The Dissociative Mind

Elizabeth F. Howell

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135469719
• Edition: 1
• Topic: Psychologie
• Subtopic: Zwischenmenschliche Beziehungen in der Psychologie

Drawing on the pioneering work of Janet, Freud, Sullivan, and Fairbairn and making extensive use of recent literature, Elizabeth Howell develops a comprehensive model of the dissociative mind. Dissociation, for her, suffuses everyday life; it is a relationally structured survival strategy that arises out of the mind's need to allow interaction with frightening but still urgently needed others. For therapists dissociated self-states are among the everyday fare of clinical work and gain expression in dreams, projective identifications, and enactments. Pathological dissociation, on the other hand, results when the psyche is overwhelmed by trauma and signals the collapse of relationality and an addictive clinging to dissociative solutions. Howell examines the relationship of segregated models of attachment, disorganized attachment, mentalization, and defensive exclusion to dissociative processes in general and to particular kinds of dissociative solutions. Enactments are reframed as unconscious procedural ways of being with others that often result in segregated systems of attachment. Clinical phenomena associated with splitting are assigned to a model of "attachment-based dissociation" in which alternating dissociated self-states develop along an axis of relational trauma. Later chapters of the book examine dissociation in relation to pathological narcissism; the creation and reproduction of gender; and psychopathy. Elegant in conception, thoughtful in tone, broad and deep in clinical applications, Howell takes the reader from neurophysiology to attachment theory to the clinical remediation of trauma states to the reality of evil. It provides a masterful overview of a literature that extends forward to the writings of Bromberg, Stern, Ryle, and others. The capstone of contemporary understandings of dissociation in relation to development and psychopathology, The Dissociative Mind will be an adventure and an education for its many clinical readers.

1

DISSOCIATION

A Model of the Psyche

September 11, 2001

My experience during the World Trade Center disaster of September 11, 2001, illustrates the initially protective role of dissociation in the moments of trauma, as well as its later consequences. I was on my way to work about 9:00 a.m. on the subway in New York City. People were talking about planes that had hit the World Trade Center, but I was focused on avoiding being late for a session with a patient, and pictured these as small planes, causing at most small fires. I thought to myself, “Small fires happen everyday.” As I was on the subway and talked to more people and got more information, I decided I would get out and have a look at this fire, before proceeding on the subway under it (the next stop on the subway was the World Trade Center). When I exited, I saw the twin towers three short blocks away, burning rapidly, like matchsticks. They had already burned about a quarter of the way down. People were standing around staring, and appeared transfixed. I was transfixed too for a moment, and then I decided it was time to leave. But there was no way back by subway because the service had been stopped. Nor were there any cabs. It was too far to walk to my office, and I decided to walk home to Brooklyn. I made my way to the Brooklyn Bridge and walked across with a throng of others, many of whom had been in the towers and had escaped the fire. I talked with a man who had walked down 66 flights of stairs and believed that everyone had exited safely. At that moment, I believed that, too. Everyone was calm. No one was running. In short, people were in a state of shock en masse. I had an eerie moment of noticing what a beautiful, clear, crisp, near-autumn day it was, as a backdrop for the image of the towers rapidly burning, now more than halfway down. It was clear to me that they would collapse, and I began to worry about the impact of collapse on the stability of the bridge. Not knowing of the validity of this speculation in physics and not wanting to frighten others, I walked faster alone, but like everyone else, I was calm. Now there was a huge black cloud of smoke and fumes and debris, billowing larger and larger and rapidly gaining on us. As I was exiting the bridge, I heard someone say that one tower had collapsed. (When someone asked me later if I saw the towers collapse, my answer was no, because I had been so absorbed, so intent on getting off the bridge.) As soon as I arrived home, there were calls from the superintendent to everyone to close their windows against the now arrived black cloud of soot and burned remains. I remained calm. It was a heartrendingly emotional time, but I thought that psychologically, I was fine. It was only a few days later that it hit me: I realized that I narrowly missed being caught in the conflagration. If I had stayed on the subway, the train would have either stopped at the World Trade Center, which was an underground maze, mostly leading into the towers, or in the tunnel, from which evacuation would have been, at best, a time-consuming process, with an exit close to the fires. I worried about all the people in the subway car, some with whom I had spoken, who had not left. I wondered what had happened to them, whether they survived. When I realized how imminent the danger had been, I couldn’t stop telling anyone who would listen. To people who had no idea what had happened, this might have seemed a bit crazy. But many of the elements of trauma and dissociation are here—the calm narrowing of the focus of attention to only the most salient matters or helpful things, and the later realization of fear, concomitant with frightening, intrusive thoughts and hyperarousal. For persons who don’t know or can’t understand what the frightening event was, the subsequent agitated behavior might seem bizarre. Fortunately for me, I received enough understanding that my mild posttraumatic stress symptoms abated. However, people who are in chronic posttraumatic stress may be experienced by others as disordered or as behaving bizarrely, especially if the stressor is unknown, as is often the case.

