Treating Dissociative Identity Disorder

The Power of the Collective Heart

Sarah Y. Krakauer

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135826475
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This is a book about the triumph of inner authority over the debilitating effects of trauma and abuse. In a simple and straightforward style, a three-phase model for treating dissociative identity disorder (previously known as multiple personality disorder) in introduced. The Collective Heart model is consistent with the current standards of care which emphasize caution and restraint. Additionally, the Collective Heart model has several unique features: It highlights the retrieval of personal authority rather than the retrieval of traumatic memories, identifies the fundamental inner unity underlying the fragmented personality system, and introduces techniques that facilitate communication between personalities and between each personality's conscious mind and the collective heart.

Six chapters of fascinating case vignettes illustrate therapeutic techniques and show how clients tap into their underlying inner unity to create the conditions for their own maturation, making it safe for their alters to grow, heal, and eventually join the host as a seamless, harmonious whole.

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CHAPTER

The Nature and Early History of Hypnosis and Dissociation

It is of course easier to reject en bloc a teaching that has incorporated errors than to undertake the difficult task of selecting the grain from the chaff, and, as Janet had to conclude, “hypnotism is dead … until the day it will revive.”

—H. F. Ellenberger, The Discovery of the Unconscious

In 1784, a member of the French aristocracy made a remarkable psychological discovery. Amand-Marie Jacques de Chastenet, Marquis de Puységur, who had been trained by Franz Anton Mesmer in the technique of animal magnetism, found that he was able to induce a “magnetic sleep” state in which the subject displayed enhanced insight and lucidity. Puységur reported that, in this state, his subject was able not only to diagnose his own medical and interpersonal problems and determine their etiology, but also to foresee the appropriate course of treatment and mobilize the resources necessary for successful implementation (Ellenberger, 1970).

This book introduces a treatment model for dissociative identity disorder (DID) that relies heavily on the human capacity discovered by Puységur. In illustrating the Collective Heart treatment model, I use case material from several dissociative cases to demonstrate that Puységur was right, at least for individuals with DID, who can learn to enter an altered state of consciousness with ease. Without the use of heterohypnosis, I have been able to facilitate in dissociative clients the enhanced insight and lucidity, the capacity to direct and pace their own treatment, that Puységur achieved via his “magnetic sleep” induction.

This chapter addresses the nature of dissociation and reviews historical developments bearing on dissociation and hypnosis. The following chapter summarizes major 20th century developments in traumatology and the treatment of dissociative states, discusses the nature of memory, and highlights the delayed memory debate and its impact on clinical practice. Together, these two chapters provide an historical overview to contextualize the Collective Heart treatment model.

The Nature of Dissociation

The psychological term “dissociation” refers to the disconnection or lack of integration between the normally integrated functions of memory, identity, or consciousness (American Psychiatric Association, 1994). The concept of a dissociative continuum has been used to describe responses ranging from nonpathological dissociation—reflected in such experiences as daydreaming—to pathological dissociation, with DID (formerly known as multiple personality disorder, or MPD) as the endpoint of the continuum. However, as Courtois (1999) argued, the construct of the dissociative continuum may be of limited utility because pathological dissociation is not merely a more extreme manifestation of the tendency underlying normal dissociation. The important distinction is that normal dissociation doesn’t involve the inaccessibility of specific memories that characterizes pathological dissociation. Four characteristics distinguish pathological from normative dissociation: Only in pathological dissociation do we encounter loss of executive control, change in self-representation, amnestic barriers, and loss of ownership over behavior (Kluft, 1993b).

The capacity to dissociate is normally distributed in the population. Traumatized individuals may utilize whatever dissociative ability they possess to defend against otherwise unbearable experiences. DID, the most severe manifestation of dissociative pathology, is a complex posttraumatic condition that can develop when a highly dissociative child is traumatized, most commonly before the age of 5 (Loewenstein, 1994), and almost always by 9 or 10. The greater the severity, chronicity, and emotional complexity of the trauma, the more complex the DID condition tends to be. These two factors, the innate capacity to dissociate and the experience of childhood trauma, are the two fundamental etiological factors in DID. An ancillary factor has been suggested: the absence of supportive responses within the social environment that might help the child process traumatic experience and thereby serve a mitigating function. While this is true in the vast majority of cases, I have treated one DID client whose nurturing caretakers would almost certainly have assisted the child had the trauma been detected.

