Psychiatric Annals

CME Article 

A Cognitive-Psychoanalytic Perspective on the Treatment of Complex Dissociative Disorders

Richard A. Chefetz, MD

Abstract

This exploration of the treatment of complex dissociative disorders is an attempt to openly describe the experience of having a “dissociative mind.” It is in this context that I believe it is most useful to write about treatment. Discussion about the treatment of the dissociative disorders often focuses mainly through the lens of alter personalities and their variations. A broad orientation to dissociative experiences and, additionally, attention to the particular influence of dissociative processes on the conduct of psychotherapy can be valuable perspectives in treatment that is exceedingly challenging for both patients and clinicians. The perspective here may be thought of as a cognitive-psychoanalytic view.

Dissociation, in its broadest sense, is the separation of psychological processes that are normally related to each other. The result of dissociative experience is a loss of coherence for moment-to-moment experiencing, as well as past experience. For example, loss of emotional awareness reduces or eliminates a compelling dimension of experience that may be terrifying, but also may include feelings of closeness, or intimacy with others, a miserable interpersonal distancing and sense of alienation.1 This isolation of affect produces a secondary alexithymia and sense of emotional deadness that is also a criterion in post-traumatic stress disorder.

Dissociative process destroys the meaning of experience and the context of living a life. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) criteria for diagnosis include depersonalization, derealization, amnesia, identity confusion, and the more extreme identity alteration representing the salient dissociative experiences (Kluft, see page 633). The loss of discernable experience creates a significantly decreased capacity to emote and to identify feelings, as well as gaps in knowledge of the world, gaps in knowledge of personal history, and alterations in subjectivity. Memory, in this context, is more like “Swiss cheese” than a coherent whole. Thus, dissociation causes alterations in subjectivity, perception, and memory, and may create behavior that feels to be outside personal control and is denied, disavowed, and attributed to a different subjective sense of self or an alternate identity.

While dissociative experience is rooted in neurobiology, it also may result from psychodynamic motivational factors such as a wish to avoid unbearable fear. It is reasonable, in this context, to think of dissociative process as providing for a “regular dysregulation of affective experience.”2 Those people who have large blocks of personal history (eg, all of childhood or high school) missing from their memories may have the experience that these apparent losses of memory in one subjective state are common knowledge in an alternate subjective state. This disparity is maintained through a psychological barrier of amnesia that usually stems from not only a wish not to know but also a terror of knowing.

While we know these barriers tend to be “leaky,” the moment-to-moment personal experience for memory may be “completely” lost even in the face of emphatic contradictory information from a trusted other. Skills that are present one day are gone the next as the sense of self shifts as a function of the emotional demands of the moment, not just the day. Thus, people with dissociative disorders learn that they cannot necessarily count on being the same tomorrow as they are today. Projects enthusiastically started today languish tomorrow for lack of any interest at all. It is a serious understatement to say that this is demoralizing.

Just as problematic is to be able to function routinely but to know that, in a crisis or unanticipated challenge, the unpredictable is the rule. In a crisis, many people with dissociative adaptations become organized, only to collapse when the stress is over. These subjective alterations range from the merely confusing…

This exploration of the treatment of complex dissociative disorders is an attempt to openly describe the experience of having a “dissociative mind.” It is in this context that I believe it is most useful to write about treatment. Discussion about the treatment of the dissociative disorders often focuses mainly through the lens of alter personalities and their variations. A broad orientation to dissociative experiences and, additionally, attention to the particular influence of dissociative processes on the conduct of psychotherapy can be valuable perspectives in treatment that is exceedingly challenging for both patients and clinicians. The perspective here may be thought of as a cognitive-psychoanalytic view.

Dissociation, in its broadest sense, is the separation of psychological processes that are normally related to each other. The result of dissociative experience is a loss of coherence for moment-to-moment experiencing, as well as past experience. For example, loss of emotional awareness reduces or eliminates a compelling dimension of experience that may be terrifying, but also may include feelings of closeness, or intimacy with others, a miserable interpersonal distancing and sense of alienation.1 This isolation of affect produces a secondary alexithymia and sense of emotional deadness that is also a criterion in post-traumatic stress disorder.

Dissociative process destroys the meaning of experience and the context of living a life. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) criteria for diagnosis include depersonalization, derealization, amnesia, identity confusion, and the more extreme identity alteration representing the salient dissociative experiences (Kluft, see page 633). The loss of discernable experience creates a significantly decreased capacity to emote and to identify feelings, as well as gaps in knowledge of the world, gaps in knowledge of personal history, and alterations in subjectivity. Memory, in this context, is more like “Swiss cheese” than a coherent whole. Thus, dissociation causes alterations in subjectivity, perception, and memory, and may create behavior that feels to be outside personal control and is denied, disavowed, and attributed to a different subjective sense of self or an alternate identity.

While dissociative experience is rooted in neurobiology, it also may result from psychodynamic motivational factors such as a wish to avoid unbearable fear. It is reasonable, in this context, to think of dissociative process as providing for a “regular dysregulation of affective experience.”2 Those people who have large blocks of personal history (eg, all of childhood or high school) missing from their memories may have the experience that these apparent losses of memory in one subjective state are common knowledge in an alternate subjective state. This disparity is maintained through a psychological barrier of amnesia that usually stems from not only a wish not to know but also a terror of knowing.

While we know these barriers tend to be “leaky,” the moment-to-moment personal experience for memory may be “completely” lost even in the face of emphatic contradictory information from a trusted other. Skills that are present one day are gone the next as the sense of self shifts as a function of the emotional demands of the moment, not just the day. Thus, people with dissociative disorders learn that they cannot necessarily count on being the same tomorrow as they are today. Projects enthusiastically started today languish tomorrow for lack of any interest at all. It is a serious understatement to say that this is demoralizing.

