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Chapter 1 Introduction
Chronically traumatized individuals are caught in a terrible dilemma. They lack adequate integrative capacity and mental skills to fully realize their horrific experiences and memories. But they must go on with daily life that sometimes continues to include the very people who abused and neglected them. Their most expedient option is to mentally avoid their unresolved and painful past and present, and maintain a façade of normality as much as possible. Yet their apparent normality, their life at the surface of consciousness (Appelfeld, 1993), is fragile. Dreaded memories that are awakened by strong reminders haunt survivors, especially when they have exhausted their emotional and physical resources. And unfortunately, many survivors live their lives on the edge of exhaustion, and thus are more prone to the intrusion of traumatic memories. Survivors find it is beyond them to accept the painful realities of their lives, and they thus remain stuck in dread, hopelessness, and terror. They often struggle with deficits in skills to regulate overwhelming internal and relational experiences: Skills that their caretakers failed to help them develop and that seriously limit their mental level (integrative capacity). They seem unable to achieve an adequate balance between their level of mental energy and the capacity to apply that energy to engage in adaptive mental and behavioral actions, which we call mental efficiency. They are beset by ineffective but repetitive actions and reactions that do not support a growing maturity and capacity to cope adequately with the vagaries and complexities of life.
In this introductory chapter we embark upon our journey into understanding and treating the chronically traumatized individual by first offering some conceptual clarity, in particular, a more precise definition of trauma-related “dissociation.” We then outline the essentials of the theory of structural dissociation of the personality, particularly the role of mental and behavioral actions in traumatization. Finally, we discuss the basics of the practical clinical treatment approach that is informed by this theory.
Trauma-related Dissociation
We believe that dissociation is the key concept to understanding traumatization: This is a fundamental premise of the book. But we have not come easily to this appreciation, largely because many concepts in the trauma field need further clarification, and dissociation is chief among them. Virtually everyone in the trauma field uses the term “dissociation” in different ways, and there are many disagreements about its causes, its essential characteristics, and its role in the psychopathology of the traumatized individual. Often in a single discussion “dissociation” can be used to denote a process, an intrapsychic structure, a psychological defense, a deficit, and a wide array of symptoms. And the symptoms considered to be dissociative vary tremendously from one publication to the next, and from one measurement instrument to the next. For example, even though phenomena such as intense absorption and imaginative involvement were originally distinguished from dissociation, they have now been subsumed under the concept of dissociation. Thus, “dissociation” is a much misunderstood, confusing, and sometimes maligned concept. Some have even suggested that the term be abandoned altogether. In the course of this book we will address these issues in depth.
But for now, suffice it to say that the major premise of this book is that dissociation is an undue division of the personality, and that it is at the heart of trauma-related disorders. Perhaps these ideas will be hard for many to accept, not in the least because so many authors have lost sight of the original definition of dissociation, which is most clear and involves the essence of traumatization. We find that a more precise definition, briefly described below, is upheld in light of more contemporary research and clinical experience.
Structural Dissociation of the Personality
Dissociation orginally referred a division of the personality or of consciousness (Janet, 1887, 1907; Moreau de Tours, 1845; cf., Van der Hart & Dorahy, in press). More specifically, Pierre Janet noted that dissociation involved divisions among “systems of ideas and functions that constitute personality” (Janet 1907, p. 332). He indicated that the personality is a structure comprised of various systems, as more contemporary definitions also assert. A system is an assembly of related elements comprising a whole, such that each element is a part of that whole in some sense. That is, each element is seen to be related to other elements of and/or the whole system. The personality as a system can be understood as being comprised of various psychobiological states or subsystems that function in a cohesive and coordinated manner. For example, Allport (1981) proposed that personality is “the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought” (p. 28). Likewise, systems theories (e.g., Benyakar, Kutz, Dasberg, & Stern, 1989) conceptualize personality as an organized or structured system comprised of different psychobiological subsystems which are normally more or less cohesive, and function together as a whole in healthy individuals. Structure has been defined as “the composition of component parts, an organization of a complex whole … with reference to the positional and functional interdependence of their parts” (Drever, 1952, p. 285). Indeed, in terms of evolutionary psychology, humans comprise a number of various psychobiological (sub)systems that have evolved by natural selection and that serve different functions, i.e., that allow them to function at their best in particular environments (Buss, 2003, 2005; Metzinger, 2003; Panksepp, 1998).
