Abstract
Areality of human existence is that humankind, given the opportunities, will traumatize fellow humans in about every way it is possible to traumatize them, or at least enough individuals will do so as to make it unsafe to assume otherwise. Those who themselves failed to establish enough selfhood in their own development, act out their vengeance or exploit others with essentially no more sophisticated reasons other than that they can. Rationalizations, projections and denial serve only to provide superficial justifications for actions that contravene the beleaguered concept of universal human rights.
Thus, the opportunities to traumatize and exploit others with apparent limited likelihood of consequences occur when: (i) the actions are subsumed in the collective activities of legitimized groups (e.g. army squads involved with ethnic cleansing or prisoner interrogation); (ii) the agencies of civil order are absent or overwhelmed (e.g. looting and raping in the immediate wake of war); (iii) potential victims have no access to a functioning hierarchy of individuals who can and will use their power to effectively intervene (e.g. the situation that has existed in many family homes, in orphanages, state institutions and in many churches); or (iv) the actions are carried out as part of a plan allowing for the principal perpetrators to avoid capture or retribution (e.g. terrorist attacks or the precisely planned operations of some sexual predators/killers).
The extent and range of mankind's propensity for inhumanity in all possible settings and venues has become increasingly hard to deny or rationalize, 1 but such hard-fought awareness comes at the cost of challenging our inherent need to view the world as safe and predictable.
Although at the global level, collective denial has facilitated the continuance of trauma in numerous settingswhere timely intervention could have averted much suffering, at the individual level such denial seems if anything to be predictive of health. The individuals who view the world through rose-tinted glasses, who profess to see good in everyone, and who hold positive illusions and somewhat inflated opinions of themselves, are likely to be ‘healthier physically and emotionally than those who don't’ (p. 177). 2
In a world where health is correlated with positive illusions that distort an objective analysis of the real and potential traumas that surround us, what of the many who have lived through unrelenting abuse and exploitation? To maintain beliefs that the world is basically safe, there is a powerful need to reconstruct the circumstances of those who are traumatized, such that rather than being the recipients of random barbarism or abuse that could essentially happen to anyone, they are viewed as somehow initiating their own trauma. While such a dynamic is operative with regard to views expressed about all trauma that ultimately does not collectively involve a whole society (in which case the illusion of safety is universally shattered), it has been particularly pronounced in respect of those symbols of social stability and continuity that form the bedrock of illusions of safety: church and family. It follows logically that any societal appreciation of abuses perpetrated in such settings was very long in coming and that the victims of such trauma have been discredited inmany ways. 3 The history of ‘hysteria’ and ‘borderline personality’ are littered with pejorative and undermining assessments that contribute to the socially safe assessment that by and large such individuals' accounts are to be discredited and that they were architects of their own fate. A self-sustaining platform for ongoing widespread abuse is in place when abusers will use any opportunity and setting (particularly those where they have most power and least likelihood of detection) to find their victims, and health in society is correlated with a need to maintain an illusion of safety that necessitates blaming victims for their own trauma or denying its reality. Thus the forces associated with physical and emotional health of some are exploited by others to entrench exploitation and abuse at the very core of what society would like to believe are its safest institutions. The confluence of these two groups in avoiding the objective evidence of such abuse is aided by those factors that deter victims from reporting: fear, shame, ambivalent attachment, self-protective denial and the nature of their dissociative defences.
It was not by chance that incestuous and other abuses perpetrated in families and State institutions, as well as widespread abuse perpetuated by clergy, have only really been defined in recent years. Studies dating from the mid-1980s demonstrated incest rates of around 16% among women in Western society. 4 The Catholic Boston Archdiocese reported in February 2004 that 162 of its priests had been accused of molesting 815 minors since 1950, a number representing 7% of priests who had served from 1950 to 2003.5 Deidre Grusovin encountered enormous opposition (which included being removed from the front bench of her own party) in successfully pushing for a royal commission into paedophilia in NSW.6 In the gradual and patchy unfolding of a more accurate perspective on our society, it is likewise not by chance that those individuals with dissociative disorders who fall at the extreme end of the child abuse spectrum in terms of extent and duration of abuse, as a group, have been well-publicized recipients of society's need to discredit that which is too unsettling (not to mention the vested interests abusers and their protectors have in using all means available to avoid exposure and convictions).