Just as problematic is to be able to function routinely but to know that, in a crisis or unanticipated challenge, the unpredictable is the rule. In a crisis, many people with dissociative adaptations become organized, only to collapse when the stress is over. These subjective alterations range from the merely confusing (“I don't know my name”) to the provocative (“Her name is Mary, but I'm Jane. I'd like to get rid of her if I could!”).

One woman, a valued employee, approached her supervisor at work and told her, emphatically, that she was leaving. The supervisor was so taken aback by this odd behavior that all she could mutter was, “You're leaving?” What the supervisor didn't know was that the patient was depersonalized, “watching” herself do this, and also was taken aback, but she couldn't control what she saw and heard herself saying and doing. When she arrived home, she had no idea why she had wanted to be there!

When considering treatment of a person with a dissociative disorder, many clinicians balk at the strangeness of thinking that another person has an alternate identity, and rightly so. The problem is that “it's true, and it isn't true.” From the patient's perspective, the wish contained in the experience of being “someone else” is not a casual concern. It is a desperate need not to be the target of severe, inescapable abuse, emotional or otherwise. From the thoughtful clinician's perspective, it is an outrageous claim, except if one appreciates the desperation in a person who is being raped, beaten, tortured, humiliated, and so on, to escape that experience. Long ago, Winnicott admonished us to not analyze the transitional object.3 It is worth considering this as a logical injunction when dealing with a person who insists she is someone else in the context of meeting the SCID-D criteria for a dissociative disorder. However, it is also reasonable to say to Mary, who insists she is Martha: “I know you experience yourself as Martha, rather than Mary, but at the same time, my experience of you is that Martha is another way of being Mary. So, I'm glad to call you Martha, and I also want you to know that while I do that to respect your point of view, I am also aware that you are really another way of being Mary. Eventually, we'll figure out what being Martha, as another way of being Mary, means to you.”

Developmental theories of the origin of dissociative disorders rely on a model of the mind that is an elaboration of Bowlby's theories of attachment.4 Ainsworth's “Strange Situation” was extended to explain a pattern of insecure attachment that seemed unclassifiable in early work.4 Understood now as Type D attachment, disorganized/disoriented, this infant response to the frightened, frightening, severely depressed, or emotionally unresponsive parent illustrates that simultaneously and sequentially contradictory mental models of parental behavior are at the origin of infant behavior that is a phenotypic match for adult dissociative disorders4 (Sidebar 1) It also shows that high grade sexual or physical abuse is not required for development of an adult dissociative disorder. Sadly, some studies have found gross abuse present in somewhere between 85% and 95% of patients with dissociative disorders.5

Sidebar 1.

Disorganized/Disoriented Infant Attachment Patterns as Dissociative Disorder Phenotype4,15–18

People with dissociative disorders may display adult versions of simultaneous or sequential contradictory internal working models in their behavior. Freezing/stilling may be seen as a “speechless” moment in therapy. It does not necessarily represent the absence of something to say. Rather, it may represent the presence of conflicting internal working models.

Infants are judged to fit the disorganized/disoriented, Type D, attachment pattern if they display behaviors in the presence of their caretaker, such as:

  1. Sequential displays of contradictory behavior: calling loudly for parent and then avoiding when the parent enters.

  2. Simultaneous display of contradictory behavior: clinging to parent while arching body away.

  3. Undirected, misdirected, incomplete and interrupted movements and expressions: turning around and greeting the stranger brightly, arms raised, as parent enters the room.

  4. Stereotypes, asymmetrical movements, mistimed movements and anomalous postures: rocking vigorously on hands and knees, or assuming an awkward, uninterpretable posture.

  5. Freezing, still, and slowed movements and expressions: suddenly stopping and freezing, hands in air, for 25 seconds or more; or moving toward a parent in extremely slow motion, as though resisting forward movement.

  6. Direct indices of apprehension regarding the parent: fear-smile or hand-to-mouth gesture at parent entrance.

  7. Direct indices of disorganization and disorientation: raising hand to mouth on return of parent, accompanied by confused expression.

Given our knowledge of attachment and what makes for production of a dissociative phenotype in adults, a treatment model that avoids recreating these conditions would be in order. It is not that the conditions will never be present in the transference, or through enactment; rather, it is that the treatment frame itself, and the capacity for holding and containing, ought not preclude a stable treatment. The treatment frame I use in my practice and general recommendations for the course of treatment (see Sidebar 2, page 660 for furthe reading) are consistent with revised guidelines for treatment of the dissociative disorders that will be published this year by the International Society for the Study of Dissociation.6 (Further information is available at the society's web site, ( http://www.issd.org.)

Sidebar 2.

Further Reading on the Treatment of Dissociative Disorders

Bromberg PM. Standing in the Spaces. Hillsdale, NJ: The Analytic Press; 1998.

Cohen BM, Cox CT. Telling Without Talking. New York, NY: W.W. Norton; 1995.

Courtois CA. Recollections of Sexual Abuse: Treatment Principles and Guidelines. New York, NY: W.W. Norton; 1999.

Davies JM, Frawley MG. Treating the Adult Survivor of Childhood Sexual Abuse. New York, NY: Basic Books; 1994.

Freyd JJ. Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Cambridge, MA: Harvard University Press; 1996.

Gelinas DJ. The persisting negative effects of incest. Psychiatry. 1983;46(4):312–332.

Gleaves DH, May MC, Cardena E. An examination of the diagnostic validity of dissociative identity disorder. Clin Psychol Rev. 2001;21(4):577–608.