As 19th century French psychiatry already noted, dissociation involves a particular organization of the psychophysical systems that constitute personality. In our view, this organization is not arbitrary or coincidental, but in traumatization it likely follows rather well-defined evolutionary prepared metaphorical “fault lines” in the structure of the personality. Based on this understanding of the personality, we have begun to use the term structural dissociation of the personality (Nijenhuis, Van der Hart, & Steele, 2002, 2004; Steele, Van der Hart, & Nijenhuis, 2004, 2005; Van der Hart, Nijenhuis, Steele, & Brown, 2004). Dissociative divisions do not just occur among mental actions, such as experiencing sensations or affects, but primarily take place between the two major categories of psychobiological systems that make up personality (Carver, Sutton, & Scheier, 2000; Gilbert, 2001; Lang, Bradley, & Cuthbert, 1998). One category involves systems that are primarily geared to approaching attractive stimuli in daily life, such as food and companionship. The other category of systems involves avoiding or escaping from aversive stimuli, i.e., various threats. The purpose of these systems is to help us distinguish between helpful and harmful experiences, and to generate the best adaptive responses to current life circumstances. These situations encompass our interoceptive and exteroceptive worlds, i.e., our internal and external environments as we perceive them. We refer to these psychobiological systems as action systems, because each involves particular innate propensities to act in a goal directed manner (Arnold, 1960; Frijda, 1986).
Whereas different action systems can share action tendencies (e.g., speaking, walking), they also include their own action tendencies and related goals (e.g., attaching to one’s mother, eating, drinking, flight, fight, playing with a friend, love making). The concept of action tendencies plays a major role in this book, and differs from the concept of actions. We tend to think of actions as being carried out or executed. Action tendencies are not merely propensities to act in certain ways, but involve the complete cycle of action, including latency, readiness, initiation, execution, and completion (Janet, 1934). Action tendencies involve adaptations to environmental challenges. Whereas many of these tendencies have been developed over the long course of evolution, thus are genetically transmitted, most of them still require maturation and adequate environmental stimulation to blossom. Each tendency comprises a more or less complex range of mental and behavioral actions. Action systems help us to behave, think, feel and perceive in particular ways, i.e., engage in certain action tendencies that are meant to be beneficial to us. Thus we may behave, think, feel, and perceive differently when we are hungry than we are curious about what has happened to a friend, or when we have a conflict at work.
The first category of action systems that make up personality involves action systems that support individuals in efforts to adapt to daily life, and the second category pertains to the action systems for defense from major threat and recuperation. Whereas evolution has prepared us both for tasks of daily living and of survival under threat, we are not able to engage easily in both simultaneously. Thus when both are necessary, particularly for long periods of time, some individuals develop a rather rigid division of their personality to deal with these very discrepant goals and related activities. For example, Marilyn Van Derbur (2003), the former Miss America who was molested as a child, described her personality as being divided into a “day child,” that was avoidant, numb, detached, amnestic, and focused on normal life, and a “night child” that endured the abuse and focused on defense.
The lack of cohesion and integration of the personality manifests itself most clearly in the alternation between and coexistence of the reexperience of traumatizing events ( e.g., a “night child”) and avoidance of reminders of the traumatic experience with a focus on functioning in daily life (“e.g., a “day child”). This bi-phasic pattern is a hallmark of posttraumatic stress disorder (PTSD; APA, 1994) and is also observed in patients with other trauma-related disorders. It involves a division between action systems for defense, i.e., those which guide us to avoid or escape from threat, and for functioning in daily life, i.e., systems that are primarily for seeking attractive stimuli in life that help us survive and feel well. This division is the basic form of structural dissociation of the personality. Trauma-related structural dissociation, then, is a deficiency in the cohesiveness and flexibility of the personality structure (Resch, 2004). This deficiency does not mean that the personality is completely split into different “systems of ideas and functions,” but rather there is a lack of cohesion and coordination among these systems that comprise the survivor’s personality.
We describe the division of personality in terms of dissociative parts of the personality. This choice of terms emphasizes the fact that “dissociative parts” of the personality together constitute one whole, yet have at least a rudimentary sense of self and are generally more complex than a single psychobiological state. Moreover, traumatized patients generally find “parts of the personality” or “parts of yourself” an apt description of their subjective experience.
“Apparently Normal” and “Emotional” Parts of the Personality
In conceptualizing these prototypical dissociative parts of the personality, we begin with the important work of a British World War I psychologist and psychiatrist, Charles Samuel Myers (1940). He described a basic form of structural dissociation in acutely traumatized (“shell-shocked”) World War I combat soldiers (cf., Van der Hart, Van Dijke, Van Son, & Steele, 2000). This dissociation involves the co-existence of and alternation between a so-called Apparently Normal [Part of the] Personality (ANP) and a so-called Emotional [Part of the] Personality (EP). Throughout the book we will refer to these prototypical parts as ANP and EP. Survivors as ANP are fixated in trying to go on with normal life, thus in action systems for daily life (e.g., exploration, caretaking, attachment), while avoiding traumatic memories. As EP, they are fixated in the action system (e.g., defense, sexuality) or subsystems (e.g., hypervigilance, flight, fight) that were activated at the time of traumatization.
ANP and EP are unduly rigid and closed to each other, because they are constrained to some degree by the specific action systems by which they are mediated and by the level of action tendencies that they can attain. That is, survivors as ANP and EP exhibit their own relatively inflexible patterns of action tendencies, at least some of which are maladaptive.