Mindful of this context, what does a psychiatrist do to assist the dissociative and traumatized individual besieged by self-denigrating internal voices, who is affectively unstable, readily triggered, prone to suicidal ideation, who self-soothes by cutting, burning or using drugs/alcohol, who loses time, who is prone to derealization/ depersonalization, and who struggles to have any clear boundaries or sense of personal identity? Not unusually there is virtually no contact with the abusive family of origin, or alternatively there is an enmeshed, boundaryless morass of interaction and dysfunction indicative of the lack of separation and individuation.
Treatment of dissociative patients that takes close account of the extent of abuse and deprivation they have endured and which is informed by an understanding of the dissociative defences is a relatively recent phenomena. To dissociate reveals a need to not know of and to not feel that which would otherwise be overwhelming. To have to repeatedly use such a mechanism in growing up speaks of an environment largely devoid of safety, stability and trusted others, and one that will impact on all the parameters that facilitate the growth of selfhood.
It has become apparent that the treatment of patients with dissociative identity disorder (DID) or related dissociative conditions, has evolved to include much more emphasis on the other components of which are in fact complex trauma conditions. 7 Treatment of such patients is now much more informed by attachment theory, by cognitive behavioural techniques, by staged processes spelled out in trauma models, by maintaining patient functionality in respect of work/study/relationships, and by essentially avoiding overwhelming abreactions or the occasioning of destabilizing regression. 8
While there have been controversies concerning the status of alter states (and how susceptible their appearance is to suggestion), 9 the nature and validity of recovered memories of trauma,10 the use (ormisuse) of therapeutic suggestions, 11 the phenomena of allegations of satanic ritual abuse 12 etc., these tend to be epiphenomena that surround the larger issue of how repetitive trauma and emotional deprivation impact on the development of selfhood and more generally how such issues shape society's response to such individuals and those who seek to assist them.
Informed by having particular clinical and research interests in the trauma and dissociation field for well over a decade, 13 by contact with the literature of the field and with its writers, and by being heavily involved in establishing and directing a trauma and dissociation unit (with both inpatient and day hospital programmes), 14 my intention here is to briefly outline a personal but evolving conceptual and treatment model that takes account of Australian conditions.
In considering patients with DID, it is perhaps most helpful not to view them as having multiple personalities but rather as generally having access to less than one: reflecting fragmented and undeveloped selfhood.
THE SELF
Although there is no collective agreement on the definition of self, most writers would be sympathetic to the notion that the self and its boundaries are central to our understanding of human nature. Acknowledging the lack of an agreed universal definition of self, Stern nevertheless observed that: … as adults we still have a very real sense of self that permeates daily social experience. It arises in many forms. There is the sense of a self that is a single, distinct, integrated body; there is the agent of actions, the experiencer of feelings, the maker of intentions, the architect of plans, the communicator and sharer of personal knowledge. Most often, these senses of self reside out of awareness, like breathing, but they can be brought to and held in consciousness. We instinctively process our experiences in such a way that they appear to belong to some kind of unique subjective organization that we commonly call the sense of self (pp. 5–6).
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a capacity to remember one's life and to have a coherent and chronological self narrative, 16 thus enhancing the capacity to reflect and to be introspective 17 (humans are able ‘to link their representations of objective events with their representations of themselves as experiencing observers of events’ 18 (p. 32));
affective stability, or the capacity to autonomously limit, minimize, and soothe painful affects; 19 − 21
having clear boundaries and being able to readily identify and activate them, whether the issue be physical, sexual, financial or ethical etc.;
being able to live life for oneself rather than principally for, or through, others;
having a capacity to self-activate and to support and defend one's position when under attack; 19 − 21
having the capacity to commit oneself to an objective or a relationship and to persevere despite obstacles or ambivalence; 21
having the capacity to share emotional/sexual intimacy (including allowing one's partner to be who he or she is), and to thus grow beyond relating from a standpoint of dominance, avoidance or fear of engulfment; 19 , 22
having and maintaining self-esteem; 16
having access to, and the capacity to express and to respond to a full range of human feeling;
having an appropriate sense of entitlement, that is, that one is deserving of appropriate experiences of mastery and pleasure, as well as to the environmental input necessary to achieve such objectives;
having a capacity for truth and honesty rather than a lack of ownership of one's own actions or utterances;
having, and expressing, creativity;
being able to remain grounded in current objective reality and to be able to distinguish inner from outer reality; 23
having the ability to tolerate the pain necessary for growth; 22 , 24
having a capacity for differentiated, autonomous identity and functioning instead of existing in dependent, fused or codependent states;