Hunter ME. Understanding Dissociative Disorders: A Guide for Family Physicians and Healthcare Workers. Williston, VT: Crown House Publishing; 2004.

Kluft RP, ed. Childhood Antecedants of Multiple Personality. Washington, DC: American Psychiatric Publishing; 1995.

Kluft RP, Fine CG, eds. Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Publishing; 1993.

Krystal H. Integration and Self Healing: Affect, Alexithymia, and Trauma. Hillsdale, NJ: Analytic Press; 1988.

Liotti G. Disorganized/Disoriented attachment in the psychotherapy of the dissociative disorders. In: Goldberg S, Muir R, Kerr J. Attachment Theory. Hillsdale, NJ: The Analytic Press; 1995: 343–363.

Lyons-Ruth K. Dissociation and the parent-infant dialogue: a longitudinal perspective from attachment research. J Am Psychoanal Assoc. 2003;51(3):883–911.

Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B. Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Dev Psychopathol. 1997;9(4):855–879.

Pearlman LA, Saakvitne Karen W. Trauma and the Therapist. New York, NY: W.W. Norton; 1995.

Pollock PH. Cognitive Analytic Therapy for Adult Survivors of Childhood Abuse: Approaches to Treatment and Case Management. New York, NY: John Wiley & Sons; 2001.

Putnam FW. Diagnosis and Treatment of Multiple Personality Disorder. New York, NY: The Guilford Press; 1989.

Putnam FW. Dissociation in Children and Adolescents. New York, NY: The Guilford Press; 1997.

Ross CA. Multiple Personality Disorder: Diagnosis, Clinical Features and Treatment. New York, NY: John Wiley & Sons; 1989.

Shusta-Hochberg SR. Therapeutic hazards of treating child alters as real children in dissociative identity disorder. J Trauma Dissociation. 2004;5(1):13–27.

Siegel DJ. The Developing Mind: Toward A Neurobiology of Interpersonal Experience. New York, NY: The Guilford Press; 1999.

Stern D. Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press; 1997.

Treatment Frame: Holding and Containment

Allan Schore's groundbreaking work7 relates the neurologic basis of dissociative process primarily to compromised right hemispherical processes. He proposed that a failure of executive control in the right orbito-frontal cortex, especially medial prefrontal regions, to modulate activity in the amygdala, which organizes fear-related affective responses, creates inadequate controls on the output and regulatory function of the autonomic nervous system. This right hemispherical “top-down” failure of modulation is related to what he surmises is a failure of right brain to right brain communication in the parent–child dyad, a failure that leaves the developing child without a capacity for affect regulation and self-soothing. The hypothesis is that the regulation of affect is an implicitly communicated skill between empathically attuned right cerebral hemispheres in parent and child.7 If the hypotheses generated by the Type D attachment internal working models are accurate, then dissociative disorders are born in part out of the inconsistencies, the incongruencies, and the failure of secure parenting.

In these patients, a treatment frame that pays close attention to the need for healthy affect regulation is more likely to succeed than a frame that duplicates the chaotic environment of the Type-D childhood. Appointments should be regular, vacations should not be a surprise, and proper coverage is a must. If the covering clinician is not well versed in dissociative disorders, the patient should be warned of this limitation. A clear and helpful directive message on an answering machine also is important. Consistency in the therapist's concern that the patient receive what is promised by the “therapeutic contract” communicates caring. The therapist must follow through on promises.

With these patients, a therapist's actions will be trusted much more than words. In fact, this is a major treatment issue; many patients with a dissociative disorder do not trust words alone. Demonstrating thoughts and feelings, rather than speaking them, often becomes the primary mode of communication from patients who don't trust spoken language as having real meaning.8 Awareness of this situation, and open curiosity about the possibility of learning to trust spoken words, may help decrease the use of action to communicate. However, if the therapist still uses action, rather than words, to communicate with the patient, trust will be tested, resulting in a reactive therapy that mimics the action-prone but communication-deficient family of origin.

For example, failure to return a telephone call in a timely way provokes additional telephone calls to find out if the therapist will respond. The therapist's last-minute cancellation spells greater interest in someone or something else and is felt as a betrayal or abandonment. Failure to start or stop sessions on time speaks volumes to patients who expect violations of their most personal boundaries, just like they have experienced with “trustworthy” people in their past.

It is also wise to advise the patient, early in the treatment, how the entire course of treatment will be managed, including fees, vacations, on-call coverage, availability after hours and on weekends, telephone calls, telephone time, and missed visits. A preference for times to call — early in the evening, during the day, etc. — should be stated clearly. Inevitably, patients with histories of boundary violations by family, or past therapists, may test at least one or more of the limits of the treatment frame severely. How else, they will reason, would they know what to expect? They couldn't trust what they were told before; why should they trust what you “say” now? Their trust will be earned with consistency over several years, not weeks or months. It does not work to tell a patient, “I need you to trust me. After all, I am your therapist.” The patient who has failed other therapies may be quick to point out that people who have tried to trick them have petitioned for their trust in the past. Consistency is the byword for maintaining the frame, as well as holding and containing the response.

It is worth mentioning that it is not helpful for a therapist to try to be “nice” or “especially responsive” to and accepting of the patient's boundary testing productions so as not to duplicate the unresponsive environment of the patient's childhood. The therapist's “niceness” or flexibility likely will not be trusted. Gratification of wishes the patient believes are unreasonable frightens her if she has experienced severe boundary violations. The patient provokes the “too good to be true” therapist to see what the therapist's limits really are. Until the therapist sets a limit, the patient remains anxious. The more demanding the patient and the more accepting the therapist, the more disbelieving the patient becomes about the therapist's capacities to respond appropriately. If the therapist does not say “no” to unreasonable demands, the patient may believe the therapist has no sense of the boundary between the reasonable and the unreasonable. This is a prescription for clinical disaster.