Myers was not implying that emotion was only experienced by EP. Rather he was emphasizing the overwhelming or vehement nature of EP’s traumatic emotions in comparison to ANP. Vehement emotion differs from intense emotion in that it is not adaptive, is overwhelming to the individual, and its expression is not helpful. In fact, the more it is expressed, the more dysfunctional and overwhelmed the survivor becomes. For example, this is commonly seen in “borderline” patients who express rage: The more they express, the more out of control they become.
Structural dissociation may also occur along the lines of particular emotions or beliefs that may be less obviously related to a particular action system or constellation of action systems at first glance. For example, a part may contain mental actions such as sadness, guilt, despair, or shame, and other parts may find those emotions intolerable. However, such emotions are very likely connected to action systems that help regulate our attachments and social positions. As Gilbert (2000) noted, individuals may be ashamed of certain actions when they fear that others will reject or despise them for engaging in those actions, and they may feel guilty if their actions have hurt others (such as giving up a caring role, harming children via divorce). They may thus avoid those actions to maintain the current status of attachments and social positions. These action systems for achievement of goals in daily life and for defense from major threat are thus insufficiently cohesive and coordinated.
Structural dissociation can range from very simple to extremely complex divisions of the personality, and these levels of complexity have implications for treatment. These levels represent a dimensional picture of dissociation and are merely prototypes of dissociative organizations. It is to be expected that there is quite a lot of deviation from these prototypes the more complex structural dissociation becomes. There can be infinite individual variations of the expressions of dissociation.
Primary structural dissociation. The most simple and basic trauma-related division of the personality is between a single ANP and a single EP. We have referred to this as primary structural dissociation. While ANP is the “major shareholder” of the personality, as described by incest survivor Sylvia Fraser (1987), EP usually is quite limited in scope, function, and sense of self. That is, the part of the survivor that is EP remains unelaborated and not very autonomous in daily life. More complex forms of structural dissociation that involve wider ranges of dissociative parts are variations on primary structural dissociation of the personality.
Secondary structural dissociation. When traumatizing events are increasingly overwhelming and/or prolonged, further division of EP may occur, while a single ANP remains intact. This secondary structural dissociation may be based on the failed integration among various kinds of defense that have different psychobiological configurations, i.e., different combinations of affects, cognitions, perceptions, and motor actions. These include such conditions as freeze, fight, flight, and total submission.
Martha was a patient with the diagnosis of complex PTSD and borderline personality disorder. She had a childhood history of serious physical abuse and profound neglect. One part of her personality (EP) tended to become enraged at the smallest perceived slight, another (EP) froze in terror when she was triggered, a third (EP) was constantly on the lookout for danger, a fourth (EP) was always searching for somebody to take care of her, and a fifth (ANP) functioned quite well at work as long as relationships did not feel threatening to her.
Tertiary structural dissociation. Finally, division of ANP may occur, in addition to divisions of EP. This tertiary structural dissociation occurs when inescapable aspects of daily life have become associated with past trauma, i.e., triggers tend to reactivate traumatic memories through the process of generalization learning. Alternately when the functioning of the ANP is so poor that normal life itself is overwhelming, new ANPs may develop. In severe cases of secondary and in all cases of tertiary dissociation, more than a single part may have a strong degree of elaboration (e.g., names, ages, genders, preferences) and emancipation (Janet’s [1907] term that denotes actual or perceived separation and autonomy from the influence of other dissociative parts), often with secondary characteristics such as names, ages, gender, etc. This is not commonly observed in primary structural dissociation, nor in many cases of secondary structural dissociation.
Levels of structural dissociation and DSM-IV diagnoses. In order to understand structural dissociation, it is essential to have a basic grasp of how the various levels fit with current diagnostic categories. Our basic premise is that all trauma-related disorders involve some degree of structural dissociation, with acute stress disorder and simple PTSD being the most basic and DID the most complex. The more the dissociation, the more complex the disorders are. Many survivors experience structural dissociation without the elaboration and emancipation of some dissociative parts found in Dissociative Identity Disorder. Table 1.1 shows the proposed relationships between levels of structural dissociation and trauma-related disorders.
[Place Table 1.1 about here]
Developmental Pathways to Structural Dissociation of the Personality
In primary structural dissociation we have assumed that the personality was a relatively integrated mental system prior to traumatization. However, this is hardly the case in traumatized children. An integrated personality is a developmental achievement. The more complex levels of structural dissociation in adults who were chronically traumatized children are thus developed within a personality that lacks the normal cohesion and coherence of the healthy adult. Children also lack the requisite skills to cope with difficult affects and experiences, and need much support to do so. Most chronically traumatized individuals were never taught those skills, nor did they have emotional support in times of stress (cf., Gold, 2000).
Structural dissociation involves hindrance or breakdown of a natural progression toward integration of psychobiological systems of the personality that have been described as discrete behavioral states (Putnam, 1997). It involves a chronic integrative deficit largely due a combination of the child’s immature integrative brain structures and functions (for reviews, cf., Glaser, 2000; Van der Kolk, 2003), and inadequate psychophysiological regulation by caregivers, i.e., insufficient soothing, calming, and modulation (Siegel, 1999).
