Dissociative Disorders: A Personal ‘Work in Progress’

Don't personalize issues in respect to differing views held by colleagues.

With respect to the acceptance of dissociative disorders, as with most issues in life, it is counterproductive to spend time trying to convince people of things they don't want to know.

It is unwise to view dissociative patients, or the scientific and clinical issues concerning them, as ‘special’.

In having an interest in dissociation, it is unhelpful both clinically and professionally to abandon virtually all other roles, such that one stays

The most effective way of advancing clinical and scientific knowledge regarding patients in the dissociative spectrum is to do the best clinical work possible, to work with colleagues and staff in developing programmes that tangibly improve outcomes and management options, to support and contribute to relevant research, to remain friendly and accessible to all colleagues, and to assist in convening seminars and conferences that are open to all who are interested.

If an individual were to be dragged out of the wreckage of a train crash and dispatched to the nearest hospital emergency department he could perhaps be diagnosed with ‘compound fractured tibia-fibular disorder’, ‘respiratory distress disorder associated with pneumothorax’, ‘hypofusion, hypotensive disorder’, ‘renal shock disorder’, ‘tachycardia’, ‘endocrine stress disorder’ or ‘postabrasion skin integrity disorder’ etc. Alternatively, such an individual could be seen as (barely) surviving a major physical trauma that impacted on all bodily systems and where particular physical defences automatically became operative from the point of trauma, for example peripheral vascular shutdown, acute endocrine responses, compensating for blood loss by increasing the heart rate etc. If such an individual survived, it may be that he carries a permanent limp with some leg shortening, that full vital lung capacity is never fully restored, that there is some ongoing renal impairment, that he has marked scarring from his wounds, and that he has recurrent sepsis associated with his fracture sites. Were he unlucky enough to be involved in another major physical trauma, it is not unlikely that he will not do as well. Indeed were he to sustain a series of similar traumas, it is likely that sooner or later his body would succumb. We can view the survivors of emotionally deprived and severely abusive childhoods as suffering from multitudinous DSM-IV diagnostic entities: post-traumatic stress disorder (PTSD), borderline personality disorder, dissociative disorders, somatization disorder, affective disorder, drugand alcohol-related disorders, sexual dysfunction etc., or we can view them as the survivors of a psychological train wreck in which no psychological system was unaffected and in which whatever psychological defences that were available were pressed into service to ensure survival.

There is already a vast literature highlighting the crucial importance of the early years of childhood with respect to individuals acquiring what might be succinctly described as healthy and developed selfhood. Selfhood includes characteristics such as clear boundaries, affect regulation, positive selfesteem, having a capacity for truth and honesty rather than a lack of ownership of one's own actions or utterances, having a capacity to selfactivate and to support and defend one's position when under attack, having a capacity to commit oneself to a relationship or objective and to persevere despite obstacles or ambivalence, having access to a clear and continuous memory of one's life, being able to self-soothe without self-harming etc. The importance of consistently functioning, validating and nurturing parents (particularly mothers) is central to the secure attachment style described by Bowlby, Winnicott's ‘good enough mothering’, the attainment of Melanie Klein's depressive position, and figures prominently in the work of Fairbairn, Kernberg, Kohut, Masterson, Putnam and many others.

Despite an earlier literature that placed a disproportionate emphasis on concepts of Oedipal fantasy, hysterical mendacity etc.,[2] it is now unarguable that the severe abuses of children including incest, paedophilia, church and institutional abuses in all their forms etc. have been, and are, widespread. Basically, in every type of setting that affords the opportunity for the abuse and exploitation of children, we will see elements of it, and in those settings where power, non-accountability and lack of public scrutiny are maximized, we can expect to find the most extreme examples. Where boys, for example, have lacked affectionate relationships with father figures, they are particularly vulnerable to sexual abuse by paedophiles who sexualize their emotions, leading such vulnerable boys to believe that their abuser loves them. Such a dynamic is particularly likely to be seen in the developmental history of sexually abused boys who as adults become offenders themselves.[3] In an age where our newspapers report almost daily new cases of the severe abuse of children, where the mainstream churches have been shaken to their foundations by the proven abuses of children and others by their clergy, where prominent senior politicians are doing time in jail for paedophilia, where press and governmentsponsored enquiries into orphanages document patterns of severe and ongoing widespread abuse and neglect spanning many decades, and where a Governor General has resigned essentially over his handling of reported child abuse, society could be seen as heading into an abyss. Yet the ability to actually report on and publicly discuss child abuse and neglect to the degree that is now possible is something that is new and healthy. It is not that society's abuses of children have become worse in recent years, it is just that, for the first time, we are actually able to report and speak more freely about the sorts of abuses that previously were well-hidden and where it was unsafe for victims to disclose, notwithstanding the complicating ambivalence, shame, or fear that so frequently characterizes the abuser-victim relationship.