Stage-Oriented Treatment

During the past several years, a number of authors have offered a model of clinical practice dubbed “stage-oriented treatment.” Consisting of a sometimes lengthy stabilization phase, followed by phases of “working through” and termination, this model is a simplification worth keeping in mind. Patients may not be ready to work through traumatic experiences for many months or even years of treatment. The intense affects associated with these experiences may still be unbearable. Focus on the current context of the patient's life and assessment and stabilization of current relationships and living arrangements may be a much wiser initial approach.

This approach also provides a base of therapeutic collaboration that can be an excellent model for later, more difficult therapeutic interactions. The initial phase of stabilization may include more than reducing the chaos in current relationships, workplace, and home; it may also involve a lengthy process related to diagnosis (Welzant, see page 678).

The Diagnostic Crisis: Pitfalls and Promises

Diagnosis has great meaning to our patients. While diagnosis should inform treatment, for the patient, it may be the first time they have “stopped to notice” that they have a mind that does not work like other people's minds. A lifetime of experiences of depersonalization can remain hidden from the observational capacities of an otherwise very bright person.

There are two salient reasons for this. First, why would anyone think that de-personalization were not normal if it had “always” been present? Second, the body, through dissociative process, sometimes is objectified as the “scene” of abuse, or disowned as dirty or shameful, and there would be little reason to seek ownership of it. This is especially true regarding the lack of a wish to be associated with “other ways of being Mary,” as in the case described previously, who have always been observed with the mind's eye but are experienced dissociatively as “Not-Me.”9 Other experiences, such as analgesia in association with cutting or burning skin, serve to reinforce the sense of lack of ownership of the body.10

Clinicians must appreciate that a lifetime of deep, hypnotic absorption in the personification of different “ways of being Mary” — “alters” who may feel child-like, teenaged, adult, or even like an infant or senior citizen — may have created an inward-gazing mind absorbed in personified and fantasized interactions and experiences. Such a mind may attribute as much “realism” and value to the presence of this private inner, transitional world as to the external world. People with dissociative adaptations to living appreciate that there is a difference, but the real, felt, emotional effect of such an absorbing internal world causes a compelling need to pay attention to that world. If you find this unbelievable, then you may be experiencing what your patient experiences as they become conscious of different perspectives, thoughts, feelings, and skills that are theirs, but to which they have never felt “connected.”

It is important to understand that the dissociative mind is a hiding place for many different alters, polar opposite self-experiences or fantasies, desperate and terrified personified experience, or fantasy places designed to protect an “untouched, never abused” alter from a harsh world. What person, having found a hiding place, would disclose this fortress that cannot be seen? Likewise, the victim of repetitive and sadistic abuse knows from experience that a goal of the abuser was to look deep into their eyes for the moment of the collapse of their self, a moment of surrender and submission, and enjoy the power of taking over the victim. Learning to hide in such sadistically scripted scenes, in a sense, outfoxes the fox. Additional scenes of intensified physical punishment may be covered by a deep veil of amnesia because abusers often track the dissociative adaptations in their victims and do whatever they need to do not to be robbed of their moment of triumph.

Diagnosis, for the patient who has been reading about dissociative disorders before or after they present for treatment, also may be fraught with the fear or expectation that to know about the form of one's mind is to be able to recall memories of abuse that are otherwise not known or remembered. Some patients will state, emphatically, that they had a great childhood, with a very good family, but will be unable to remember what was so good or great. The clinician's scrupulous curiosity about the details of the patient's life will serve a treatment course well.

The focus of treatment in the diagnostic phase may simply be related to making a thorough inquiry of the patient's life, current and past, and to make room for increased consciousness about associated affects, thoughts, reactions, and problems in current relationships. It is often in discussion of the mundane that logical inconsistencies in the patient's personal narrative come into view and the appearance of intense affects provokes shifts in subjectivity that make identity alteration obvious, or at least a consideration. It is the meaning of diagnosis — the implications for the person's subjective sense of self — that provokes a crisis in the patient's life.

Transference–Countertransference

It is not only that patients struggle with knowing about identity alteration. Sometimes, the abuser knows about the “switches” and how to provoke, for example, the presence of a hypersexual, compliant alternate self. The patient often watches, helplessly, as this change happens. In the clinical setting, the therapist's interest in alters may provoke the patient's concern that the therapist is interested in provoking a switch to another of the patient's compliant states. There are many variations of these transference–counter-transference themes,11 but three stand out: incredulity, erotic, and traumatic.

Incredulity

This theme includes the patient's incredulity in the discovery of the inner workings of her mind, the clinician's incredulity about the patient's subjective experiences, and other similar reactions. The patient is incredulous about her life history, the behavior of others in the past, the manner in which she was treated, and the form of her mind. The patient may not have been believed when she reported abuse or may have feared not being believed. Memories are sometimes quite fragmentary, as is consistent with “in-the-moment” depersonalization and derealization during emotionally overwhelming experiences, and there often is internal tension about how to interpret what is in the mind (Gleaves and Williams, see page 648). The conflict belongs within the patient, as does the exploration of his or her own incredulity.

However, the patient may externalize this conflict into the therapeutic relationship by asking, “Do you believe me when I tell you I was hurt by my _______?” An inexperienced therapist may feel obligated to say: “Yes, I believe you.” However, because the patient is not really sure they can interpret what is in her mind, this confirmatory response then takes on the quality of a suggestion. This is more than an error on the part of the therapist; it may be interpreted as dishonest because it falls beyond what can be understood within the boundaries of a therapeutic inquiry.