PTSD Is Evidence of Dissociation

In posttraumatic stress a person may experience the intrusions of dissociated experiences, such as flashbacks, somatosensory experiences, or even obsessions, into consciousness, but may also vigilantly attempt to avoid any reminders of the trauma. These are the intrusion and avoidance aspects of PTSD. This was what happened to me in the World Trade Center disaster on September 11, 2001: my previous experience of terror was not accessible to me for a few days. Then, the memories began to intrude. Although I felt like Coleridge’s Ancient Mariner (who had to wander from town to town, endlessly telling his story), I began to heal. This process assumes dissociation, because some experience had to be cordoned off from other experience (dissociated) to intrude (Van der Hart, Van Dijke, Van Son, and Steele, 2000). The intrusion aspects are the dissociated memories of the trauma, often intruding in response to “triggers” or reminders of the trauma. The hyperaroused behavior may appear senseless to an observer and even to the individual in question. The avoidance aspects of the PTSD refer to the efforts to avoid the dissociated material which could be triggered by a reminder of the trauma.

Trauma

Until fairly recently trauma was officially viewed as an “out of the ordinary” experience (DSM-III described trauma in these terms). But such a view is inconsistent with observable reality (Brown, 1991; Herman, 1992). In times of war, trauma is not rare. Neither has it been rare in times of relative national tranquility. Indeed, trauma has never been rare. Rates of child abuse, including physical and sexual abuse, are shockingly high. A recent national survey, conducted by telephone, of 2000 randomly selected youths, aged 10 to 16, found that almost one half of the boys and one third of the girls had been subjected to some form of violent victimization (Boney-McCoy and Finkelhor, 1996). In a large study in which 900 women were interviewed, Russell (1986) found that the rate of contact child sexual abuse of girls before age 18 was 38%, and the rate of incest was 16%. A recent study of 600 college men indicated that 18% reported contact sexual abuse before the age of 16 (Lisak, Hopper, and Song, 1996). Assuming that much of this trauma is not resolved and has dissociative sequelae, these rates might push expected normal personality structure into the realm of what one might call the “pathological normal”—that is, an area that is statistically normal but highly problematic, even pathological.

We now understand that trauma is ubiquitous. In the statistical sense, it is normal. And so is dissociation, which is often a sequela to trauma. It follows then that everyday functioning for most people is bound up in the effects of trauma and dissociation. Although significant trauma does affect the majority of us, there are also many less extreme traumas and dissociations of everyday life. And these affect us in ways that may be at first unexpected. Pollack (1995, 1998) contends that in our culture little boys frequently undergo a “normative developmental trauma” involving dissociation of affectively longing parts of the self and resulting in fears of isolation and feelings of deprivation. Indeed, many gender-related phenomena can be understood as post-traumatic adaptations, involving dissociation (Howell, 2002b).

Not Only Posttraumatic

Despite the prevalence of trauma-related dissociation, problematic dissociation does not proceed from trauma alone (Gold, 2000). It encompasses not only the “shattered self” of posttraumatic severed connections, but also more general failures of integration (Putnam, 1992, 1997). Poor psychological integration proceeds from family environments that are chaotic, abusive, neglectful, or all three; from attachment dilemmas, including disorganized attachment; and from severe interpersonal anxiety caused by interactions with caregivers and with a dissociogenic culture. Developmentally, lack of integration characterizes our beginnings (Siegel, 1999), and facilitative maturational environments enable disconnected sets of experiences to be linked (Putnam, 1997). In his important book, Not Trauma Alone, Gold (2000) amends the trauma–abuse model and emphasizes that individuals most likely to be characterized by severe dissociation have generally grown up in interpersonal environments that failed to provide the infant and child with requisite interpersonal resources to obtain full human status. He observes how remarkably consistent individual incidents of abuse often are with the family atmosphere in which they have occurred, and that atmospheres of neglect, deprivation, and rejection fail to nourish fundamental skills in living.