having a stably evolving sense of identity, not one that is a fleeting facsimile modelled on a temporary association;
owning one's body 25 and being at peace with it such that it does not need to be a focus for self-hate or attacks upon some split-off other, or a repository for self-harm and damaging self-soothing in all their forms;
having an array of ego defence mechanisms that are self-sustaining, invite positive reciprocation and which are not at others' expense, as is the case with denial, projection, acting out etc. (this repertoire can include humour, but not to one's own or another's detriment);
being comfortable in spending time alone and being comfortable in spending time with people;
not being unduly vulnerable at times of stress to the reactivation of latent traumatically formed self concepts based on self-perceptions of weakness, helplessness, unworthiness etc. 26 , 27 or in being triggered into the restaging of early life traumas; 28
an ability to differentiate oneself from the shared emotions and actions that characterize mob behaviour;
possessing a sense of having roots or foundations that are in turn tethered to introjected objects grounded in support and safety; 10 , 29
not being subjected to ‘black hole’ experiences, a painful frightening void triggered by traumatic memory, and from which selfhood has been banished; 27
having an internal awareness of personal existence that is stable across contexts, experiences and affects; 30 and
a capacity to differentiate from the beliefs of others so that one is willing and able to trust oneself. 24
SELFHOOD AND DISSOCIATION
The patient with DID or dissociative disorder not otherwise specified (DDNOS) has used their capacity to psychologically remove themselves from repetitive and inescapable traumas in order to survive that which could easily lead to suicide or psychosis, and in order to eke some growth in what is an unsafe, frequently contradictory and emotionally barren environment. Not unusually they arrive at their psychiatrist's or other therapist's door having stumbled through a number of years ofmutually frustrating or inconclusive contacts with health professionals (e.g. in the first Australian series of DID, patient diagnosis on average took 11.9 years). 13 Perhaps one-third have already experienced major sexual boundary violations in their vulnerable quest for treatment. 7 , 13 Deeply traumatized, developmentally arrested in many ways, feeling unsafe and untrusting, struggling to remain grounded in present time and place, hoping for the best but expecting the worst, they guardedly make it through your office door, checking the shortest escape route as they do so. They sit, either avoiding eye contact or clutching at it, their bodies frequently displaying the unconscious defensiveness that comes from being pervasively and inescapably exposed to unspeakable things. Their scarred arms are the external manifestations of a chronic internal war conducted in a world where there is as yet limited selfhood. Their childhood has been spent accumulating a mounting psychological debt in which present survival is paid for by dissociating otherwise overwhelming affect and the incessant contradictory elements that otherwise would destroy the lifeline to the barest of attachment opportunities, involving parental figures who themselves have little selfhood and no interest in developing any.
A diagnosis of DID merely encompasses one axis of a multiaxial adaptation to chronic developmental trauma. However, being knowingly able to interact with the components of an elaborately evolved defensive system that is the repository for partial or total amnesias and the affects directed at past trauma via differing identity states (including the personifications of introjected abusers), provides a framework for the therapist to understand things that because of their defensive origins were generally secretive and not well understood by the patient himself/herself. (Indeed, for the defence to be effective patients must, to a largemeasure, dissociate the fact that they dissociate…)
In looking for the embodiment of selfhood, one could reflect on some words by Victor Frankl:
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We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken away from a man but one thing: the last of the human freedoms – to choose one's attitude in any given set of circumstances, to choose one's own way (p. 104). … a significant part of the motivation of the abuser may be to evoke projectively in the child the unwanted negative images of the self – to make the abused one feel utterly helpless, humiliated, shamed, violated and abject – and to bring about a near annihilation of the true self of the abused.
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In the dissociative individual, ‘there is no uniting self which can remember to forget’. Rather than use repression to avoid traumatizing memories, he/she resorts to alterations in the self ‘as a central and coherent organization of experience… DID involves not just an alteration in content but, crucially, a change in the very structure of consciousness and the self’ (p. 187). 29 There may be multiple representations of the self and of others.
The development of selfhood involves differentiation and individuation. Self-differentiation involves a capacity for self-representation to others, which in turn relies on a capacity to access representations of oneself as an experiencing observer of events (p. 32). 18 For a child dependent on a caregiver who also abuses her, the only way to maintain the attachment is to block information about the abuse from the mental mechanisms that control attachment and attachment behaviour.10 Thus, childhood abuse is more likely to be forgotten or otherwise made inaccessible if the abuse is perpetuated by a parent or other trusted caregiver.