The response of a clinician challenged by the patient's incredulity is more appropriately one of honesty, neither belief, nor disbelief. For example:

“What happened to you in the past is very important because it teaches us about how you became who you are. By understanding who you are in the present, and whatever you can honestly recall about your past, we can learn something about why there is so much distress in your mind and in your life. I only know what you've told me about your past, and what I can see and hear about your present life. It's really hard for you to tolerate so much uncertainty in your mind, and we are both going to have to work hard to help you do that, until things become clear. We don't know now to what extent they will.”

When memory is complete or unclear, a patient's wish for litigation to “right the wrongs of the past” may be ill conceived. Waiting until after the healing has helped someone to gather her strength and then deciding what to do about the potential for legal action may be a wise choice. Unresolved grief usually is present for this patient population, and taking action may bypass the need for grieving. However, grieving also may reduce or eliminate the need to take action.12

Erotic

When there is a history of sexual abuse in a patient's life, the appearance of an apparently erotic component to a treatment is to be expected. However, appearances may not tell the whole story. The patient's expectation of a sexual boundary violation from the therapist must be met not only with the therapist's scrupulous maintenance of the boundary but also with room to explore the thoughts and feelings that motivate the emergence of this theme in the treatment.

Moreover, the underlying reason behind this emergence often is that of childhood longings for satisfaction of the need for safe physical contact that is sensual, rather than sexual. There may be a wish to be “special” that is conveyed with the emergence of what appears to be adult sexuality. There may be a perspective, left over from scenes of childhood abuse, that interprets the presence of a feeling of intimacy that is typical of therapeutic relationships as a call for the patient's sexual action that would have matched their childhood experience with a seductive adult. Interest may simply feel equivalent to seduction. Gentle and thoughtful clarity in a prepared clinician's response to a patient's overtures is part of the normal clinical armamentarium.

The clinician who is in emotional turmoil, in the midst of a painful divorce, or losing an intimate relationship in his or her personal life may be particularly vulnerable to the transference elaborations of sexuality in these cases. When a clinician is vulnerable in these ways, it may be wiser to defer acceptance of new cases with known sexual abuse histories, or arrange for additional supervision with a trusted colleague.

The patient's insistence that a sexual attraction or interest in the clinician is the “genuine thing” and that they cannot accept anything but satisfaction of their wishes is not unique in the treatment of dissociative disorders. However, the clinician's wisdom in these situations must extend to an appreciation of the multiple meanings, and multiple transference constellations, that may exist simultaneously from different perspectives within the patient. Childhood, teenage, and adult attitudes all may be present, simultaneously or sequentially within a few minutes. It is often very helpful for patients to hear that a clinician's gentle refusal to act, and insistence on discussion of a sexual wish, is respectful of all the different alters. Some alters might be terrified about things sexual, regardless of the apparent longing of other alters.

Additionally, insistence on things sexual in the therapeutic discourse is often a distraction from other intense affects, or additional affect scripts. For example, a reduction in emotional tension may be part of a sequence of “appearances” by different alters, some of whom have memories of longing for intimacy but no memory of the subsequent abuse, or dissociative amnesia for what followed. Adult expressions of longing for intimacy may more simply be a reflection of unsatisfied childhood longings that, with an understanding therapist, feel within reach of now being satisfied. Recognizing, validating, and releasing these longings are steps along the road of grieving childhood losses, a previously impossible task. Sexualization of a relationship may be one example of the introduction of “familiar chaos” into a therapy in a conscious or unconscious effort to distract from other intense affects.13

Traumatic

The traumatic transference is the expectation that the patient will be the victim of the therapist and even that the patient and therapist may occupy alternating roles of rescuer and perpetrator.14 What is least often appreciated is that the therapist's countertransference responses follow the same pattern in the drama triangle.

Therapists may have a hard time appreciating the rapidity of shifts from one transference–countertransference constellation to another as the patient's simultaneous and sequential shifts in subjectivity move from one corner of the triangle to another, in mid-session. This may be confusing for both patient and therapist. It requires very careful listening and a high tolerance for misunderstanding, clarification, redirecting, and creating coherent and explicit themes that are present in a session. The therapist's ability to tolerate his or her own confusion and request clarification becomes a model for patients.

The need to set limits on the therapist's availability must include naming and interpreting actions that undermine or emotionally injure the therapist. If that is not done, then the patient may be frightened by the therapist's willingness to suffer, which is an all-too-familiar aspect of the patient's own experiences. Paradoxically, setting limits reassures the patient that whatever rage, resentment, anger, or emotional vitriol he or she feels will not result in damage to the therapist. Interaction that mimics sadomasochistic behavior often is inevitable, so the clinican should remain aware of this possibility.

Traumatized people often believe that they are bad, and that bad things happen to people who know them. Moreover, being bad has a number of psychological advantages as an explanatory strategy for abusive or untoward events and as fantasized protection from additional harm (Sidebars 3 and 4, see page 663).

Sidebar 3.

Belief in Badness as ‘Affect Management’

All of these strategies are affect regulatory. This means that in addition to the face value of the meaning of the patient's words, there is likely an underlying script of affects19 that tell the story of additional meanings. Numbers 8 and 9 are examples of motivations, which may underlie tenacious attachment to badness that may show up clinically as intractable shame. The bottom line is that one set of emotions blocks another from being present. It is often the case that shame blocks terror. Fear and anxiety often block anger. There are numerous pairings idiosyncratic to each person.

