In 1859 Briquet stated that
"Hysteria is a disease that modifies the whole organism" (Janet,
1909). When Janet developed his dissociation theory, he focused much of
his attention on somatoform dissociation, describing symptoms of loss of body
sensations and movements (mental stigmata) as well as increased body sensations,
movements and perceptions (mental accidents). Janet and his cohorts would have
found the modern dissociation theory of the 1980's and early 90's to be
incomplete, with somatoform symptoms such as sexual dysfunctions, eating
disorders and conversion disorders "dissociated" into other DSM
classifications. But as those working with traumatized clients have
struggled to decipher the languages of eating disorders, self-injury, skin
reactions, pseudoseizures, conversion paralyses, body dysmorphic disorder and
pain, the trauma field has evolved toward reintegrating the body in both theory
and clinical practice.
It was with much anticipation that I began to read the newest
collaborative effort of psychiatrist Jean Goodwin and psychologist Reina
Attias--Splintered Reflections: Images of the Body in Trauma. Ever
since I discovered Jean Goodwin's work fourteen years ago, I have appreciated
her passion for giving voice to the suffering and the strengths of traumatized
clients, the clinical and theoretical acumen that she brings to her task, and
the eloquence of her expression.
The book is divided into four sections. Part I, called
"Symptoms: Body Responses to Trauma", reviews what we know about both
acute and long-term bodily responses to trauma. Part II, "Experiences: Body
Image in Trauma", is devoted to the impact of psychological trauma and
bodily damage on symptomatology and ego functioning. Part III,
"Psychotherapy: The Traumatized Body in Treatment", reviews and
connects concepts from psychoanalytic, trauma and attachment theories as
they relate to the experiences of survivors in therapy. Part 4,
"Reflections: Body and Self in Dialogue" presents further case
material describing the growing connection between body and self as it occurs in
treatment.
Each section of this book contains chapters dealing with
topics in research and clinical assessment, and others integrating analytic
theory and clinical practice. The case examples found in most of the
chapters are powerful and well thought out. Both historic and literary
references help to enrich the dialogue and to bring perspective.
Bruce Perry's chapter on the brain's response to trauma is
highly readable and includes powerful clinical examples (chapter 1). Richard
Lowenstein and Jean Goodwin (chapter 3) provide an overview of somatic symptoms
in traumatized patients as they present in medical settings. Ellert
Nijenhuis and Onno van der Hart contribute two chapters in the book (2 and 4),
with a detailed review of Janet’s somatoform dissociation model and a
discussion of animal models of defense. The Somatoform Dissociation
Questionnaire (SDQ-20 and SDQ-5) is also discussed by Nijenhuis and van der Hart
(although the scale itself is not included). Barry Cohen and Anne Mills
(chapter 9) refer to the Diagnostic Drawing Series (Cohen, Mills and Kijak,
1994), focusing their chapter on the tree drawing portion of the DDS. This
chapter has a short, but intriguing section on the
relationship of paper or canvas to skin and skin-ego.
Mary Taylor Armsworth, Karin Stronck and Colleen
Carlson (chapter 5) address body image and self-perception in incest
survivors. Richard Kluft discusses body-ego and body image changes in DID
patients as they move through the process of integration (chapter 11). Valerie
Sinason (chapter 8) after discussion of Shakespeare's Richard III and the Greek
god Hephaestus, provides detailed clinical examples of body image in
developmentally disabled
children.
Goodwin and Attias contribute five of the 13 chapters in the
book as well as the editorial sections that link the work of the
contributors. In chapter 6 they discuss body image distortion in the wake
of childhood sexual abuse. In chapter 10 they attempt to go back to the
childhood trauma experience, to the moments of attack and "inarticulate
protest", to describe two different patterns of somatic, self-image and
memory disturbances in our patients. In chapter 12 they look to Franz Kafka's
Metamorphosis to focus on cases in which the self escapes by assuming animal
form. In chapters 7 and 13 they review psychotherapeutic techniques and
interventions that can be successfully employed to explore body-ego and body
image in these clients, leading to symptom resolution.
The editors' can be applauded for successfully weaving a
number of strands into a very rich discussion of the body in trauma. This
is a volume that will be greatly appreciated by experienced trauma clinicians
and theorists as well as by newcomers to the field. Interested primary
care physicians would benefit from reading it as well. I enthusiastically
recommend Splintered Reflections: Images of the Body in Trauma for its
comprehensiveness and for the quality of the individual contributions.
Janet, P. (1901). The mental state of hystericals. NY: Putnam. Reprint: University Publications of America, Washington, D.C., 1977.