It needs to be emphasized that the reality of human experience is such that there are at times vast differences between individuals' exposure to the nurturance, safety and opportunities (educational, creative and economic) that assist the development of selfhood. Destroy the cultural and spiritual heritage, sense of belonging, role models and sources of self-esteem for an individual or for an entire cultural group, and the consequences are similar, singly or collectively. Entire indigenous societies, displaced by their encounters with colonization, functionally exist like a traumatized and griefstricken individual.
One of the enduring paradoxes of the human condition is that despite the ascendancy of our species and the prodigious intellectual and creative feats that we are capable of, we struggle as individuals in actually clearly recognizing and adopting simple and oft repeated truths, so evident from the lives of many around us. An example might be that, generally speaking, life is much more manageable when we treat others as we'd like to be treated ourselves.
OBSERVATIONS ON TREATMENT
What follows is not an exhaustive review but rather a selection of brief but pertinent observations regarding the treatment of dissociative individuals that are informed by the model of selfhood outlined here, as well as the guidelines for treating dissociative identity disorder complied by the International Society for the Study of Dissociation. 33
Never work harder than one's patient
Unless the patient is an active participant and willing to tolerate the pain and grief that are the necessary prerequisites for growth, little can change. Many patients may want some connection, yet at the same time are unwilling to realistically confront key contradictions in their life, including their ongoing exposure to the sorts of trauma that caused their dissociative defences originally.
Playing the hand one's been dealt
Life is exceedingly unfair. Not only have dissociative patients suffered years of abuse/neglect, from which in a just world they would be rescued and provided with restitution, they, in fact, if they are to grow the selfhood necessary to explore their potential, have only their own circumstances, talents and opportunities with which to achieve it. Although some might reasonably argue that they have suffered enough and that it should be someone else's duty to make up to them what they have lost/missed out on, assuming a victim mindset ensures stagnation.
Central importance of the therapeutic alliance
A core issue that perhaps defines human relatedness is that to address the damage done by the abuse and neglect experienced in relating to humans, it is necessary to relate to other human beings. In the transference, the therapist can almost simultaneously be the actual or potential abuser, a focus for attempted seduction, and a longed-for loving parent with intact boundaries. Providing a safe and integrative landing for such divergent emotions that frequently are embodied within a fragmented and unevolved self, is a central therapeutic objective and one particularly dependent on the strength of the therapeutic alliance, a facilitating resource that needs to be added to throughout therapy. The therapeutic alliance forged by empathy and protected by boundaries, provides the capital that sustains the hard work of daring to grow.
Boundaries
Dissociative disorders could alternatively and accurately be categorized as boundary violation disorders. Brought up in environments devoid of safety, security, and privacy, dissociative patients had to endure repetitive abuses. Many such patients when seen still remain enveloped to a greater or lesser extent in the boundaryless oppression they were brought up in. Firm and consistent boundaries are a guiding reference to safely negotiate situations where there is the potential to lose more than can be gained. They are essential to constructing the safety of the therapeutic frame such that abuse and exploitation are not re-enacted in the guise of ‘therapy’, while their modelling and discussion is central to patients growing and strengthening a sense of self based upon boundaries of their own.
Safety
Logically, one is in no position to deal with effects of past abuse and neglect if currently locked in the continuing dynamic. Many patients presenting, even as adults, are still being repetitively abused by the same people who abused them as children, or by facsimiles of them. Alternatively, life circumstance in terms of accommodation, finances, support systems etc. are so precarious, that there is not enough basic stability in the patient's life on which to base therapy. The starting point for therapy is thus a basic level of safety and security. Some active measures may be necessary in facilitating the cessation of abuse (e.g. a period of hospitalization) and in securing safe accommodation (e.g. social worker involvement etc.).
Personal responsibility
While neglectful, abusive environments deleteriously effect the development of selfhood in the growing child, so too do environments that are overprotective and which do not support a goal of achieving mastery of a balanced life. Seeing patients many times for prolonged periods of time (e.g. several hours), seeing them many times per week and encouraging repetitive phone contact out of hours, has more to do with the rescuing therapist's needs to conform to a self-image of knowing more, doingmore, caring more, than it does to any objective need of the patient. The cumulative message of such overinvolvement is to demonstrate to the patient that they are incapable of getting through a day without support or are incapable of making any decision for themselves without consultation. It also communicates an unwillingness on the part of the therapist to have reasonably firm boundaries around their own family life/out ofwork time.