  1. I am bad, and that is why bad things happen to me.

  2. People do bad things to me because my badness makes them do it.

  3. I am so bad that I am completely worthless.

  4. In my worthlessness, I am easily overlooked, and that is what happens to bad, worthless people.

  5. My badness is so bad, that when I am around others my badness hurts them and makes them unhappy.

  6. I cause so much unhappiness in the world that I should be dead to protect the world from me.

  7. Everyone would be better off if the bad me that I am were not around.

  8. Because I am worthless, and completely of no value, no person would have any interest in hurting me and I am safe.

  9. If I am not bad, and these things are happening to me, then I am in danger from the people around me, and my badness is not in control of what they are doing.

Belief in Badness as ‘Affect Management’

Boundaries

The establishment of proper clinical boundaries begins before the first visit when the therapist negotiates the terms of that first meeting and sets expectations and tone for the conversation to take place during an evaluation. Unreal offers of help or assistance by an unwitting therapist will be tested and often form the basis for therapeutic difficulties. Patients with dissociative disorders often have had experiences that comprise a catalogue of human misdeeds based on efforts to wield power and control over others. Problems in treatment related to crossing of boundaries and more problematic violation of boundaries can be traced to sadomasochistic patterns of relating.

Abuse often results in enactment of childhood experiences of submission or surrender to an all-powerful other. These traumatic experiences of loss of selfhood (loss of agency) are known implicitly but often not at all explicitly (Gleaves and Williams, see page 648). To the patient, unconsciously, it feels as if the only psychological path for expressing that loss is through action. Requests for special accommodations and alteration of the treatment frame (erotic transference), may be couched in the language of the traumatic transference: “I can't leave your office. I am frightened of going out into the world without assurances of safety from you”; or: “It would feel so good if you would hug me before I leave the session. It feels so safe here, and so bad out in the world!”

Recurrent Suicide Crises

Thoughts of suicide rarely are a simple wish to die rather than suffer, although this obviously is a concern. Careful and skillful exploration of affect-laden fantasies of suicide and parasuicidal behavior is required.

The clinician must be able to approach these fantasies in great detail, as one would conduct the most careful analysis of dream material. The potential for discovering new meaning should be exhausted, and then it may still be useful to come back to these fantasies again, later, when more meaning is discernable.

Elimination of suicidal fantasy is not the goal. These fantasies may be life-saving in providing the potential for a fantasy “escape-hatch” from unbearable experience. Acting on these fantasies is the concern. When the therapist engages in a detailed inquiry of these fantasies, the therapist then become part of the patient's associations “in” the fantasy, and this often has a stabilizing effect.

Grieving

The need for grieving is an aspect of the treatment of dissociative disorders that is sometimes overlooked but is immediately obvious on reflection of the overall course of treatment. Large parts of a person's life are lost to the obfuscation and interpersonal distance created by the emotional trauma of abuse. There is often an effort to block the experience of loss or grief because it is so profoundly painful.

Many models of dissociative process revolve around unspoken conceptions of dissociation as a major unconscious effort not to know about painful experience in the past or present. It is also true that people on the verge of knowing their story may be reluctant to make the effort required to know.13 It is often toward the end of a treatment that the clincian hears, “Well, it's not that I have never known this. It's just that I have had a sense that I could have reached for these things that I had put at the edge of my mind, but I never wanted to. I just didn't reach. Now, it's so close, it is just there, and I know it.”

A wish not to experience loss often is a motivation in these situations. Attention to this dynamic early in treatment and modeling of an ability to tolerate loss, and the associated pain may be very helpful. Tenacious erotization of the transference, intractable shame, and the generation of chaos when calm could prevail are mechanisms by which the need for grieving is obscured, delayed, and avoided. There is an effective “phobia” to intense affect. Blocked grief may be a way not to acknowledge the events of the past or the presence of particular alter personalities. It is as if the patient says, “If I don't have this feeling, or this thought, then I don't have to believe what is in my mind could really have happened to me.”

Treatment Termination

When is a treatment over? Is it when there is mutual agreement between patient and therapist? Does the therapist have a goal in mind? Does the patient? Is there a requirement that all the different alters become one? What about personal and interpersonal functions such as work, play, living in a community, and spiritual dimensions of living?

In these complex treatments, it often feels as if an entire life is shifting, changing, and being recreated. This is qualitatively different than the treatment of what has been thought of as “neurotic” concerns. Treatment termination requires a reiterative process across many months or years, thoughtful negotiation with the patient, and drawing the patient out about what his or her model of living truly is.

This level of reflective awareness is not present at the start of treatment and is often actively resisted. By mid-phase and while working through trauma, it rises from the ashes of a person's life, often becoming a central issue. Negotiation is the core of discerning the patient's goals, and the focus is on negotiation between different alters, not just between patient and therapist, as a way to decide under what conditions the treatment will end. That is not to say the therapist may have no opinion. What it means is that the therapist's opinion about the “form” of the patient's mind at the time of termination is just that — an opinion.

Periodic follow-up after treatment termination also may be of value to the patient. Life's challenges may provoke some dissociative adaptations from time to time, and periodic follow up is a good way to help keep people on track. Self-care is always the goal, and there is very little data on how long annual follow-up visits might be of value. As with other issues, negotiation with the patient is perhaps the best way to proceed.

Summary

In the end, the treatment of the person with a complex dissociative disorder is about being able to feel comfortable with, as well as thrive with, a “mind of my own.” The sadomasochistic and otherwise emotionally painful origins of the person who becomes an adult with a complex dissociative disorder often precludes the feeling of being able to have one's own thoughts and feelings. Submission and surrender may have been the main interpersonal themes of their life. Ideas and emotions that are at all different from the primary attachment relationships that formed the beginnings of a compromised identity may be sensed as incompatible with a sense of personal safety.