Subsequent chapters will convey the phenomenology of DID to readers unfamiliar with the inner landscape characteristic of this disorder. However, before the history of hypnosis and dissociation is summarized, a brief description of the core features is provided for purposes of introduction. “Dissociation can be conceptualized,” wrote Loewenstein (1994), “as a basic part of the psychobiology of the human trauma response. In dissociation, there is thought to be a protective activation of altered states of consciousness as a reaction to overwhelming psychological trauma” (p. 3). Highly dissociative individuals are able to “leave the body,” effectively disconnecting the “observing self” from the “experiencing self” (van der Kolk, 1996, p. 192).

DID originates when the child dissociates, using this innate capacity to distance or remove herself psychologically in order to avoid experiencing otherwise unbearable trauma. Another personality is created to endure the experience and hold the memory, thereby sparing the original personality, or host, the knowledge of what has occurred. This additional or alternate personality, commonly known as an alter, continues to function as a distinct compartment within the individual’s collective mind, actively seeking to protect the host from repeated trauma and to avoid disclosure of the forbidden knowledge to the host. Should additional trauma occur, and should the alter be unable to endure it herself, additional personalities may be created in order to take over for the overwhelmed alter. The host and alters are referred to collectively as the personality system. As pointed out by van der Kolk, van der Hart, and Marmar (1996), dissociation in response to early traumatization increases the likelihood that a child will continue to rely on dissociation when stressed and decreases the likelihood that alternative coping strategies will be developed. The poorly developed nondissociative coping strategies, in combination with dysfunctional learning and the search for mastery and meaning, may explain the likelihood of revictimization in survivors of childhood abuse (Sandberg, Lynn, & Green, 1994).

Occasionally alters are formed in a nontraumatic context. For example, they may be created to perform a specialized function, such as numbing the host emotionally or helping the host cope with academic or occupational demands. In the event of abuse (in contrast with naturally occurring trauma such as accidents, fires, earthquakes, and the like), alters may also be created to ensure that secrets are guarded from those outside the personality system, such as family members, teachers, neighbors, and so forth. These alters, who may have internalized threats made by perpetrators regarding the consequences of disclosure, often use quite intimidating methods to ensure that the abuse is not reported.

A personality system can be large or small, but regardless of size, certain types of alters are typically present in DID clients. Kluft (1984b), Coons, Bowman, and Milstein (1988), Ross, Norton, and Wozney (1989), and Putnam (1989) all offer useful typologies. In my clinical experience, almost all DID clients have at least one child alter, and the more complex cases often have numerous child and adolescent alters. Child alters may be fearful, pleasing, helpful, and so forth. Also nearly universal in DID cases are angry alters, who have sometimes been labeled “persecutors.” These alters are best understood as fiercely protective, and they become tremendous assets in the therapeutic process once their fundamentally protective nature is affirmed and alternative means of safeguarding the system are discovered. Most DID clients also have at least one acting-out alter, who may engage in high-risk behaviors, such as sexual promiscuity, substance abuse, spending money recklessly, speeding while driving, gambling, and the like. In female clients, these alters may be highly flirtatious and provocative. Severely depressed alters are not uncommon. Frequently, there is at least one overtly nurturing alter. There is often an efficient, “take-charge” alter who excels at managing the task demands of daily life, but may not be skillful at handling affect. Internal self-helpers (ISHs) are discussed in Chapters 2 and 13. They are mentioned here because they are conceptualized as alters by many experts. Alters can be any age, including ages older than the host, and either gender. Putnam (1989) reported that “at least half of all MPD patients have cross-gender alter personalities” (p. 110). Male alters in female clients are common. Although in 1980, Coons noted that “only one case of a male multiple personality with a secondary female personality has been reported” (Coons, 1980, p. 331), within a decade it was reported that the majority of male MPD patients appeared to have female alters (Putnam, 1989). The sexual orientation of an alter can sometimes differ from that of the host. Alters can also differ in terms of race. I have treated three DID clients who had certain alters who were racially different from the host. Needless to say, when an alter emerges in the body, an observer sees him or her as having the age, race, and gender consistent with the body, despite the subtle or obvious changes in posture and demeanor determined by the alter’s personality type, role, and needs. The full range of internally-perceived physical characteristics of any alter, including age, gender, race, hair color, stature, body type, and so forth, is, of course, derived from a psychological representation of the alter.