Transference
In treating dissociative patients, who may recurrently be not orientated to present time and present place, and where most have experienced prolonged inconsistencies or neglect in the emotional responses of primary care givers, the therapist needs to be as real and wellgrounded in current reality – and their communications to be as clear – as possible. Many patients came from environments characterized by ‘double-bind’ type communication, severe retribution if one spoke out or complained, and an absence of ever experiencing an apology from anyone. Paradoxically, the angry remonstrations to the therapist or the ‘bad-mouthing’ 34 of him/her to others regarding things that conventionally might be viewed as fairly trivial, are frequently positive, a demonstration of fledgling selfhood in an environment safe enough to include the outward expression of anger.
Countertransference
In dealing with traumatized individuals whose selfhood is undeveloped in many ways such that they can be affectively unstable, prone to splitting or projection, readily triggered into dissociative re-enactments or who are struggling to recognize and respond appropriately to boundaries in general, it is salient to keep at the forefront of consciousness the dynamics that underlie Karpman's triangle. 35 This recognizes the relative ease with which the therapist in their countertransference reactions can switch from the role of therapist to that of abuser, at the same time as feeling victimized themselves. Early and clear enunciation of the principles of therapy and the joint responsibilities of patient and therapist in that process help build the therapeutic frame. The process needs to be safe for both participants. If it is not, the endeavour should be terminated.
Avoiding the rescuer role
Most parents know that in having their children negotiate the developmental challenges of adolescence, one of the most useful strategies to assist them is the judicious application of the ‘law of consequences’, applied in a non-punitive but nevertheless consistent manner. It is unhelpful to shield such individuals from learning by dealing with the results of their actions or to accept rationalizations for behaving badly. It is similar with those dissociative patients who would have their rescuing therapist buy into accepting poor behaviour on the basis that it is not remembered, ‘done by a different alter’, or that as the patient has already experienced much past trauma, it should be overlooked. Particularly, one should be very aware of the dynamic in which the therapist accepts the role of telling the patient what to do as the immediate solution for what will prove to be the first of an unending series of crises. Having had their therapist assume responsibility for their life, they will then blame him/her for its failure. In any given situation, the patient may need to be directed at examining their options and after due consideration owning the course they chose.
Avoiding specialness
Narcissism has its origins in childhood hurt, humiliation and abuse.36 Dissociative patients did not have childhoods in which they were validated or made to feel special. If later in life they have a presentation that represents a focus for wonder or fascination, they risk engaging in therapy with a person who likewise has a particular need to also be special: whether as someone heroically treating a patient assumed to be poorly understood by their colleagues, or as someone treating a ‘fascinoma’ with the therapy destined for a best-selling book. Where there are agendas on the part of the patient and/or their therapist in which the pursuit of healthy functioning is not the primary goal, the therapeutic alliance is illusionary and a poor outcome is likely. ‘Having a life’ encompasses developing the multiple dimensions of selfhood so as to be able to love, work and play most effectively. Those who get well know that they need to deal with the unfinished business of their past and its impact on their present. As much as possible, they want to put behind them the identity of being a dissociative individual, not enshrine it.
Empathy
Richard Kluft observed the centrality of empathy in the therapeutic process with dissociative patients. 37 About the most powerful thing a therapist can do for any patient is to truly listen, and this applies in particular measure to dissociative patients who carry large burdens of shame and guilt, have very good reasons to be untrusting and who have frequently experienced first-hand disbelief, invalidation or blame and punishment from those whose primary role should have been that of their protector. The foundations of selfhood are stable positive introjects and it is far better to have them late than never. To live for even a little bit of time in a protected and safe space, and to live with constant boundaries, validation and positive regard, is to experience in a tangible way how the world could be ordered and to begin to assemble an introject that can start to neutralize the negative self-images derived from the experience of past abusers. Those whose birthright to access positive introjects as they grew up was denied, must, in order to achieve functional selfhood, assemble them later in life, if they find suitably empathic individuals.
Staging of therapy
It is wise not to try to run before one can walk. Therapists need to be very mindful of where their patient is in terms of safety and stability of environment, social and emotional supports, as well as their strengths and current capacity to deal with stress and change. 38 The price of growth is pain but for many, particularly in the early stages, there are very few coping resources in reserve and a delicate titration exercise is necessary: too much focus on progressing the many unresolved issues (including past trauma) and the patient decompensates and abandons the attempt, too little and one is accepting a state of long-term stagnation. The focus of therapy should be integrative and to build step-wise on strengthening the foundations of emerging selfhood, for example the achievement of workable boundaries in one area of life can be extrapolated to all other comparable areas of life.