Structural Dissociation versus Integrative Actions
Actions shape our lives for better or worse. But actions are not exclusively about behavior: Actions are also essential mental endeavors. All but the most reflexive behavior is guided by a multitude of mental actions, e.g., planning, predicting, thinking, feeling, fantasies, wishes. Behavioral actions include a synthesis of both mental and motor actions. Mental actions and behavioral actions may be adaptive or not. Our concern with survivors is in supporting their ability to raise the adaptive level of their actions.
Hierarchy of Action Tendencies
Janet (1926a, 1938) outlined various levels of low, intermediate, and high order action tendencies. These are referred to as the hierarchy of action tendencies. This hierarchy is useful in clinical practice, as it helps the patient and therapist understand which actions are in need of improvement and which are at high levels already.
Lower order action tendencies are automatic and relatively simple, often involving reflexive actions, i.e., those that are reactive and rather automatic instead of carefully considered. Reflexive actions are necessary in situations where more automatic behavior is useful (e.g., driving or getting dressed), but they do not make adequate substitutes for higher order actions (e.g, thinking through and deciding how to behave when one’s feelings have been hurt). Modern life often involves complicated situations that require complex and flexible responses. Thus lower order action tendencies are usually least adaptive in these situations, while higher order ones are most adaptive.
Allison, a patient with a severe abuse history, hit her head or fist on the wall as soon as she felt intense emotion, unable to allow herself to feel and to think about those emotions. Higher order actions are creative and often complex, requiring many mental actions. Over the course of therapy, Allison gradually was able to stop herself when she had the urge to hit the wall, would sometimes hit a pillow instead, and could allow herself to feel. Eventually she was able to talk about her feelings and resolve them, actions that were much more adaptive, and more complex and creative than hitting the wall.
Whatever their level of complexity, action tendencies have stages of activation, ranging from latency, planning, initiation, execution, to completion. Survivors often have trouble starting or completing actions, whether they are mental or behavioral. They can plan, but not begin. Or they can begin, but not finish. Or their actions may lack adequate quality. Such problems indicate that an individual does not have sufficient mental energy or adequate ability to focus that energy in order to complete successfully various mental and behavioral actions.
Mental Level
The highest level of action tendencies an individual can attain in a given moment is called his or her mental level (Janet, 1903, 1928b). One’s mental level involves two factors that are in dynamic relation with each other, i.e., available mental (and physical) energy and mental efficiency (which Janet called psychological tension, a term that can be easily misunderstood because we associate “tension” with stress, which was not Janet’s intention in using the term), i.e., the ability to efficiently focus and use whatever mental energy is available in the moment. Mental efficiency includes the concept of integrative capacity. Thus being able to reach a high mental level is fundamental to one’s capacity to integrate experiences. Many survivors have difficulties attaining and sustaining higher mental levels, regardless of how much mental energy is available to them. Traumatization involves fixation at or regression to unduly low levels of action tendencies, and by implication, low mental levels, for at least some parts of the personality.
There are three major problems related to mental energy and mental efficiency: (1) low mental energy, (2) insufficient mental efficiency, and (3) imbalances between mental energy and efficiency. Adaptive actions generally expend a lot of physical and/or mental energy. A first problem is that many survivors function at a level of exhaustion that offers little mental energy because they try to do too much and are tired, or because they are too depressed. Physical illness, a frequent companion of many survivors, also lowers mental energy. In such cases, mental energy is insufficient, even though in principle individuals may have adequate mental efficiency to accomplish actions. A second problem is related to insufficient mental efficiency, even though the individual may have sufficient mental energy for a given task or action. In dissociative individuals, the mental level can vary to some degree for each dissociative part.
A third problem with adaptive actions is typically not only due to specific emotional and relational skills deficits, but involves a more pervasive impediment that generally is not recognized or treated explicitly in therapy. This is the problem of imbalance between the patient’s mental energy and mental efficiency, i.e., an imbalance between how much mental energy is available, and how well that mental energy can be utilized to engage in adaptive action in the present. There are various combinations of mental energy and mental efficiency (see Chapter 10).
Therapists are often trying intuitively, without much clarity, to help patients raise their mental efficiency so they can maximize their mental energy. Our focus to a large degree in this book will be on how to assess systematically and improve the mental efficiency of patients and regulate their mental energy, thereby helping them engage in more adaptive mental and behavioral actions. To this end the therapist encourages the patient to plan, begin, engage in, and complete various mental and behavioral actions at gradually higher levels.
Substitute Actions
Maladaptive mental and behavioral actions are implied in affect and impulse dysregulation, attachment problems, and other difficulties that plague survivors. Inadequate mental actions are also implicit in the ongoing maintenance of dissociation. Such actions are referred to as substitute actions, i.e., those that are less adaptive than required when the challenges of life exceed the mental level of the patient. For instance, when intense feelings are evoked, a patient may resort to cutting or purging as lower level substitutes for more adaptive actions such as journaling, thinking through, self-soothing, or other actions which would actually resolve the feelings rather than perpetuate them. People not only fall back on substitute actions when they are unable to engage in higher order adaptive actions, but also when integration is not yet attainable.
