Summary of Dan Brown's February 2003 NESTTD Presentation

A detailed summary of Dan Brown’s comprehensive overview of the many meanings of dissociation would occupy our whole newsletter.  Following are a few highlights I found especially useful:

In the famous “stranger situation” experiments, children in the “disorganized attachment” group showed alternate, or simultaneous, clinging and avoidance or fight behavior.  Tapes showed “frightened and frightening” parental behavior, with inadequate parental soothing, leaving children emotionally disregulated.  “Disorganized attachment” at 12 to 14 months strongly predicted dissociative phenomena in childhood and early adulthood.

For some of these children, progressive involvement in trance behavior becomes a learned coping style. (For some, this evolves into excessive care taking or excessive controlling behavior.) These dissociative responses (numbing, zoning out, etc.)  become “traits” when the response gets organized into an emancipated neural network (what we would call a “part’). Both can be called “dissociation.”

Dan, who spends sixty percent of his time in court on “false memory” lawsuits, warned us to look carefully at trauma patients with histories of medical factitious disorder. About a third of the high profile false memory suits have involved patients with very disorganized attachment behavior, who have learned to get their attachment needs met through the medical system, rather than through a parenting system. Some of these folks may now be getting their attachment needs met in the legal system. Although many of them do, in fact, have abuse histories, the need to confabulate their medical history extends to expanding upon their abuse history, landing all too many trauma therapists in court. 

Some notes about DSM IV: The current definition of dissociation is all cognitive: Amnesia, depersonalization, identity diffusion, etc.  Somatoform disorders appear in another chapter. All negative symptoms appear under dissociation (amnesia, depersonalization), while all the positive symptoms appear under PTSD (intrusive thoughts, etc.). The ICD adds behavioral enactments to the definition of dissociation. Dan suggests that DSM revise its current definition of dissociative disorder to combine cognitive, somatoform, and behavioral re-enactment.

Concerning the latter, the behavioral system develops before the ability to store memories in narrative language.  At two years old a child can enact a traumatic sequence with dolls, though not until four years does a child have the narrative memory system, which enables him or her to tell the story.  Dan notes that in trauma, we see enactment first, for instance, in children’s play, or in the adult transference, while the narrative memory initially remains incomplete and disorganized. 

Given Lauren Slater’s recent article extolling “repression” in the New York Times Magazine, Dan presented some fascinating research gathered in the wake of the California earthquake. Because the job of removing heavy debris safely required proceeding very slowly, CalTran rescue workers toiled many hours hearing, but unable to reach, trapped and injured people.  Under these conditions of profound helplessness, those workers were who able to put aside their feelings and to dissociate were the “heroes” who were able to work long hours.  However, probably because dissociation disrupts processing, they were also more likely to show symptoms of PTSD later.  Those who processed closer to the moment looked much worse early on, but showed fewer signs of PTSD later. Similarly for Viet Nam vets, high dissociative responses were a better predictor of later dissociative disorder than the level of exposure to traumatic events. This has important implications, of course, for heroes and heroines involved in the 9/11 clean up efforts—“the best workers will have the most trouble later.”

Likewise, children with a dissociative coping style will appear to be higher functioning, but are more likely to become symptomatic as adults.  Children with a more active style of dealing with trauma, who maintain continuous memory, will look worse at the time, but are more likely to get timely treatment.  Whether a person forgets and remembers later, or processes the event at the time, is not a characteristic of the abuse but a personality trait. Dan makes the argument that the current legal system’s statute of limitations unfairly gives the child with the active processing style the opportunity for justice while depriving the child with the dissociative processing style.

Dan believes that the work of Ellert Nijenhaus and his colleagues, on structural dissociation, is most relevant to what we do clinically.  Borrowing terminology from the work of Charles Meyers with traumatized WWII Vets, the Nijenhaus group has identified two operating systems:  The Apparently Normal Personality (ANP) is devoted to the every day functions of energy regulation, attachment, and care taking. The Emotional Personalities (EP’s) provide us with an evolutionarily wired animal defense system in response to trauma.  In sequence we, like animals, respond first with Fight, then Flight, then Freeze, and finally Submit. (Author’s note: Nijenhaus and his colleagues now also add “attachment cry.”)

All traumatized people respond to trauma by splitting their ANP function from their EP responses.  This allows for the survival of the species, as the ANP continues the activities of daily living (going to school, working, parenting), while the trauma stores separately in the EP.

SPECT brain scans add the data that DID patients show a significant deficit in the parietal lobes (responsible for organization) and in the frontal areas, the areas of executive control.  This means that DID patients have a neuro-biological processing deficit in the areas of executive control and organization.  Nijenhaus notes a substantial decrease in the hippocampus (the part of the brain responsible for integrating and differentiating past and present) in trauma survivors. There is a concomitant increase in the hippocampus with treatment.

In the small time remaining, Dan could only tantalize us with his thoughts about the implications for treatment: The structural model tells us that the fundamental problem in DID and DDNOS is structural disorganization.  This means that treatment is NOT about recovering memories.  It is about integrating the system, with the emphasis on putting together the whole, and restructuring the memory, not on calling out and exploring the parts.

Dan suggests that we can restore executive functioning by teaching awareness skills and mindfulness training to our DID patients (as in Marsha Linehan’s DBT model).  “Concentration increases internal organization of the mind.” “We need to teach our dissociative patients how to keep their minds on something and stay on it.”  The goal is to increase continuous awareness of experience. 

The principle is whole to part, not part to part. Onno van der Hart (a colleague of Nijenhaus) suggests that we encourage co-presence of parts. Encouraging all parts to stay “out” (rather than taking turns) makes integration happen faster.  Similarly, in Internal Family Systems all intervention goes to the whole.  In IFS, the patient, rather than the therapist, is asked to do the work of talking to the parts: “Ask the ___part about this.” “Ask the __ part what its role in ….is.”  In these “more robust interventions” therapists reinforce the concept of the whole, a whole bigger than the parts.

Although we longed for another couple of hours devoted to treatment implications, we thank Dan for bringing us this overview of current thinking.

-- Patricia Papernow

(with help from Janina Fisher, Joanne Twombly, & Debbie Korn)

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