Recovery of feeling
Van der Hart et al. offer a model developed from Myers' observation of shell-shocked World War I combat veterans, 39 in which a failure to integrate traumatic experiences results in the structural dissociation of the premorbid personality into two mental systems. 40 This primary structural dissociation results in an emotional personality that is associated with re-experiencing the trauma, and an apparently normal personality that has failed to integrate the trauma, but which engages in matters of daily life. 41 , 42 In many ways, the capacity to feel represents the richest facet of life, but for the severely traumatized, feeling may also be the most dangerous. Triggers may unleash dissociated feelings that would otherwise have been too overwhelming to have been expressed in the context of ongoing trauma at the time: short of risking suicide or psychosis. Although affectively unstable in terms of triggers that can precipitate dysphoria or fight/flight responses, they are generally avoidant of feeling and many learnt long ago that to react to their abuse, for example to cry, only made it worse. They have a sense that to release feelings is to risk relinquishing control of something that could destroy them. As with loss more generally, the key to not remaining incapacitated by it is to grieve it, and in the case of dissociative individuals this means accessing and expressing the sadness of a childhood lost. Safety, empathic connection and care in letting the patient gain confidence by not tackling too much, too early, facilitates the emergence of connected feeling.
Processing of trauma
The more integrated one is, the more accessible one's memories and emotions are in any particular circumstance. The dissociative defences include the sequencing of traumatic events in a compartmentalized fashion, with the walls of such compartments akin to levee banks precariously holding back flood waters. Attention to the growth of safety and selfhood allow for a lowering of the water level as the contents of compartments are progressively assimilated. The less there is that is held behind walls, the less need there is to continue to have the walls, and the less danger there is that an incapacitating torrent will be unexpectedly released by a particular trigger breaching a wall that is not directly observed. The more one can know oneself, the less exposed one is to precarious defences, and the less vulnerable one is to further trauma. Additionally, one canmore quickly and comprehensively respond when one is able to marshal one's full internal resources. Confidence begets confidence. There is some truth in Nietze's famous observation that that which does not kill us makes us stronger. However, to be overwhelmed by trauma, either acutely or in reconfronting it, is to be weakened, while resistance to subsequent attempts to deal with trauma is increased. If there is significant doubt regarding the patient's current ability to process trauma within a spectrum of tolerable affect, then don't attempt to; rather, concentrate further on building stronger foundations.
Memory
It is unhelpful to focus on memory in ways that give it more prominence than integrated selfhood. Some traumas are more verifiable than others, and some (but not all) dissociative patients have fairly accurate memories of traumas that occurred in early years. Two decades ago, Richard Kluft made the valuable and still applicable observation that ‘in a given patient, one may find episodes of photographic recall, confabulations, screen phenomena, confusion between dreams or fantasy and reality, irregular recollection, and wilful misrepresentation. One awaits a goodness of fit among several forms of data, and often must be satisfied to remain uncertain’ (p. 40). 43 Although not often referred to as such, it is useful to view memory as a boundary issue that challenges the required therapeutic neutrality. 44 Generally speaking, we remember about as much about traumatic events as we are psychologically capable of dealing with. Therefore, it makes little sense to add to the load of someone already crippled and struggling with the incomplete memories they already have. In order to have a handle on who we are, we need to remember where we came from; thus, using memory extraction techniques on someone whose selfhood is not growing stronger can only unnecessarily traumatize them, trigger malignant abreactions and/or invoke previously used defences to redissociate that which would otherwise remain too overwhelming.
Suicide
While untreated patients with DID have very high suicide rates, in the order of several thousandfold in excess of the American national average, 45 there is a marked reduction in suicide risk when they are in any form of soundly based therapy incorporating a stable therapeutic alliance.46 Enquiry will reveal that, for many, thoughts of suicide are so frequent as to represent a constant option that over time seems like ever-present background scenery. It makes sense and feels less alarming when it is appreciated how threatened, powerless and immersed in double-bind communications such individuals usually were in their childhood circumstances. To have the option of suicide means that whatever happens they at least can exercise some personal power. Suicide as a potential but unused option is a more powerful position than submitting without the possibility of exercising choices. The goal of therapy is to substantially widen this option base.
