Abstract
Dissociation of traumatic experience, as Janet called it, or splitting of consciousness, as Freud did, is the title of this book. Because dissociation is a core traumatic experience, a text on what we may call the parcellation of awareness which dissociation involves, and its subsequent elaborations, would be very welcome indeed. This is because according to trauma theory, dissociation of trauma, its parcellation, and later reverberations, are the basis for many psychiatric symptoms and disorders.
However, to understand the context, strengths and limitations of this book, we need to digress for a moment, and consider the dissociation, parcellation, and history of trauma theory itself. Very briefly, starting with Freud, psychoanalysis has sidelined trauma theory by making internal fantasies the roots of pathology, while psychiatry has buried it along with psychodynamics by paying obeisance to phenomenology and statistics.
Following major wars trauma theory has been reinstated for short periods. The last 20 years, following the Vietnam War, has seen trauma theory re-emerge through a minority of psychoanalytic psychiatrists who established traumatology. Both psychiatry and psychoanalysis have reluctantly reaccommodated trauma and dissociation, albeit as encapsulated fragments (in psychiatry in posttraumatic and dissociative disorders). Nevertheless, for the moment, traumatology, psychiatry and psychoanalysis are still mostly unaware of each other.
It is in this context that one can place Ira Brenner's Dissociation of trauma: theory, phenomenology and technique. It falls within the psychoanalytic reaccommodation of trauma and dissociation. Its purpose is to (re)convince psychoanalysts of the centrality of traumatic dissociation. If readers are interested to complement their reading from the side of traumatology, they could do worse than read Trauma, memory and dissociation [1].
Brenner's approach has certain strengths, even for non-psychoanalysts. He initially demonstrates that without alertness to traumatic dissociation, the significance of its later manifestations in psychiatric symptoms may be missed, even (perhaps especially), over years of treatment. Brenner cogently and very usefully delineates dissociation into what may be called ‘everyday’, ‘common garden psychiatric’, and dissociative identity disorder (DID), previously known as multiple personality type dissociations.
Each type of dissociation is a defensive manoeuvre to avoid actual or potential traumatic annihilation. Each is associated with an altered state of consciousness, or hypnoid (hypnotic-like state). The depth, breadth, and criss-crossing of dissociation is ever deeper, the more severe, recurrent, and early were the traumas of childhood.
The rest of the book deals with DID, resulting from the most severe, recurrent and early traumas, especially sexual abuse. According to Brenner, DID is a specific characterological disorder, resulting from the deep criss-crossing of dissociation in the developing, severely traumatized child. The different personalities (alters, personifications) represent different physical, psychological and social/moral aspects of traumas.
The middle chapters describe how traumas can be unconsciously re-enacted, surface in dreams and be transmitted across the generations. The final chapters describe treatment of DID. Brenner maintains that hypnotherapy and drugs are contraindicated in treatment. Drugs, often given on grounds of a mistaken diagnosis of schizophrenia, may even aggravate dissociative phenomena.
Brenner says that psychoanalysis, with modifications in technique, is the treatment of choice for DID. Orthodox psychoanalytic techniques still include free association, catharsis, interpretations of defences and transference. They have the goal of full awareness of trauma(s), and integration of the various personalities in which traumatic fragments are embedded. The accompanying regression, however, may require adaptation of orthodox techniques, and include hospitalization, and a more proactive and revealing attitude by the analyst than is usual. Psychoanalysis may take a long time, as alters may take a long time to reveal themselves, and then each, even tens of personifications, has to be dealt with as if each was a person in his or her own right.
The plentiful clinical cases provide graphic descriptions of dissociation and its consequences in early, severe and chronic sexual abuse. Brenner also gives us a revealing view of the use of transference and countertransference in the diagnosis and poignant reintegrations of these patients.
The book raises perennial issues, such as the pathway for the evolution of multiple personalities. Brenner rejects iatrogenicity, and suggests the matter is a subject for future research. A wider issue is the objectivity of recovered memory of early childhood sexual abuse. Brenner's clinical cases (all independently corroborated for sexual abuse), suggest that apart from dissociation and its secondary elaborations, traumas are recorded and retrieved faithfully. With regard to the significance of traumatic dreams, Brenner describes them as thinly screened fragments of past traumas.
The self-imposed constraint to join trauma and mainstream psychoanalysis, with its emphasis on the centrality of fantasies, leads to self-defeating tensions and some quaint language. Examples of the latter are reference to incest as an oedipal victory, and a transsexual fantasy serving to solve sexual vulnerability being explained as search for a maternal phallus. Brenner's solipsistic acceptance of the death instinct, the theoretical alibi for repetitive relivings of traumatic events, is a further example of a theoretical tension.
An overlapping weakness of the book is that it is a compilation of prior talks and papers to psychoanalytic audiences. The result is that the book does not flow as well as it could, is a little repetitive and its references are almost solely psychoanalytic and not up to date.
With respect to the claim of the title, it is a pity that Brenner does not follow a coherent generic view of traumatic dissociation and its consequences as he outlined in the introductory chapters. By excessive linking of traumatic dissociation with DID and orthodox psychoanalysis, he limits his stated aims, and potential audience.
In context, we must recognize the dearth of books which provide an amalgam of the current wisdoms of traumatology, psychoanalysis, and psychiatry. Brenner's book, though weighted toward psychoanalytic explanations of DID consequences of severe trauma, is nevertheless well worth reading by general psychiatrists.