Trauma, Dissociation and Multiplicity

Working on Identity and Selves

Valerie Sinason, Valerie Sinason

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136584978
• Edition: 1
• Topic: Psychologie
• Subtopic: Posttraumatische Belastungsstörung (PTBS)

Trauma, Dissociation and Multiplicity provides psychoanalytic insights into dissociation, in particular Dissociative Identity Disorder (DID), and offers a variety of responses to the questions of self, identity and dissociation. With contributions from a range of clinicians from both America and Europe, areas of discussion include:

• the concept of dissociation and the current lack of understanding on this topic
• the verbal language of trauma and dissociation
• the meaning of children's art
• the dissociative defence from the average to the extreme
• pioneering new theoretical concepts on multiple bodies.

This book brings together latest findings from research and neuroscience as well as examples from clinical practice and includes work from survivor-writers. As such, this book will be of interest to specialists in the field of dissociation as well as psychoanalysts, both experienced and in training.

This book follows on from Valerie Sinason's Attachment, Trauma and Multiplicity, Second Edition and represents a confident theoretical step forward.

Chapter 1

The Foreclosure of Dissociation within Psychoanalysis

Phil Mollon

There is a paradox in the origin of psychoanalysis. The most famous case depicting the ‘talking cure’, that of Anna O, a patient treated by Josef Breuer, is one that clearly displays dissociation as a prominent feature – and yet this characteristic does not find a place in Freud’s theorising about repression and the unconscious. This is because the division between conscious and unconscious mind, and a process of ‘repression’, which banishes unwanted contents of the mind to the unconscious, does not accommodate dissociation of the mind into alternate states of consciousness. As a result, psychoanalysts have, for decades, been puzzled by, and unable to conceptualise coherently, the widespread phenomenon of dissociation. Without the cognitive tools to think about dissociation, its presence has tended to be ignored, overlooked, or scotomised by psychoanalysts. It has, in short, been foreclosed from psychoanalytic perception and discourse.

Anna O was described as presenting two states of consciousness, rather than a tension between a conscious and an unconscious mind:

Throughout her entire illness her two states of consciousness existed side by side: the primary one in which she was quite normal psychically, and the second one which may well be likened to a dream in view of its wealth of imaginative products and hallucinations, its large gaps in memory and the lack of inhibition and control in its associations . . . [T]he patient’s mental condition was entirely dependent upon the intrusion of this secondary state into the normal one . . . It is hard to avoid expressing the situation by saying that the patient was split into two personalities of which one was mentally normal and the other insane.

(Breuer and Freud 1893–5: 45)

In contrast to Freud’s theory of psychoneuroses of defence – whereby repressed mental contents (unacceptable desires) are repressed and banished to the unconscious mind, subsequently finding disguised expression in symptoms, dreams, parapraxes, and free-associations – Breuer’s case of Anna O presented alternate states of consciousness, each being incompatible with the other. One was ‘normal’ and the other dreamlike – her illness seeming to consist of the intrusion of the dreamlike state into her ‘normal’ state. In addition, a third state (or part) of the mind is indicated in the following comment:

Nevertheless, though her two states were thus sharply separated, not only did the secondary state intrude into the first one, but – and this was at all events frequently true, and even when she was in a very bad condition – a clear-sighted and calm observer sat, as she put it, in a corner of her brain and looked on at all the mad business.

(Breuer and Freud 1893–5: 46)

The presence of a clear-sighted observer has been noted in other conditions where consciousness is split into several states or parts. On recovering from a schizophrenic psychosis, a patient may report an awareness of a sane but helpless part of the mind observing the madness. Freud himself, in his last book, An Outline of Psycho-Analysis (1940a), described this process in states of psychosis:

one learns from patients after their recovery that at the time in some corner of their mind (as they put it) there was a normal person hidden who, like a detached spectator, watched the hubbub of illness go past him . . . Two psychical attitudes have been performed instead of a single one – one, the normal one, which takes account of reality, and another which under the influence of the instincts detaches the ego from reality. The two exist along side of each other.

(Freud 1940a: 202)

This is also a common feature of Dissociative Identity Disorder. Some alters may appear unaware of the existence of others within the system, but there may be at least one alter that has an overview of the entire internal system, and who can provide a helpful and sane perspective.

While some (more neurotically organised) patients may present phenomena indicative of their being unconscious of the source of troublesome feelings, those whose minds are organised dissociatively display something more along the lines of a constellation of consciousnesses competing for temporary executive control – like a meeting of people who are each striving for their time with the microphone.