Fairbairn and Ferenczi (chapter 3) have articulated forms of dissociative adaptations to attachment dilemmas. Bowlby noted the importance of segregated internal working models, which modern attachment theorists such as Liotti, Lyons-Ruth, and Stern have observed is both phenotypic of dissociation and predictive of dissociative disorders. Interestingly, and counterintuitively, Lyons-Ruth (2003) has found that disorganized attachment is a better predictor of dissociation at age 19 than is trauma. The current attachment–theory emphasis on dissociated relational procedural enactments (chapter6) intersects with current relational psychoanalytic models of Bromberg, Davies, and Stern (chapter 4).

Sullivan (1953) described the interpersonal genesis of dissociation. As a result of unbearable anxiety arising from interactions with caregivers, including extreme parental disapproval, certain kinds of experiences may become dissociated and part of “not-me.” Selective inattention to anxiety-fraught areas of experience leads to experience remaining unformulated, and hence dissociated (Stern, 1997). Thus, dissociation refers to the unconscious avoidance of formulating certain aspects of experience into meaningful constructs (Stern, 1997). Finally, the culture itself may be dissociogenic and discontinuous, such that experiences of self are also marked by discontinuities (Gold, 2004a).

What Is Dissociation?

In a general sense, dissociation refers to the separation of mental and experiential contents that would normally be connected. The word dissociation is laden with multiple meanings and refers to many kinds of phenomena, processes, and conditions. Dissociation is both adaptive and maladaptive, both verb and noun, both cause and effect (Spiegel, 1990b; Tarnopolsky, 2003). Dissociation is often psychologically defensive, protecting against painful affects and memories, but it can also be an organismic and automatic response to immediate danger (Van der Hart, Nijenhuis, Steele, and Brown, 2004). Dissociation can be understood as taxonic or, alternatively, as existing on a continuum—describing all of us, varying in degrees (Putnam, 1997). It is both occurrent (in evidence or in process) and dispositional (a capability that can be tapped) (Braude, 1995). It refers to such psychical events as spacing out, psychic numbing, and even experiencing oneself as floating above one’s body. Dissociation has been thought of in spatial metaphor, as acts of “keeping things apart” (Tarnopolsky, 2003) as well as “vertical splitting” (Kohut, 1971; Hilgard, 1977).

Thus, multiple views of the etiology and nature of dissociation exist. According to Putnam (1997), these views “converge around the idea that dissociation represents a failure of integration of ideas, information, affects, and experience” (p. 19). Yet, when dissociation is so many things, how do we understand it? All of these different meanings potentially create a conceptual confusion. A danger is that the word dissociation can be used so loosely that it begins to lose its meaning.

A significant divergence of opinion currently concerns whether dissociation is best understood in terms of a continuum model or a psychopathological taxon model. Both models are supported by the evidence. The first posits a continuum from adaptive, normative dissociation to the extremes of pathological dissociation. The taxon model addresses dissociation as classified by symptoms, exemplified by dissociative disorders.

The Health-to-Psychopathology Continuum

At the healthy end of this continuum are dissociative experiences that are normative, that enhance enjoyment and effectiveness in living, or both. Dissociation is not necessarily evidence of a history of trauma, or even of psychopathology. For example, hypnosis can result in one or more sets of experiences becoming inaccessible to ordinary consciousness. Many see dissociation as a capacity, which can be life-enhancing as well as defensive. A prime exemplar of such normative, life-enhancing dissociation is absorption, which appears to be normally distributed throughout the population (Putnam, 1997). Absorption, which is highly interrelated with hypnosis (Putnam, 1997; Maldonado and Spiegel, 1998), is the ability to be “carried away” in a narrowed, concentrated focus of attention, to become so immersed in a central experience that context loses its frame. It has been classified as dissociation because the intense focal concentration can result “in the exclusion (dissociation) of other contents from the phenomenal field and, often, the context in which it is experienced” (Butler, 2004, p. 4). Some examples of absorption are being engrossed in a book or movie, having a highly engaging fantasy while driving, contemplation, reverie, and “flow” (Csikszentmihalyi, 1990, cited in Butler, 2004, p. 7). Butler (2004) believes that normative, adaptive, and enhancing experiences of dissociation have been generally overlooked. She notes that flow

shares many features with dissociative experience including intense, focused concentration, a merging of action and awareness (i.e., attention is completely absorbed in the present action that results in the loss of reflective self-consciousness and distorted time sense). The features that distinguish flow from other dissociative experiences are the sense of self-efficacy experienced with respect to the task at hand and the intrinsically rewarding nature of the experience [p. 8].