The body
For many dissociative patients, their body represents the front line of an enduring conflict and it bears the scars and the disposition of battle. Negative introjects, self-deprecating internal commentary, shame, humiliation, fear, internally directed anger, distressing flashback phenomena, the need for self-soothing using selfharming options, recurrent frightening disconnections associated with depersonalization/derealization or sexually connected triggers, collectively result in a person who holds his/her body in low regard. It can be the recipient of repetitive cutting, burning, overdosing, unsafe and harmful sexual practices, anorexia, bulimia, as well as drug and alcohol abuse. At the same time as being empathic to, and validating of, the person, the message from the therapist has to be that the goal is to cease such self-harming and to progressively replace such strategies with adaptive ones that enhance body image. Loneliness and lack of connection play a big role in self-harming. Facilitating healthy activities involving the body, particularly in group contexts (e.g. aerobics, tai chi, sport etc.) can only assist. As with twelve-step programmes, the underlying message is that, hard as it may be and despite the multiple undeserved traumas of the past that can be incorporated into rationalizations for continuing, if the patient wants to be better they have to get serious about progressively ceasing the multiple forms of selfharm that in reality are forms of addiction. 7
Alters
Alters are not people, and although at times they may demonstrate a sense of separateness approaching delusional intensity, they are never integrated personalities. They are a solution arrived at, using what seems to be to a greater or lesser extent a universal potential to dissociate. At an age where selfhood is not well developed, and particularly so in abusive, ‘double-bind’ environments, identity states are incorporated that provide semipermeable walls that hold the otherwise overwhelming memories, affects and somatic foci, at the same time as providing a means of satisfying the impossibly contradictory demands of abuser/attachment figures. In someone where all components of personality are subjected to fragmentation and compartmentalization and where fear, shame and invalidation have been constant companions, it is logical that treatment is integrative (i.e. building internal communication, shared affect, collective responsibility and better informed decisionmaking), and that it encompasses an equal acceptance of all parts of the patient (i.e. there is no split that favours certain parts and ignores others). Treatment should not potentiate separateness and it is wise to refer to named identity states as ‘parts’, to emphasize that, whatever their representations, one is ultimately dealing with a single individual. Kluft points out, ‘The therapist's consistency across all of the different alters is one of the most powerful assaults on the patient's dissociative defences’ (p. 37). 37 Alters, whatever their initial descriptions, are usually ultimately revealed as attached to the core sadness and associated wish that childhood could have been loving and non-abusive.
Cognitive restructuring
Embedded in the therapy of dissociative patients is empathic confrontation with the distorted logic that is encompassed by denigrating and invalidating parental figures, as well as the mutually incompatible beliefs that are encompassed within the system of alter states. In order to maintain a minuscule sense of power, the dissociative individual had to assume that there was something that they could have done to alter their abuse, a source of enduring guilt and self-criticism. In order to maintain such a belief system, they have to transpose the options and abilities of an adult into a small child. The logical inconsistencies of this position will need to be repeatedly and empathically addressed. At the same time, the abuse experience is reframed as one of pain and sadness in which courage and ingenuity were used to ensure survival.
Involvement of partners
Dissociation can contribute to particular relationship challenges that can range from individuals in dissociated states continuing sexualized relationships with primary abusers and/or strangers or with others known to them, through to masochistic submission, or repeated crises involving self-harm in all its forms. It is a mistake to assume, however, that the primary focus of concern in relationships is always the dissociative individual. Indeed, there is usually a complementarity of emotional and developmental issues for both parties in enduring relationships, while in relationships that do not endure, there can frequently be abuse and exploitation on the part of the non-dissociative individual that mirrors behaviours of previous abusers. Functional partners are a major resource to the patient's life and to the therapy, while the fact that they exist is indicative of the growth potential.
Realistic goals
It is imperative to appreciate that the extent of some individual's trauma and the damage it has wrought on all aspects of developing selfhood are such that for some there are not enough strengths, nor is there enough time remaining in their lifespan to ever process their trauma, grieve the losses and develop integrated functioning. Chronically fixated by their traumas, they cannot move past them, nor can they develop new aspects of life outside the prison of their past. Appelfeld observed that such individuals live life ‘on the surface of consciousness’ (p. 18). 47 Kluft coined the term the ‘mathematics of misery’ to help conceptualize those individuals subjected to major sexual trauma, perhaps more than a thousand times. 48 Some dissociative patients seize the opportunity given by therapy and make major gains within relatively short times (e.g. a year); others have much lower treatment trajectories although they make sustained and steady progress over years.38 With the very traumatized, chronically suicidal, self-harming individual with very little self-hood, treatment of necessity has to be primarily supportive in nature, with immediate goals being more in terms of maintaining connection, support and staying alive. It also needs to be recognized that there is a significant minority of dissociative patients who are essentially untreatable, for example because of an inability to maintain enough boundaries to ensure the safety of the therapist, inability to maintain any permanent residence, psychopathy or extreme hostility.