Substitute actions may vary in their level of adapativity, with some reaching more adaptive and complex levels than others. Some substitute actions are behavioral, such as physical agitation, compulsions, and self injury. But many substitute actions are mental in nature. There are times when emotions become overwhelming and intolerable. These are are the vehement emotions to which we referred earlier, and they are in themselves substitute actions for other ways to cope with a situation. Individuals prone to vehement emotions may employ maladaptive mental coping strategies such as profound denial, disavowal, projection, and splitting.
Integrative Actions
“Integration” is a familiar term in the trauma field that implies patients must somehow assimilate traumatic experiences (and dissociative parts of the personality) in order to move forward with their lives. But integration is also an integral part of and necessary for adaptive living on a daily basis. The actions of integration require the highest degrees of mental energy and mental efficiency.
Integration is an adaptive process involving ongoing mental actions that help both to differentiate and link experiences over time within a flexible and stable personality, and thus promotes the best functioning possible in the present (Jackson, 1931/32; Janet, 1889; Meares, 1999; Nijenhuis et al., 2004a&b). The capacity to be open and flexible allows us to change when required, whereas the capacity to stay closed allows us to remain stable, i.e., to act in preconceived ways. A mentally healthy individual is characterized by a strong capacity to integrate internal and external experiences (Janet, 1889).
What specific mental actions are involved in the process of integration, and how can they be achieved? It is helpful to understand two major types of integrative mental actions in order to effectively treat traumatized individuals: synthesis and realization.
Synthesis. One major type of integrative mental actions is synthesis, i.e., binding (linking) and differentiating a range of internal and external experiences within a moment and across time. Synthesis includes binding and differentiating sensory perceptions, movements, thoughts, affects, and sense of self. For example, we know how one person is like another (binding), but also the ways in which he or she is different (differentiation), and how our present situation is similar to, but also different from our past. We also know that feeling mad and acting mad are similar in some ways, but significantly different from each other. Much synthesis occurs automatically and outside conscious awareness. Our capacity for synthesis fluctuates along with our mental level. For example, when an individual is fully awake, synthesis will be of a higher quality than when he or she is tired. Synthesis provides for the individual’s normative unity of consciousness and history. Alterations of consciousness and dissociative symptoms can emerge when synthesis is incomplete.
Realization. A related, but higher level integrative mental action is realization, i.e., the mental actions of developing awareness of reality as it is, accepting it, and then reflectively and creatively adapting to it. Realization implies the degree to which closure of an experience is achieved (Janet, 1935; Van der Hart et al., 1993). It consists of two mental actions that are constantly maturing our view of ourselves, others, and the world (Janet, 1903, 1928a). The first type of action involves integrating an experience with an explicit, personal sense of ownership: “That happened to me, and I think and feel thus and so about it.” The second type of action is that of being firmly grounded in the present and integrating one’s past, present, and future. It manifests in acting in the present in the most adaptive, mindful manner.
Both ANP and EP lack full realization of the present, i.e., are unable to live fully in the present. They also lack complete realization of their traumatization, i.e., that it is over, and often have been unable to realize a multitude of other experiences, leaving much unfinished business. With regard to traumatization, ANP lacks full realization of these experiences and their aftereffects. Thus ANP may deny or experience varying degrees of amnesia regarding the event(s). ANP perhaps acknowledges traumatic experiences but insists, “It doesn’t feel like it happened to me.” And EP does not experience that the traumatization has ended, is still immersed in it, and thus lacks the ability to be fully in the present. Restricted by their respective action systems and their limited coping skills, both ANP and EP selectively attend to a limited range of cues, e.g., those that are relevant for care taking or defensive interests. This further reduces the capacity to fully realize and integrate traumatic memories and to be completely in the present.
Maintenance of Structural Dissociation of the Personality
Structural dissociation has become chronic in those patients with trauma-related disorders. There are a number of interwoven factors that converge to maintain dissociation once it begins (which will be discussed in depth in Chapter 11).
The lower their mental level, the more individuals must rely on substitute actions that may protect against overwhelming emotions and thoughts, but that are at odds with integration of traumatic memories and associated dissociative parts. The mental level of survivors remains low when they have significant relational and emotional skills deficits. In many cases, these deficits are due primarily to a lack of adequate modeling and training by caretakers: many survivors grew up in environments in which these skills were never used. A low or modest mental level can be compensated for by social and relational supports that crucially assist a survivor in integrating traumatic experiences. However, many survivors have little to no support. They face the monumental task of integration alone and find it too overwhelming. Trauma-related changes in neurobiology also impede integration (Nijenhuis, Van der Hart, & Steele, 2002; Vermetten & Bremner, 2002).
