maltreatment. In contrast, no one with diagnosable dissociative identity disorder, even those with long periods of good functioning, has escaped severe trauma. Anyone with pronounced hysterical symptoms should be questioned about dissociation.
The therapeutic ramifications of this differential revolve around the importance with hysterical people of interpreting their recurrent impulses, fantasies, and unconscious strivings, as opposed to an emphasis with dissociative clients on reconstructing a traumatic past. If one does the former with a basically dissociative client, one will reinforce denial, increase guilt, and fail to deal with the pain that a terrible history has created. If one does the latter with a histrionic client, one may prevent the flowering of the sense of agency that comes from acknowledging internal dynamics and redirecting one’s energies in directions that are genuinely satisfying.
Dissociative versus Psychopathic Conditions
As I noted in Chapter 7, many antisocial people have dissociative defenses or frank dissociative identity disorder (Lewis et al., 1997). Discriminating between a psychopathic person with a dissociative streak and a dissociative person with a psychopathic alter is maddeningly difficult—mostly because by the time this question is asked, so many legal consequences hinge on the answer. A person accused of a serious crime may have a huge stake in convincing a judge or jury of multiplicity; less commonly, a persecutory alter may be punishing another part of the self by getting it assessed as antisocial. It is prudent to assume psychopathy when someone has powerful reasons to malinger (see Thomas, 2001, on differentiating malingering from dissociation).
If we do become adept at reliably differentiating essentially dissociative from essentially psychopathic people, even when there is significant advantage to a person in presenting as one or the other, the consequences for the criminal justice system could be substantial. Because most dissociative people have a better prognosis than psychopathic individuals, there would be significant crime-preventive value in giving intensive therapy to perpetrators discovered to have dissociative identity disorder. Clinicians can resolve dissociation more expeditiously than they can modify antisocial patterns; under conditions of limited resources, people working in jails or with the probation system could concentrate on those clients most receptive to their help.
SUMMARY
In this chapter I have discussed the history of the concept of dissociation and the psychology of people with dissociative identities. In accounting for individual development of dissociation as a core process, I mentioned constitutional talent for self-hypnosis, often coexisting with high intelligence, creativity, and sociophilia. These factors may predispose a person to respond to trauma with a dissociative defense invisible to outsiders. I mentioned Braun’s (1988) BASK model of dissociation as an alternative to Freudian concepts of defense. I described object relations of dissociative people in terms of disorganized or avoidant attachment caused by childhood relational trauma. I depicted the self of someone with a dissociative identity as not only fragmented but also as permeated by paralyzing fears, shame, and self-blaming cognitions. Still, I noted how well many dissociative people function, in their highly compartmentalized way.
I emphasized the power of transference and countertransference reactions with dissociative patients, especially as they provoke rescue fantasies and overinvolvement in the therapist. Treatment implications of this diagnosis included a stress on nurturing a sense of basic safety; teaching techniques in self-soothing, self-care, grounding, and stabilization of emotional lability; fostering cooperation in the therapeutic relationship; and only after stabilization promoting recall and emotional comprehension of dissociated experiences. Overall, I recommended maintaining consistency toward all personalities, being “real” and warm while adhering strictly to professional boundaries, analyzing pathogenic beliefs, using adjunctive techniques such as hypnosis and EMDR, and respecting the client’s need to take time to tolerate the therapeutic process. I differentiated dissociative dynamics from schizophrenic and bipolar psychoses, generically borderline conditions, and hysterical and psychopathic personality organizations.
SUGGESTIONS FOR FURTHER READING
Herman’s classic Trauma and Recovery (1992) and Terr’s (1992) study of traumatized children are foundational for understanding the phenomena involved in dissociation. Putnam’s (1989) text remains the starting point for anyone dealing with dissociative adults, and his 1997 book extends his work into the treatment of children and adolescents. R. J. Loewenstein’s (1991) overview on diagnosis of chronic, complex dissociation is especially valuable. Kluft and Fine (1993) have published a good edited book on treating dissociation. For readers integrating psychoanalytic ideas with research and clinical experience with dissociation, I recommend Kluft’s (2000) article, Ira Brenner’s (2001, 2004, and 2009) contributions, and Elizabeth Howell’s (2005) relational tour de force. Also within the relational tradition, both Philip Bromberg (1998, 2010) and Donnell Stern (1997, 2009) write eloquently about addressing dissociation in the clinical process. As I write this, Richard Chefetz is planning to publish a book on working with dissociative patients that I expect to be particularly valuable to therapists.