Similar to flow are meditative experiences and many positive trance experiences, which also involve loss of reflective self-consciousness. Indeed, part of the process of yogic meditation involves a kind of surrender such that reflective self-consciousness is relinquished as it arises (Waelde, 2004).

A phenomenon commonly known as “highway hypnosis,” in which the driver of an automobile travels a well-known route and arrives at the destination without remembering the drive, has often been cited as an example of dissociation. What happens here is that the driver, focally attending to other thoughts than the road, is able to perform the drive automatically. It is an example of automatic dual tasking. Highway hypnosis is one of the items in the Dissociative Experiences Scale (DES) and may also measure absorption (Putnam, 1997), but it is not one of the taxonic, or typological, items indicating dissociative pathology.¹ How likely we are to drive safely while under the influence of highway hypnosis may depend on our degree of absorption in our own thoughts.

Is dissociation phenomenologically the same in pleasant experiences of absorption as it is in trauma? And are the same processes involved? A key issue relevant to adaptive versus pathological dissociation is whether the dissociation is under voluntary control. Thus, in meditation and peak experiences, a person consciously decides to become absorbed or to allow absorption to occur, and the person can return to everyday modes of functioning without difficulty. Highway hypnosis would be extremely dangerous if the person could not return attention to the road when necessary. Furthermore, there is the question of whether dissociation promotes or impedes integration. For example, meditation, which is consciously controlled, tends to promote integration (Waelde, 2004), whereas involuntary dissociation impedes it.

The same ability, absorption, can be used to enhance experience or to avoid it; it can be used for pleasure (Butler, 2004) or for defense. Many highly dissociative patients report that they have found ways to voluntarily disappear from traumatic experiences: deliberately going into a state of trance or absorption, becoming lost in the wallpaper, or mentally going into a mousehole in the wall. Here we have an initially adaptive response to interpersonal violence or threat in which the ability to become absorbed or go into trance is a coping mechanism. The problem is that the outcome of continuously avoiding painful experience is that it cannot be integrated and will therefore intrude into experience or dominate it at times. In all forms of problematic dissociation, too much is involuntary. People with dissociative disorders and with PTSD often cannot control the intrusive experience. Often people with DID and BPD cannot control the switching between self-states. Unformulated experience is involuntarily enacted.

The Taxon

Taxon refers to type or classification. Hence, according to the taxonic perspective, dissociation is equated with severe dissociation. There are individuals whose dissociativity is so chronic and severe that they fit into a taxon or personality type. Despite the fact that dissociation has often been understood as highly interrelated with hypnosis, Putnam (1997) has found that the supposed dissociation–hypnotizability relationship does not hold for the general population (and that most DID patients are not “highly hypnotizable”), suggesting that the dissociation–hypnotizability relationship is nonlinear. However, high hypnotizability does seem to characterize a group of abuse victims who had an earlier onset of incest and many more perpetrators. He called this relatively small subgroup of subjects “double dissociators”; that is, they scored high on both dissociation and hypnotizability. This finding is consistent with a taxon rather than a continuum model of dissociation for this group of people.

Putnam’s finding is also consistent with the age-related aspect of dissociative abilities: the ability to dissociate is greatest in childhood and gradually decreases with age, except for a period of increase in adolescence (Bernstein and Putnam, 1986, cited in Chu, 1998). High dissociative ability continues into adulthood only in situations of ongoing traumatic abuse (Kluft, 1984). Thus, people who encounter even extreme trauma in adulthood do not develop extreme, florid symptoms of DID (Chu, 1998) if they were not highly traumatized in childhood.

Structural Dissociation

One highly significant construct of pathological dissociation is Van der Hart et al.’s (2004) theory of the “structural dissociation of the personality.” These authors believe that the word dissociation should denote structural dissociation, a division of experiential parts of the personality. Invoking Janet’s postulation that “dissociation denotes an organized division of the personality,” Van der Hart et al. (2004) note that this division involves inadequate integration among two or more systems of ideas and functions, each of which encompasses a “sense of self, no matter how rudimentary or vastly developed” (p. 907). They believe that “conceptual clarity regarding trauma-related dissociation is urgently needed. There is pervasive misunderstanding of the nature of dissociation. It precludes con...