What begins as a creative survival strategy for an otherwise completely vulnerable child becomes disruptive as the child experiences amnesia for the times when the alters assume executive control of the body, and becomes confused by evidence of activities carried on outside of awareness. Discrepancies between the child’s experience and responses of others in the environment, such as parental accusations that the child did things the child has no memory of having done, contribute to the child’s growing sense of personal deficiency or defectiveness. Some alters resent having to endure traumatic experiences, and they express considerable anger toward the host for not being adequately self-protective. The host’s experience of hearing voices inside the head offering advice or criticism or arguing with one another, combined with the increasing awareness that other people don’t seem to hear such voices, compounds the child’s sense that something is amiss. In addition, the alters experience flashbacks, which have been described as “brief dissociative episodes during which the trauma is reexperienced in sensorimotor form or as intrusive cognitive recollections” (Pope & Brown, 1996, p. 54). One first-person account of DID described flashbacks as “intrusions of recollection so violent and so vivid that the past nearly obliterates the present” (Phillips, 1995, p. 78). The alters’ flashbacks may infiltrate the host personality’s consciousness, terrifying the confused host, who is unable to determine whether the flashback material reflects actual experience or merely imagination. However, the symptoms of DID are most likely to motivate the individual to seek psychotherapy in adulthood, when discontinuities in memory, behavior, and sense of personal identity tend to preclude fulfillment of societal expectations and to result in suicidal behavior and other manifestations of severe psychopathology.

The History of Dissociation and Hypnosis

The Early History of Dissociation and Hypnosis

Long before dissociation was understood from a psychological perspective, cases of “demonic possession” were observed and reported. By carefully reexamining the documentation of these cases in the late 19th century when posttraumatic disorders were first understood psychologically, Désiré Bourneville, a colleague of Pierre Janet, was able to identify the essential clinical features of “doubling of the personality,” later renamed MPD and DID, in these cases of demonic possession (van der Hart, Lierens, & Goodwin, 1996). One such case that was reexamined by Bourneville is the intriguing case of Jeanne Fery, a 16th century Dominican Nun who had been treated for demonic possession via exorcism in 1584 and 1585. This case has been described in detail by van der Hart, Lierens, and Goodwin (1996) as “perhaps the earliest historical case in which DID can be diagnosed retrospectively with confidence” (p. 18) because the trauma history as well as all the core clinical manifestations of the disorder were documented meticulously.

Modern psychological theories of dissociation are best informed by a series of developments beginning in the last quarter of the 18th century. Ellenberger’s (1970) fascinating historical analysis, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry provided a thorough chronology of these developments. Ellenberger (1970) has traced the origins of dynamic psychiatry from 1775, when the Austrian physician Franz Anton Mesmer challenged the renowned German Exorcist Father Johann Joseph Gassner by introducing a secular treatment for the convulsions, seizures, and other symptoms that were previously understood to reflect possession states. Mesmer argued that these apparent possession states were actually caused by insufficiency, imbalanced distribution, or poor quality of a mysterious physical fluid that fills the universe, linking individuals to one another and to the earth and the heavenly bodies. He claimed that his technique of animal magnetism cured these states by redistributing the fluid in the afflicted individual through the action of his own plentiful and superior fluid, thereby eliciting “crises” and restoring health. Mesmer’s theory, by substituting a physical entity (the universal fluid) for a spiritual process (possession), was consistent with the Enlightenment Zeitgeist in which reason was valued over superstition and blind adherence to tradition. Despite Mesmer’s use of magnets and specially designed devices to facilitate treatment, he attributed his therapeutic success to his animal magnetism, the high concentration of the mysterious fluid within his body. Furthermore, Mesmer believed that all such therapeutic successes, including Gassner’s, were ultimately attributable to animal magnetism, no matter how they were conceptualized by the practitioner.

Mesmer moved to Paris, where he treated wealthy patients and trained students in the technique of magnetism. Among his disciples was the Marquis de Puységur, a member of one of the most illustrious families of the French aristocracy. Puységur modified Mesmer’s method, abandoning the notion that the crisis was caused by the redistribution of physical fluid, and attributing his therapeutic successes to the magnetizer’s will. (Despite the rejection of a physical entity as the active ingredient in the cure, the term “magnetizer” was retained.) Puységur, through the conception of the “magnetic sleep” state, became the father of “artificial somnambulism,” which was later called “hypnosis.” Thus we see that Mesmer, in treating what we would now generally classify as somatoform disorders, introduced the first secular treatment, and Puységur introduced the first truly psychological treatment. Although Mesmer’s name has entered our vocabulary (we find ourselves “mesmerized”) while Puységur’s has fallen into obscurity, Puységur’s contribution “equals or even exceeds the importance of Mesmer’s own work” (Ellenberger, 1970, p. 70).