In these contexts, various trauma-related conditioning effects are also central to the persistence of structural dissociation. That is, survivors can develop conditioned fears of inner and outer cues (described as conditioned stimuli) when they have learned to associate these with the original traumatizing event (known as unconditioned stimuli), and which they will thereafter mentally and behaviorally avoid. Structural dissociation is specifically maintained when ANPs learn to phobically and chronically avoid intruding EPs with their traumatic memories and accompanying aversive sensations, emotions, and thoughts. The resolution of these phobias—briefly described below--is a major treatment focus.
Phobias that Maintain Structural Dissociation
Traditionally, phobias have been relegated to anxiety disorders, and have been understood to be directed to external cues (e.g., spiders, heights, germs, social phobia), and to have psychodynamic meaning. However, phobias can also pertain to inner phenomena, i.e, to mental actions such as particular thoughts, feelings, fantasies, sensations, and memories (e.g., Janet, 1903; McCullough et al., 2003; Nijenhuis, 1994). Therapists who work with chronically traumatized individuals will readily recognize that such patients are often extraordinarily fearful of mental actions as well as external stimuli that remind them of the traumatic experience.
According to Janet (1904, 1935a), the core phobia in trauma-related structural dissociation consists of an avoidance of the synthesis and full realization of the traumatic experience and its effects on one’s life, i.e., the phobia of traumatic memory. Behavioral and mental avoidance, which maintains structural dissociation, are needed to prevent what are perceived as unbearable realizations about one’s self, history, and meaning. Subsequently, additional phobias ensue from the fundamental phobia of traumatic memory. Janet (1909) stated that all phobias have in common fears of (certain) actions. Trauma-related phobias are thus treated in a specific order such that patients experience a gradually developing capacity to engage in purposeful and high quality adaptive actions, both mental and behavioral—i.e., attain higher levels of mental efficiency. Increasingly more complex and difficult experiences (past and present) then can be tolerated and integrated, and improvement in daily living can be achieved.
When survivors associate an increasing number
of stimuli with the traumatic experience and memory through stimulus
generalization, they may start to fear and avoid more and more of inner and
outer life. For example, when survivors
as ANP are intruded by traumatic memories and associate this aversive intrusion
with EP, they develop a phobia of this dissociative part.
The survivor as EP can become phobic of ANP when that part is perceived as
ignoring or harming (i.e., neglecting or abusing) EP in some way. In fact,
survivors can become anxious and avoidant of any mental action, such as having
particular feelings, sensations, and thoughts that are consciously or
unconsciously associated with the original traumatic experience(s). Thus most
survivors have some degree of phobia of trauma-derived mental actions
(which we formerly called phobia of mental contents;
e.g., Van der Hart & Steele, 1999; Nijenhuis, Van der Hart, & Steele, 2002).
The phobia of trauma-derived mental
actions evolves from the core phobia of traumatic memories, and involves the
survivor's fear, disgust or shame about mental actions he or she has associated
with traumatic memories. As long as
patients are afraid of their inner life, they cannot integrate their internal
experiences, so that structural dissociation is ongoing.
Phobias of attachment and of attachment loss easily develop because chronically traumatized individuals have been hurt by other human beings, especially caretakers. Thus attachment is experienced as dangerous, but also, of course, as necessary. Phobia of attachment is often paradoxically accompanied by an equally intense phobia of attachment loss. It manifests in desperate feelings and behaviors that motivate the individual to connect to another person at all costs. Typically, different parts of the personality experience these opposite phobias. They evoke each other in a vicious cycle, with a perceived change in closeness or distance in a relationship resulting in the well-known “borderline” pattern of “I hate you—don’t leave me,” more recently described as Disorganized/disoriented attachment (D-attachment, e.g., Liotti, 2004).
Another manifestation of generalization is the phobia of normal life. Since normal life involves at least a basic level of healthy risk-taking and change, many experiences of normal life also become vigorously avoided. Finally, more mature levels of attachment, i.e., intimacy, are avoided due to the plethora of phobias related to attachment and trauma-derived mental actions that have become conditioned stimuli, since most chronic traumatization is of an interpersonal nature.
Phase-Oriented Treatment of Chronic Traumatization
The theory of structural dissociation has major consequences for the assessment and treatment of chronically traumatized survivors (e.g., Steele et al., 2001, 2005). It is helpful for therapists to understand the implications of structural dissociation as an undue division of the personality, how it manifests, and how it must be treated. They should strive to understand the importance not only of psychodynamic, relational, and behavioral aspects of treatment, but also become proficient in assessing and working with the mental energy and mental levels of patients. Therapists need to analyze mental and behavioral actions of survivors for adaptivity. They will find it helpful to have a multitude of interventions at hand that transcend any given theoretical model. Thus, they can maximize the help they offer in raising the level of action tendencies in each part of the personality over the course of treatment.
The major treatment approaches for complex PTSD and dissociative disorders are typically phase-oriented, and are considered the current standard of care. Phase-oriented treatment includes the following phases: (1) stabilization and symptom reduction; (2) treatment of traumatic memories; and (3) personality integration and rehabilitation. Although the phases have been described in linear fashion, in reality they are flexible and recursive, involving a periodic need to return to previous phases (Courtois, 1999; Steele et al., 2004).