The first use of the term ‘unconscious’ in a psychoanalytic context was in Breuer’s description of Anna O – but, ironically, in a sentence where it makes little sense. He wrote:

Every one of her hypnoses in the evening afforded evidence that the patient was entirely clear and well-ordered in her mind and normal as regards her feeling and volition so long as none of the products of her secondary state was acting as a stimulus ‘in the unconscious’.

(Breuer and Freud 1893–5: 45)

Breuer is not referring here to an unconscious part of the mind, but to an alternative consciousness. The sentence is actually more coherent if the phrase ‘in the unconscious’ is omitted. As the editor, Strachey, suggests, the reference to ‘the unconscious’ seems to be placed there as a gesture towards the theory of repression and the unconscious of his co-author Freud.

Hysteria Resulting from Blocked Excitation

Breuer explains his view that hysteria occurs when a quantum of excitation is prevented from normal release. He gives an example of a 12-year-old boy who developed a difficulty in swallowing and a headache, refusing food and vomiting when it was pressed on him. No clear explanation was initially forthcoming. Eventually, ‘in response to strong appeals from his clever and energetic mother’, he tearfully recounted the following. On his way home from school, he had visited a public toilet where ‘a man had held out his penis to him and asked him to take it into his mouth’. The boy had run away in terror and from that point had been ill. However, as soon as he had ‘made his confession’, he completely recovered. Breuer notes that to produce the hysteria several factors were involved: ‘the boy’s innate neurotic nature, his severe fright, the irruption of sexuality in its crudest form into his childish temperament, and . . . disgust.’ He adds the crucial point that ‘The illness owed its persistence to the boy’s silence, which prevented the excitation from finding its normal outlet’ (Breuer and Freud 1893–5: 212).

Hypnoid States Versus Freud ’s Theory of Repression

Breuer’s further discussion includes an account of Freud’s theory of defence hysteria, whereby a troubling idea is repressed, thereby preventing a normal ‘wearing-away’ of the excitation or affect. However, he then went on to refer to another kind of idea whose associated excitation or affect is not worn away:

This may happen not because one does not want to remember the idea, but because one cannot remember it: because it originally emerged and was endowed with affect in states in respect of which there is amnesia in waking consciousness – that is, in hypnosis or in states similar to it.

(Breuer and Freud 1893–5: 214)

Breuer quotes some earlier comments by Moebius, who had been trying to understand how it is that an idea can generate somatic phenomena, such as found in hysteria. He had reasoned:

The necessary condition for the (pathogenic) operation of ideas is, on the one hand, an innate – that is, hysterical – disposition and, on the other, a special frame of mind. We can only form an imprecise idea of this frame of mind. It must resemble a state of hypnosis, it must correspond to some kind of vacancy of consciousness in which an emerging idea meets with no resistance from any other – in which, so to speak, the field is clear for the first comer. We know that a state of this kind can be brought about not only by hypnotism but by emotional shock (fright, anger, etc.) and by exhausting factors (sleeplessness, hunger, and so on).

(Moebius 1894, quoted in Breuer and Freud 1893–5: 215)

While disagreeing with the implication of a ‘vacant’ state of mind,¹ Breuer emphasises the importance of ‘hypnoid states’: ‘most especially, in the amnesia that accompanies them and in their power to bring about the splitting of the mind’, Breuer states his view that hypnoid states may play a part even in those hysterical conditions where Freud had found ‘the deliberate amnesia of defence’ (Breuer and Freud 1893–5: 216). He describes the hypnoid states as ‘dream-like’ and subject to amnesia in the subject’s normal consciousness. Crucially, he notes that they are protected from correction by reality:

The amnesia withdraws the psychical products of these states . . . from any correction during waking thought; and since in auto-hypnosis criticism and supervision by reference to other ideas is diminished . . . the wildest delusions may arise from it and remain untouched for long periods.

(Breuer and Freud 1893–5: 216)

Breuer argued that ‘hysterical conversion’ takes place more easily in a hypnoid state, in the same way that hallucinations and bodily movements occur in response to suggested ideas during hypnosis. He reasoned that ‘pathogenic autohypnosis’ may come about in some people ‘by affect being introduced into a habitual reverie’ – a condition in which there is first an ‘absence of mind’, such that the ‘flow of ideas grows gradually slower and at last almost stagnates; but the affective idea and its affect remain active, and so consequently does the great quantity of excitation which is not being used up functionally’ (Breuer and Freud 1893–5: 218–19).