Let us take a closer look at the nature of Puységur’s discovery, and then explore what Ellenberger and other historians of psychology emphasize as Puységur’s major contributions and the extent to which Puységur’s discovery may transcend these acknowledgments. One of Puységur’s first patients was a young peasant named Victor Race. In magnetizing Race, who presented with a mild respiratory disease, Puységur expected to observe the typical crisis that Mesmer encountered in his work, a crisis characterized by convulsions or other sudden, disordered movements. Instead, Puységur observed that Race fell into a strange sleep state in which he displayed greater lucidity than in his normal waking state. He spoke, responded to questioning, and was able to diagnose his disease, foresee its course of evolution, and articulate the appropriate treatment. Puységur called the distinctive crisis achieved during magnetic sleep “the perfect crisis.” He found that the patient was amnestic for the crisis following the magnetic sleep state. However, Puységur discovered that when magnetic sleep was once again induced in Race toward the end of his life, he recalled in extraordinary detail the crises he had experienced decades earlier (Ellenberger, 1970).

Interestingly, during a magnetic sleep state, Race was able to gain insight into interpersonal difficulties as well as medical problems. For example, during magnetic sleep Race once confided to Puységur that he was distressed about conflict with his sister. Puységur, having observed Race’s capacity for lucidity, suggested that Race look for a solution within himself. This intervention proved successful, and Race implemented the inner guidance he received and resolved the sibling tension. This extension of Puységur’s work into the interpersonal realm is especially significant because the psychological concerns we now consider commonplace weren’t articulated in his day. Ellenberger (1970) stated that Race “would never have dared talk about” (p. 72) the sibling conflict with anyone except during this remarkable state of magnetic sleep.

Puységur utilized his magnetic sleep techniques with a great many patients, always gratuitously, and received much acclaim. However, it was from his work with Victor Race that Puységur learned not only the technique but also the appropriate applications. After an attempt to use Race for a demonstration of magnetic sleep, Race became more symptomatic. Race was able to discover during magnetic sleep that magnetism should only be used therapeutically and not for purposes of experimentation and demonstration (Ellenberger, 1970).

Puységur founded a professional society in Strasbourg, the Société Harmonique des Amis Réunis, to train magnetizers, establish treatment centers, and document treatment accurately. Members, who numbered over 200 by 1789, agreed to provide treatment free of charge, meticulously record case material, and submit these records to the Société, which published annual reports. One can only imagine the wealth of data this Société would have generated had its activities not been disrupted by the French Revolution in 1789. When therapeutic activities resumed following the defeat of Napoleon, the new generation of magnetizers used Puységur’s method rather than Mesmer’s, while retaining the term “mesmerizing” to describe the induction of the lucid sleep state.

Despite his influence, Puységur’s contributions were forgotten after his death in 1825. It wasn’t until 1884 that Charles Richet rediscovered Puységur and w...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Foreword
• 1 The Nature and Early History of Hypnosis and Dissociation
• 2 Traumatology and the Treatment of Dissociative States: Major 20th Century Developments
• 3 Overview of the Collective Heart Model: Assumptions, Stages, Goals, and Techniques
• 4 Assessment of Dissociative Identity Disorder
• 5 Basic Therapeutic Techniques: Where to Go and How to Get There
• 6 The Nature of the Therapeutic Relationship
• 7 Seeking Guidance from the Inner Wisdom
• 8 Becoming a Team: Fostering Internal Communication and Cooperation
• 9 Inner Lessons in Self-Advocacy
• 10 Decreasing Anxiety to Remove Obstacles to Inner Guidance
• 11 Working Through Trauma: Sharing Memories and Internally Challenging the Authority of the Abuser
• 12 Together as One: The Postjoining Process
• 13 Current Status of the Collective Heart Treatment Model
• Appendix A: Preservation of Life Contract (Avoiding Self-Harm)
• Appendix B: Preservation of Life Contract (Avoiding Physical Harm to Others)
• References
• Index