Each phase involves a problem-solving and skills building approach within the broader context of a relational approach (Brown, Scheflin, & Hammond, 1998). The spiral course occurs as greater levels of mental efficiency are achieved, allowing previously intolerable dissociated material to become integrated, and more entrenched areas of dysfunction to be addressed. Phase-oriented treatment may be rather straightforward for relatively simple cases of traumatization. However, it may be much more complex, with more alterations among phases, needing to address multifaceted and chronic issues. Treatment planning for these phases should be based on a careful and thorough assessment of the patient.
Assessment
Chronically traumatized patients often seek help during a crisis. Although they may need immediate assistance in this regard, it is essential not to forsake normal assessment procedures, including thorough diagnosis, psychological testing, and extensive history taking (including a possible trauma history and previous treatments). Serious comorbidity may occur in these patients. They may fulfill criteria for numerous diagnostic categories, which makes a cohesive explanation of extensive psychopathology virtually impossible.
Although systematic assessment of dissociative symptoms and dissociative disorders may not be part of a routine workup, it is indicated in patients who have complex comorbidity and symptoms, report traumatization, or who present with a history of “treatment failure.” Here, we add the caveat that patients may have an underlying dissociative organization of their personality that is not reflected in a given DSM-IV dissociative disorder. For instance, a patient diagnosed with borderline personality disorder may well be characterized by secondary structural dissociation, and the same may apply to a patient with a somatoform disorder, as recognized in the ICD-10 diagnostic category of dissociative disorders of movement and sensation. However, it is usually only over time and with careful and extensive observation that the therapist develops a clearer picture of the complexity of the patient’s structural dissociation.
In planning for an appropriate treatment trajectory, it is vital to assess a patient’s unique strengths and weaknesses, i.e., his or her functioning in terms of mental level, i.e., the highest level that can be attained in the hierarchy of action tendencies, along with available mental energy. Some patients may be high-functioning in daily life, e.g., able to excel in a highly demanding profession, with occasional lowering of their mental level in situations that reactivate traumatic memories, or that require skills not yet mastered. Other patients may function at a low level, both in terms of the hierarchy of tendencies and available energy. Thorough assessment of the patient’s mental level and its fluctuations should include a wide range of domains, including work, relationships, care-taking, play, sleep/wake and eating habits, potentially threatening situations, and of the proficiency of the mental actions that accompany behavioral ones. When a patient is assessed to be unable to adaptively deal with a particular issue or situation, the lower-order substitute actions that he or she is employing should be identified as potential treatment targets.
When structural dissociation of the personality is apparent, it is helpful in planning treatment to distinguish ANP(s) and EP(s) and their differences in mental level. While ANPs typically function at higher levels than EPs, they sometimes may be overwhelmed by the intrusion of EPs. A clear picture of the number and types of dissociative parts, and of their respective mental efficiency and energy may emerge only over time. However, a thorough assessment such as briefly suggested here (more in Chapter 12) may provide sufficient information for an initial treatment plan.
Treatment Phase 1: Stabilization and Symptom Reduction
Phase 1 is dedicated to raising the mental level and adaptive actions of ANP(s) and dominant EPs to allow for more effective functioning in daily life. This phase of treatment is directed toward helping patients achieve some measure of balance in mental and behavioral actions with the mental energy and efficiency that are available to them. Therapy is directed to raising the mental level of ANP and key EPs that are intrusive and interfering with therapy and safety. This implies that survivors must improve the reflective quality and sometimes quantity of their mental and behavioral actions. This is relatively straightforward in cases of primary structural dissociation within the context of short-term psychotherapy (Van der Hart et al., 1998). However, in cases of secondary and tertiary structural dissociation typically much more strenuous and long-term therapeutic effort must be invested.
Mental and physical energy economy is an important tenet for patients to learn. They must learn to work within the constraints of their energy at a given time, learn what improves or diminishes their energy, and reduce inefficient energy expenditures. Above all, they must begin to learn and experience the fact that well completed mental and behavioral actions raise their mental level. Some patients do too much, or push themselves beyond the energy available to them. They need to learn to simplify life and rest more. Reduction of an overly full schedule allows space and time to turn to the mental actions that are being avoided by too many behavioral ones. For other patients who are severely shut down and unable to get anything done, the need is to engage in more mental and behavioral actions, not less. For yet others who are entangled in endless obsessions and over-thinking, the need is to simplify mental actions so that behavioral ones become more adaptive. In all cases, higher order actions involving thoughtfulness and planning are necessary, and the need to improve or stabilize mental energy and mental efficiency are essential.
Low mental efficiency contributes to substitute actions that manifest as major and distressing symptoms, such as self-destructive behaviors. Promotion of daily life functioning in ANP involves decreasing or eliminating these debilitating symptoms, as well as those of depression, anxiety, and PTSD. Containment of traumatic memories is paramount. Patients may need to learn and repeatedly practice many emotional and relational skills, which will raise their mental level.