Breuer then goes on to make a point about the possible role of fear and shock in generating pathogenic hypnoid states:

Since fright inhibits the flow of ideas at the very same time at which an affective idea (of danger) is very active, it offers a complete parallel to a reverie charged with affect; and since the recollection of the affective idea, which is constantly being renewed, keeps on re-establishing this state of mind, ‘hypnoid fright’ comes into being, in which conversion is either brought about or stabilized. Here we have the incubation stage of ‘traumatic hysteria’ in the strict sense of the word.

(Breuer and Freud 1893–5: 219–220)

Thus Breuer postulates that trauma creates fright, which inhibits the flow of ideas, and thereby establishes a hypnoid state – one which is re-established every time there is a recollection of the emotionally charged idea. This is very close to modern views of trauma creating dissociative states that are combined with intrusive recollections, or reliving, of the trauma. In the intrusive reliving states, the person may lose contact with present reality, experiencing a past trauma as if it were happening in the present. Current therapies for traumatic stress involve enabling the person to access the distressing recollections, while simultaneously bringing these into contact with present reality (e.g. Foa and Kozak 1985). Indeed, Breuer and Freud describe how their patient’s symptoms

immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which they were provoked and in arousing their accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words.

(Breuer and Freud 1893–5: 6)

Similarly, they describe, in a manner essentially identical to the formulations of contemporary cognitive-behavioural theorists, how traumatic memories retain their pathogenic potency because of cognitive-emotional avoidance, which prevents extinction of the anxiety:

It may be said that the ideas which have become pathological have persisted with such freshness and affective strength because they have been denied the normal wearing-away processes by means of abreaction and reproduction in states of uninhibited association.

(Breuer and Freud 1893–5: 11)

The pathogenic ideas are excluded from being ‘worn away’ by association with other ideas either because ‘the patient is determined to forget the distressing experiences and accordingly excludes them as far as possible from association’ (Freud’s theory of repression as a defence) or because ‘there is no extensive associative connection between the normal state of consciousness and the pathological ones in which the ideas made their appearance.’ (Breuer’s theory of hypnoid states) (Breuer and Freud 1893–5: 11).

Breuer and Freud agree with their contemporaries, Binet and Janet, that ‘what lies at the centre of hysteria is a splitting off of a portion of psychical activity’ – but Breuer notes that the phenomena those authors report ‘deserve to be described as a splitting not merely of psychical activity but of consciousness’ (Breuer and Freud 1893–5: 227, 229):

As we know, these observers have succeeded in getting into contact with their patients’ ‘subconsciousness’, with the portion of psychical activity of which the conscious waking ego knows nothing; and they have been able in some of their cases to demonstrate the presence of all the psychical functions, including self-consciousness, in that portion, since it has access to the memory of earlier psychical events. This half of a mind is therefore quite complete and conscious in itself. In our cases the part of the mind which is split off is ‘thrust into darkness’, as the Titans are imprisoned in the crater of Etna, and can shake the earth but can never emerge into the light of day. In Janet’s cases the division of the realm of the mind has been a total one.

(Breuer and Freud 1893–5: 229)

While the Studies on Hysteria is written jointly by Breuer and Freud, and each attempts to accommodate the views of the other, there are clear differences in emphasis between the two. Breuer places crucial importance on hypnoid states, the presence of distinctly different states of mind alternating with the ‘normal’ state, whereas Freud focuses on his notion of ‘defence’ and repression as a basis for the ‘strangulation of affect’ which leads to hysterical ‘conversion’ (of the affect into a somatic symptom).

Freud ’s Model of the Psychodynamic Mind

For Freud, ‘defence’ employed by the psychodynamic mind in a state of conflict is the basis of hysteria (and other conditions of mental pathology):

I have shown how, in the course of our therapeutic work, we have been led to the view that hysteria originates through the repression of an incompatible idea from a motive of defence. On this view, the repressed idea would persist as a memory trace that is weak (has little intensity), while the affect that is torn from it would be used for a somatic intervention. (That is, the excitation is ‘converted’.) It would seem, then, that the idea becomes the cause of morbid symptoms – that is to say, becomes pathogenic. A hysteria exhibiting this psychical mechanism may be given the name of ‘defence hysteria’.

(Breuer and Freud 1893–5: 285)

Freud saw the essence of the therapeutic task as simple – one of allowing the patient to talk of the troubling episode with an expression of the appropriate emotion:

the patient ...