Every study that has systematically examined randomly selected populations of inpatient or outpatient psychiatric patients, irrespective of their assigned diagnoses, has demonstrated very high percentages of patients who have a prior history of major trauma, whether or not it was recorded in files, and whether or not it was afforded clinical significance.

Broadly speaking, there is far more in common in the psychological responses to ongoing trauma among all traumatized groups than there are differences, with such differences as there are frequently relating to the developmental age of the victim. Generally, all victims of whatever age subjected to ongoing trauma are likely to demonstrate affective instability, a proneness to depression and anxiety, somatization, post-traumatic stress symptomatology and dissociation. Whereas a traumatized Vietnam veteran may manifest his dissociation in the guise of trance-like states or flashback phenomena, the victims of ongoing child abuse that started at an age that pre-dated the establishment of a sense of identity and adequate selfhood are likely, in dissociating, to switch between different identity states that maintain a separateness as a result of the use of the same capacity for amnesia seen in sizeable proportions of individuals from all severely traumatized groups.

Post-traumatic dissociative amnesias have been regularly documented in all groups of severely traumatized individuals for as long as this has been a focus of enquiry. The fact that traumatized combat survivors have regularly been documented to have partial or total amnesia for fully verified combat experiences has hardly been controversial. Similar examples of amnesia have been regularly demonstrated with Holocaust survivors, and with the survivors of natural or man-made disasters. The fact that such individuals can be triggered to breach their dissociative amnesias and recover access to memories that were previously inaccessible has been hardly controversial also. Yet despite the overall similarities in the human response to severe trauma in all its forms, when the issue became one of childhood sexual abuse, severely polarized views erupted in a way that represented more of a social-psychological phenomenon than a reasonably coordinated scientific enquiry. The fact that memories concerning all traumas may contain inaccuracies is also hardly controversial.

In normal childhood development, it is common to observe young children assigning animate qualities to inanimate objects, for them to demonstrate magical thinking, or to have ‘imaginary friends’. They are at this age more naturally dissociative than they will be later. In non-traumatized children, these tendencies fade as the secure and growing individual builds a sense of personal identity anchored in his/her personal selfhood. Where severe ongoing trauma and its complex multiaxial sequelae intersects a child without a central sense of identity and very limited selfhood, it is logical to expect that dissociation will manifest in particular ways depending on the circumstances and developmental age of the child victim.

The fact that individuals switch between differing ego states is so commonplace as to be self-evident. Every couples therapist recognizes very quickly when one of a dyad he/she is seeing is triggered into acting in a regressed manner that characterizes some earlier development stage and is associated with unresolved hurt. Often nothing more than a certain tone of voice or the use of expressions or mannerisms characteristic of someone who occasioned past pain is enough to have one or other of the dyad in tears, or in a state of anger, a response seemingly out of proportion to the actual content of what was said. When one adds to the natural tendency most of us have to being so triggered, the dissociative responses that date from childhood and which incorporate childhood constructions of alternative (‘not me’) identities, the sudden switches incorporating triggers and amnesic barriers become more explicable.

In defining the negative consequences of trauma, some basic trends are evident. Chronic ongoing trauma generally is worse than acute trauma. Trauma in which the individual feels powerless to alter the outcome is worse in its effects than trauma where the victim maintains some sense of control. Trauma that is not validated and in which the individual has no access to supportive people has a more negative outcome than that associated with validation and access to support. (Witness the particularly negative effects occasioned with Vietnam veterans by their alienation from a society that distanced itself from an unpopular war.) Trauma perpetuated by close family members who would normally be trusted introjected figures is more damaging than trauma perpetuated by strangers. To be the powerless victim of essentially unending childhood trauma perpetuated by close family members, where one's trauma is not allowed to be recognized and where there is no safe or supportive individual, is to be very traumatized indeed. Most would accept that to be raped once is a deeply traumatic event that may markedly impact on virtually all aspects of one's life. How then do we conceptualize the sorts of damage done to a child that is essentially raped twice weekly for a decade or more? What extreme adaptations allow such individuals to eke out some sort of psychological development in such a traumatic environment that is so frequently filled with shame, threats and double-bind communications? How does one live through such things without suiciding or becoming permanently psychotic? Undoubtedly many suicide, or die as a result of the drugs/alcohol they take to try and ameliorate painful affects, yet our society contains very many such individuals, the walking survivors of repeated psychological train wrecks.