Beyond therapy
No one gets well by therapy alone, although a positive therapeutic experience mobilizes fledgling selfhood and supports its consolidation in regard to themultiple tasks in ‘having a life’. Relying less on dissociation and avoidance means more engagement with respect to work, study, creativity and relationships. Boundary issues dealt with within the therapeutic frame provide a template for dealing with such issues in relationships outside of therapy. The need for poor outcome attachments grasped at while in the grip of loneliness or abandonment feelings, becomes attenuated, leading to increased patience and self-restraint and better quality relationships, which in turn enhance confidence and support structures. The growth of selfhood is nicely encompassed in the reflections of one patient, ‘You don't think your way to a new way of living. You live your way to a new way of thinking’ (p. 32). 24 In attracting interest and support in work or relationship ventures, it is very advantageous to have saleable commodities in the market place of life. It helps if one is intelligent, attractive or talented, such that skills or opportunities can be forged that augment the work done in therapy. Pierré Janet observed long ago that as patients resolve the effects of their trauma and engage life, they begin to forget to turn up for therapy. 49
Being real
Lemma examined the use of humour in psychotherapy, observing ‘that so little has been written on the subject of one of the most ubiquitous means of communication in our repertoire’ (p. 4). 50 Grofjan stated that although psychotherapy deals with serious business, it does not necessarily have to take on the solemnity of a ‘Wailing Wall’. 51 To quote Ross, ‘Humour helps form a treatment alliance, disrupts negative transference, has an antidepressant effect and may even benefit the immune system’ (p. 340). 7 Dissociative patients may find it difficult to remain grounded in present time and place. It follows, then, that it is helpful if their therapist is identifiably distinct, real and able to share encouragement, validation and even humour. It needs to be borne in mind that many patients, in order to survive, had to create alternative realities, something that can be a potent source of derailment if their therapist also has a vulnerability for merging with elusive spaces populated by the modern representations of 18th century demons. Opaque settings, contemplative silences and a focus on transference and associated interpretations, however, well intended, serve to make it harder to remain grounded and can evoke distress when associated with the past use of silence, criticism or incarceration by abusive/emotionally depriving attachment figures. As Kluft, Putnam and others have pointed out, therapists need to be real, with a usual range of affective response. 34 , 37 John Briere has made the comparison that the effective therapist role is somewhat akin to that of a personal trainer (pers. comm. 1996). The fragmented patient with impaired selfhood has a particular need for a therapist with healthy selfhood. Unfortunately, such a vulnerability is readily and harmfully exploited by those without it. Schnarch puts it well: ‘When therapists have sex with patients, it reflects a commingling of their respective pain and pathology, not unbridled passion’ (p. 61). 22
CONCLUSIONS
Steven Gold makes the salient point that the seemingly exceptional quality of dissociative experiences do not constitute justifications for straying from the standard structures and procedures of therapeutic practice. Indeed, as he observes ‘many of the facets of the therapeutic structure that originated in the early days of psychoanalysis and which since have become near-universal standards of practice across orientations, were developed in response to experience with cases that would, from a contemporary vantage point, be recognized as having strong dissociative elements’ (p. 1), 52 such as those reported by Breuer and Freud in Studies on Hysteria. 53
Despite stereotypes whose purpose is to deny or minimize the validation of their trauma, blame them for it, or to cast doubts on the competence of therapists who take on the not unrewarding challenge of treating very traumatized individuals, our society has experienced the general thrust of such mechanisms of denial, projection and rationalization punctured many times in a progression that has seen mainstream churches enveloped by crises occasioned by abusive clergy, commissions of enquiry into paedophilia and institutional abuses, the resignation of a Governor-General, the jailing of prominent politicians and sportsmen for the serial sexual abuse of children, and an unfolding crisis precipitated by the sexual practices of elite footballers from multiple codes. The challenge for society itself is to evolve enough collective selfhood that widespread abuse and neglect in all its forms and venues is not accepted. To quote Schnarch, ‘Humans grow with extreme reluctance (p. 104)’. 22 Trauma therapy (including that focused on dissociative patients) incorporates cognitive behavioural techniques and strategies, as well as the grief model. It is psychodynamically informed and uses many systems theory principles. For the fragmented, dissociative recipients of the unempathic, blaming responses generated by mankind's collective false-self, a way to having a lifemeans progressively addressing in therapy the developmental deficits and multiple traumas and losses that have necessitated defences against knowing, feeling and being.