The treatment of complex dissociative disorders is a long journey for patient and therapist and changes them both. While this path may be filled with some of the worst that life may dole out to a human being, the process of co-creating a safe environment for grieving and healing adds immeasurably to the sense of satisfaction that accompanies completion of such a therapeutic adventure. By the time the work is done, where there is patient and therapist, there are, in addition, partners in one of life's most difficult journeys, witnesses to all that is wonderful and terrible about being human and living in community. It is a worthy journey and effort.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
  2. Chefetz RA. Affect dysregulation as a way of life. J Am Acad Psychoanal. 2000;28(2):289–303. doi:10.1521/jaap.1.2000.28.2.289 [CrossRef]10976425
  3. Winnicott DW. Transitional objects and transitional phenomena: a study of the first not-me possession. Int J Psychoanal. 1953;34(2):89–97.13061115
  4. Main M, Morgan H. Disorganization and disorientation in infant strange situation behavior: phenotypic resemblance to dissociative states. In: Michelson LK, Ray WJ, eds. Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives. New York, NY: Plenum Press; 1996:107–138. doi:10.1007/978-1-4899-0310-5_6 [CrossRef]
  5. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM. The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry. 1986; 47(6):285–293.3711025
  6. Chu JA, Loewenstein R, Dell PF, et al. International Society for the Study of Dissociation. Guidelines for treating dissociative identity disorder in adults. J Trauma Dissociation. In press.
  7. Schore AN. Affect Regulation and Repair of the Self. New York, NY: W.W. Norton & Co.; 2003.
  8. Zetzel ER. The so called good hysteric. Int J Psychoanal. 1968;49(2):256–60.5685197
  9. Chefetz R, Bromberg P. Talking with “Me” and “Not-Me”: a dialogue. Contemp Psychoanal. 2004;40(3):409–464. doi:10.1080/00107530.2004.10745840 [CrossRef]
  10. Loewenstein RJ. An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. In: Loewenstein RJ, ed. Psychiatric Clinics of North America, vol 14. Philadelphia, PA: W.B. Saunders Company; 1991:567–604. doi:10.1016/S0193-953X(18)30290-9 [CrossRef]1946025
  11. Chefetz RA. Special case transference and countertransference in the treatment of dissociative identity disorder. Dissociation. 1997;10(4):255–265.
  12. Kavaler-Adler S. Mourning and erotic transference. Int J Psychoanal. 1992;73(Pt 3):527–539.1399285
  13. Stern D. Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press; 1997.
  14. Karpman SB. Fairy tales and script drama analysis. Transactional Analysis Bulletin. 1968;7(26):39–43.
  15. van Ijzendoorn MH. Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychol Bull. 1995;117(3):387–403. doi:10.1037/0033-2909.117.3.387 [CrossRef]7777645
  16. Liotti G. Understanding the dissociative processes: the contributions of attachment theory. Psychoanalytic Inquiry. 1999;19(5):757–783. doi:10.1080/07351699909534275 [CrossRef]
  17. Liotti G. Disorganization of attachment as a model for understanding dissociative psychopathology. In: Solomon J, George C, eds. Attachment Disorganization. New York, NY: The Guilford Press; 1999:291–317.
  18. Solomon J, George C. Attachment Disorganization. New York, NY: The Guilford Press; 1999.
  19. Tomkins SS. Script theory. In: Demos EV, ed. Exploring Affect: The Selected Writings of Silvan S. Tomkins. New York, NY: Cambridge University Press; 1995. doi:10.1017/CBO9780511663994.021 [CrossRef]
  20. Loewenstein RM. A contribution to the psychoanalytic theory of masochism. J Am Psychoanal Assoc. 1957;5(2):197–234. doi:10.1177/000306515700500201 [CrossRef]13416034

Educational Objectives

  1. Describe the five elements of dissociative disorders according to criteria from the Structured Clinical Interview for DSM-IV Dissociative Disorders .

  2. Identify three core transference–countertransference themes in the treatment of the dissociative disorders.

  3. Explain how to explore fantasies of suicide related to the patient's dissociative experience.

Sidebar 1.

Disorganized/Disoriented Infant Attachment Patterns as Dissociative Disorder Phenotype4,15–18

People with dissociative disorders may display adult versions of simultaneous or sequential contradictory internal working models in their behavior. Freezing/stilling may be seen as a “speechless” moment in therapy. It does not necessarily represent the absence of something to say. Rather, it may represent the presence of conflicting internal working models.

Infants are judged to fit the disorganized/disoriented, Type D, attachment pattern if they display behaviors in the presence of their caretaker, such as:

  1. Sequential displays of contradictory behavior: calling loudly for parent and then avoiding when the parent enters.

  2. Simultaneous display of contradictory behavior: clinging to parent while arching body away.

  3. Undirected, misdirected, incomplete and interrupted movements and expressions: turning around and greeting the stranger brightly, arms raised, as parent enters the room.

  4. Stereotypes, asymmetrical movements, mistimed movements and anomalous postures: rocking vigorously on hands and knees, or assuming an awkward, uninterpretable posture.

  5. Freezing, still, and slowed movements and expressions: suddenly stopping and freezing, hands in air, for 25 seconds or more; or moving toward a parent in extremely slow motion, as though resisting forward movement.

  6. Direct indices of apprehension regarding the parent: fear-smile or hand-to-mouth gesture at parent entrance.

  7. Direct indices of disorganization and disorientation: raising hand to mouth on return of parent, accompanied by confused expression.

Sidebar 2.