If one enquires of the dissociative adult child abuse survivor if there was anyone they trusted while growing up, chances are that the answer will be, ‘No one’. If one enquires as to whether they ever felt safe as a child, the response will frequently be, ‘Never’. It is very understandable, based on their life experience, that such individuals are exceedingly watchful in encountering new environments and with respect to strangers. Many as children experienced the harsh retribution occasioned by some attempt to reveal what was happening to them. Frequently, such attempts resulted in being labelled a liar, a forced recantation, and a worsening of abuse. All such patients have learnt long ago to be very cautious in speaking of things that were likely to unsettle or aggravate their listener. If one's life experience has been essentially that the world is an unsafe place, populated by untrustworthy individuals, it is understandable that they will avoid responding to overt scepticism on the part of a stranger. Such considerations go to the heart of the seemingly perplexing condition of ‘hysteria’ and the belief afforded to its sufferers over the past centuries.

For dissociation to be an effective mechanism in protecting individuals from being overwhelmed by the affects associated with severe past, or present trauma, it is necessary for the individual to a fairly large degree to dissociate the fact that they dissociate. If they are fully aware of the extent of their dissociation, then they are very close to being overwhelmed by the underlying reasons for it. Hence, such individuals frequently present in dysphoric, depleted, somewhat perplexed states. It is inaccurate to conceptualize a patient with DID as having ‘multiple personalities’. A more helpful conceptualization is that such individuals have access to less than one personality. (The use of other paradigms could see DID alternatively conceptualized as the extreme and chronic developmental absence of human rights, as ‘severe disorganized (ambivalent/incompatible) attachment disorder’, or as ‘severe developmental boundary violation disorder.’)

Given that abrupt changes in ego states are commonplace, for example triggered regressed states, switches into flashback modes, selfabsorbed states, trance states etc., it might seem curious that much of the division with respect to the validity of DID has focused on alter states. Fractured or fragmented identity, a high utilization of amnestic internal self-protective barriers and a high susceptibility to posttraumatic triggers, when combined, logically has to equate to something approximating what is observed, and which is far better appreciated when understood. The use of terms such as dual or multiple personality has its origin in a literature that started more than two centuries ago. Dissociative identity disorder is a much more appropriate term and focuses more appropriately on fractured identity than on an erroneous 19th century conceptualization of a body being inhabited by different people (even though a percentage of DID patients may at least initially emphatically disavow one or more alter states as being a part of them).

A capacity to feel is perhaps the richest human asset in sustaining personal growth, yet for the severely traumatized, unleashed feeling can be literally lethal. Hence, there is a repertoire of dissociative defences aside from switching between identity states, which in one way or another serve the function of protecting the individual from being overwhelmed. Included within this grouping are amnesias, depersonalization, derealization, identity diffusion, trancelike states and somatic dissociation.[4] Essentially dissociative defences provide a buffer against awareness and/or move the pain to a construction of a ‘not me’ entity or place. For the very traumatized individual, a variant of dissociation is operative to protect against overwhelming breaches and these manifest at the level of awareness, memory, identity, somatization and reality etc. ‘It's all vague; I don't remember it; it didn't happen to me; my main problem is a pain in my tummy; it's not real…’ Many traumatized dissociative individuals are susceptible to ‘black hole’ experiences, a painful frightening void triggered by traumatic memory, and from which selfhood has been banished.[5]