In order to systematically foster adaptive action, treatment in Phase 1 is directed toward overcoming particular trauma-related phobias: The phobia of trauma-derived mental actions, including the phobia of dissociative parts of the personality, as well as the phobia of attachment and of attachment loss with the therapist. The phobia of change and of normal life will begin to be addressed, and will continue at more complex levels throughout the course of treatment. The presence of these phobias imply that patients have “unfinished business” and they must expend energy to avoid or contain their unresolved issues. In response to phobias, survivors generally engage in lower order substitute actions that either further lower or prevent the raising of their mental level, so that integration is chronically out of reach. Treatment should address these serious problems with the employment of a mental energy economy. The patient must gradually develop understanding and empathy for, and enhanced cooperation among all parts of the personality, without yet sharing traumatic memories. Thus, a more cohesive, stable, and flexible personality is already being fostered from the earliest phases of treatment.
A major goal of Phase 2 is that of resolving the phobia of traumatic memories among various parts of the personality, rendering structural dissociation unnecessary. This phase of treatment generally requires patients to sustain a higher mental level than that with which they entered treatment. The careful pacing of therapy, including regulation of hyper- and hypo-arousal will be crucial to success. Resolution of traumatic memory and related emotions and beliefs is a highly complex and difficult part of treatment (see Chapter 17).
Additional phobias to be addressed in this phase include those related to insecure attachment to the perpetrator(s). Patients are both strongly attached to and inherently avoidant of perpetrators, and this core approach-avoidance dilemma must be resolved. Various parts of the personality may express polarized and often unrealistic views of perpetrators (e.g., “He knows what I am thinking and will punish me;” “He can do no wrong.”). These must be unraveled gently in the course of therapy. Survivors must ultimately grieve the loss of an ideal family and learn to appreciate functioning as an interdependent adult.
Occasional excursions into Phase 3 work may occur without much, if any resolution of traumatic memories. However, Phase 2 work is generally necessary, as resolution of the unfinished business of trauma helps raise the overall mental level of an individual, and removes the chronic obstacles of traumatic reenactments and reactivation. Typically there is rather spontaneous movement back and forth between Phase 2, and Phases 1 and 3.
Treatment Phase 3: Personality Integration and Rehabilitation
Phase 3 may contain some of the most difficult work yet (Van der Hart et al., 1993). It involves painful grief work that is necessary for deepening realization to occur, relinquishment of strongly held substitute beliefs, and the struggle to engage in the world with new coping skills that require high degrees of sustained mental efficiency and energy. Even though begun in the early phase of treatment, ongoing resolution of the phobia of change and normal life must continue in Phase 3. Finally, overcoming the phobia of intimacy is perhaps the pinnacle of successful treatment, and is essential for patients to move forward with a high quality of life. Patients who cannot successfully complete Phase 3 work often continues to have difficulty with normal life, despite significant relief from traumatic intrusions. But the quality of life for those who do well in Phase 3 work can be remarkably improved.
Summary
This chapter provides a synopsis of what is to come in this book regarding the understanding and treatment of chronic traumatization and structural dissociation. Various important issues were briefly discussed, but many more remain to be examined ahead. The essence of this book is, perhaps, that traumatized patients are plagued by intrusions of traumatic memory while they desperately try to lead a normal life, and they have been unable to fully realize their history and resolve it. Hindered by essential skills deficits and disruption of attachment bonds, survivors have to rely on a range of substitute actions instead of fully adaptive actions and synthesis and realization of disavowed aspects of their lives. Adaptive and integrative failures become part of a vicious cycle: Lack of synthesis and realization lead to symptoms; symptoms such as depression, affect dysregulation, anxiety, flashbacks, and interpersonal crises, interfere with integration. Lack of realization essentially manifests in a structural dissociation of the survivor’s personality, i.e., in a division between one or more dissociative parts motivated to engage in matters of daily life and anxious to avoid traumatic memories, and dissociative parts focused on danger/threat and fixated in traumatic experience.
Table 1.1
Diagnoses and Structural Dissociation
Primary Structural Dissociation
One predominant ANP and one EP; the latter is often not very elaborated or autonomous
Simple Acute Stress Disorder
Simple PTSD
Simple DSM-IV Dissociative Disorder
Simple ICD-10 Dissociative Disorders of Movement and Sensation
Secondary Structural Dissociation
One predominant ANP and more than one EP; the latter can be more elaborated and autonomous than in Primary Structural Dissociation, but is typically less elaborated and autonomous than in Tertiary Structural Dissociation
Complex PTSD
Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
Dissociative Disorder Not Otherwise Specified
Trauma-related Borderline Personality Disorder
Complex ICD-10 Dissociative Disorders of Movement and Sensation
Tertiary Structural Dissociation
More than one ANP and more than one EP; often several ANPs and EPs are more elaborated and autonomous (including the use of different names and physical features) than in SSD
Dissociative Identity Disorder