Further Reading on the Treatment of Dissociative Disorders

Bromberg PM. Standing in the Spaces. Hillsdale, NJ: The Analytic Press; 1998.

Cohen BM, Cox CT. Telling Without Talking. New York, NY: W.W. Norton; 1995.

Courtois CA. Recollections of Sexual Abuse: Treatment Principles and Guidelines. New York, NY: W.W. Norton; 1999.

Davies JM, Frawley MG. Treating the Adult Survivor of Childhood Sexual Abuse. New York, NY: Basic Books; 1994.

Freyd JJ. Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Cambridge, MA: Harvard University Press; 1996.

Gelinas DJ. The persisting negative effects of incest. Psychiatry. 1983;46(4):312–332.

Gleaves DH, May MC, Cardena E. An examination of the diagnostic validity of dissociative identity disorder. Clin Psychol Rev. 2001;21(4):577–608.

Hunter ME. Understanding Dissociative Disorders: A Guide for Family Physicians and Healthcare Workers. Williston, VT: Crown House Publishing; 2004.

Kluft RP, ed. Childhood Antecedants of Multiple Personality. Washington, DC: American Psychiatric Publishing; 1995.

Kluft RP, Fine CG, eds. Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Publishing; 1993.

Krystal H. Integration and Self Healing: Affect, Alexithymia, and Trauma. Hillsdale, NJ: Analytic Press; 1988.

Liotti G. Disorganized/Disoriented attachment in the psychotherapy of the dissociative disorders. In: Goldberg S, Muir R, Kerr J. Attachment Theory. Hillsdale, NJ: The Analytic Press; 1995: 343–363.

Lyons-Ruth K. Dissociation and the parent-infant dialogue: a longitudinal perspective from attachment research. J Am Psychoanal Assoc. 2003;51(3):883–911.

Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B. Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Dev Psychopathol. 1997;9(4):855–879.

Pearlman LA, Saakvitne Karen W. Trauma and the Therapist. New York, NY: W.W. Norton; 1995.

Pollock PH. Cognitive Analytic Therapy for Adult Survivors of Childhood Abuse: Approaches to Treatment and Case Management. New York, NY: John Wiley & Sons; 2001.

Putnam FW. Diagnosis and Treatment of Multiple Personality Disorder. New York, NY: The Guilford Press; 1989.

Putnam FW. Dissociation in Children and Adolescents. New York, NY: The Guilford Press; 1997.

Ross CA. Multiple Personality Disorder: Diagnosis, Clinical Features and Treatment. New York, NY: John Wiley & Sons; 1989.

Shusta-Hochberg SR. Therapeutic hazards of treating child alters as real children in dissociative identity disorder. J Trauma Dissociation. 2004;5(1):13–27.

Siegel DJ. The Developing Mind: Toward A Neurobiology of Interpersonal Experience. New York, NY: The Guilford Press; 1999.

Stern D. Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press; 1997.

Sidebar 3.

Belief in Badness as ‘Affect Management’

All of these strategies are affect regulatory. This means that in addition to the face value of the meaning of the patient's words, there is likely an underlying script of affects19 that tell the story of additional meanings. Numbers 8 and 9 are examples of motivations, which may underlie tenacious attachment to badness that may show up clinically as intractable shame. The bottom line is that one set of emotions blocks another from being present. It is often the case that shame blocks terror. Fear and anxiety often block anger. There are numerous pairings idiosyncratic to each person.

  1. I am bad, and that is why bad things happen to me.

  2. People do bad things to me because my badness makes them do it.

  3. I am so bad that I am completely worthless.

  4. In my worthlessness, I am easily overlooked, and that is what happens to bad, worthless people.

  5. My badness is so bad, that when I am around others my badness hurts them and makes them unhappy.

  6. I cause so much unhappiness in the world that I should be dead to protect the world from me.

  7. Everyone would be better off if the bad me that I am were not around.

  8. Because I am worthless, and completely of no value, no person would have any interest in hurting me and I am safe.

  9. If I am not bad, and these things are happening to me, then I am in danger from the people around me, and my badness is not in control of what they are doing.

Belief in Badness as ‘Affect Management’

Sidebar 4.

Seduction of the Aggressor

Originally described as a way to guarantee the love of a parent by engaging in masochistic submission,20 the experience of waiting in terror for a repetitively abusive parent to enter a room at night and sexually abuse a child can become too painful to tolerate. In an effort at affect regulation and to regain as sense of power, control, or agency, the terrified child may decide not to wait to be abused but to “get it over with.” In this situation, the child approaches the abusing parent and the parent then chastises the child for “making me do this to you.” On the one hand, the terror of waiting is over. On the other, feelings of self-loathing, shame, and humiliation become rife.

At an older age, teenagers who have since early childhood been the victim of incest may develop relatively independent seductive alter personalities with a fantasy of having a “special” relationship with the father. The coming into consciousness of these scenarios is one of the most painful times of the therapy of incest. It often helps greatly for the patient to understand this as a regulatory behavior started early in childhood to deal with the overwhelming terror of anticipated abuse.

Authors

Richard A. Chefetz, MD, is a psychiatrist in private practice in Washington, DC. He also is a distinguished visiting lecturer at the William Alanson White Institute of Psychiatry, Psychoanalysis and Psychology, New York, NY, and on the faculty of the Advanced Psychotherapy Training Program of the Washington School of Psychiatry, and Institute of Contemporary Psychotherapy and Psychoanalysis.

Address reprint requests to: Richard A. Chefetz, MD, 4612 49th St. NW, Washington, DC 20016-4321; or e-mail r.a.chefetz@psychsense.net.

Dr. Chefetz has no industry relationships to disclose.

10.3928/00485713-20050801-07

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