In publishing the first description of the clinical phenomenology and trauma histories of a series of patients (n = 62) meeting DSM-IV criteria for DID to appear in the Australian scientific literature,[6] Jeremy Butler and I touched upon an issue that may provide a partial explanation for some of the polarizations that occur with DID but also with PTSD. The patients whom we described were selected on no basis other than that they were seen in the normal course of clinical practice encompassing both public and private settings. No less that 34% of these very traumatized individuals were, or had been, health professionals. Included were representatives of the nursing, social work, psychology and medical professions. Although analyses of the individual trauma histories of representative groups of health professionals (including doctors) are sparse, one is struck by the fact that health professions are strongly represented, as with our study, in groups of traumatized individuals that are the focus of particular enquiry. For example, Quadrio's series of patients reporting previous sexual boundary violations in therapy was one in which 50% were health professionals with a history of childhood sexual abuse.[7] Clinical observations would tend to indicate that two adaptations are particularly prominent for very traumatized individuals who practice as health professionals and who have not resolved their trauma; some are overly immersed in trauma and prone to heavily identify with the plight of one or other group of traumatized individuals in ways that lack boundaries and balance, while at the other extreme some traumatized professionals deny the reality of any significant trauma in virtually everybody. In this later group, alternative paradigms are resorted to so that patient trauma is not afforded aetiological significance, for example its effects conceptualized as serotonin or noradrenaline deficiency. A universal biological paradigm, a fondness for the concepts of malingering and suggestion, short or infrequent clinical contacts and rationalizations, for example ‘I was beaten and caned a lot as a child, but I turned out to be a doctor, so it never hurt me’, can be combined to minimize an acknowledgement of the effects of trauma on anyone. To get close to patients’ trauma and to be empathically responsive to it is, of course, predicated on our ability to get close to whatever traumas we have experienced in our own lives. Perhaps the most effective therapists of all are those traumatized individuals who have grieved their losses and done the hard work through therapy, through relationships etc., to build upon and strengthen their own initially impaired selfhood. For them, their patients’ pain, and the defences against it, are as real and immediate as their own.

It could seem tangential, but there are highly relevant messages to be found in examining those individuals in Nazi-occupied Europe who risked their lives to rescue Jews during the Holocaust, compared with those who were the passive or active persecutors of Jews. The rescuers could not be distinguished from the persecutors on the basis of education, political opinion or even religion. The distinguishing difference was their childhood. de Mause recounts, ‘The rescuer's parents were found to have invariably showed an unusual concern for equity, more love and respect for their children, more tolerance for their activities, and less emphasis on obedience, all allowing rescuers to remain in their empathic central personalities and not enter into social alters and dissociate their feelings for Jews as human beings’ (p.110).[8]

Towards the end of his long career encompassing the development of attachment theory, John Bowlby was drawn to specifically include considerations of DID in his clinical work.[9] As a highly evolved mammal with prolonged periods of infantile dependence, followed by extended childhoods, we are as a species particularly dependent on innate attachment and psychologically will go to extreme lengths to preserve such connections in even abusive and barren environments. In the absence of developed selfhood, innate attachment will keep drawing the chronically abused individual back to the psychological prison, maintained for them by their abusers. Dissociation allows for the inherent contradictions of such a scenario to be maintained, even indefinitely. Ambivalent attachment is central to notions of chronic grief. What has been unable to be resolved in life is unlikely to be resolved in death, thus leaving the mourner with the ensconced introject of a familial abuser who throughout life emphasized how bad they were. The power of our innate attachment drive is illustrated by a study that Beverley Raphael, Paul Burnett, Nada Martinek and I conducted in which we demonstrated that usually the intensity of grief for parents who had lost a child was greater than that of a married individual who had lost a spouse and that in turn this spousal grief was more intense than that of an adult who had lost a parent.[10] Thus, in general, the loss of a young child who may have been known only a couple of years is probably going to result in more intense grief than the loss of an elderly parent who one has loved for a lifetime.

While we make heroes of sporting champions, there are no medals for the courageous traumatized individuals who painfully take on the challenge of dealing with the reality of dissociated feelings and conflicted attachments. Denied their birthright of a safe and validating childhood that supports healthy growth, they have to build selfhood for themselves later in life, while at every juncture being assailed by flashbacks, the repetitive utterances of negative introjects, a repetition-compulsion to re-enact their trauma, the need to self-soothe by cutting, burning or drug use, and the entrenched denial of substantial sections of society who want no part in acknowledging the reality of their trauma. The primary distinguishing factor in the life course of a well-educated, loved individual in a healthy caring relationship and interesting employment, compared with that of a traumatized dissociative individual from an abusive incestuous family who finds themself living on the absolute fringes of society, selling their body on the street for the sexual gratification of uncaring strangers, so as to have enough money for the next fix, is probably luck.