Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation (Wiley Series in C

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Healing of the psychologically wounded individual is based on the congruent sequence of discourse, theory, model, technique, and application , where none of these can replace any of the others. Hence this paper begins with theoretical assumptions before addressing empirical material in the later sections. Several hypotheses are revived in the context of chronic developmental trauma, the very trajectory which constitutes a threat to psychological survival of the individual. This theory claims that this division has a protective aim; i.

But what is spirit? Spirit is the self. But what is the self? Description of the optimal trajectories of both selves throughout each phase of life remains an important task which exceeds the aims and limits of the present paper. Research shows that chronic relational traumas e. Due to their pervasive and enduring character, these syndromes were for most of the twentieth century considered by mainstream psychiatry, psychology, and psychoanalysis as disturbances of personality. To consider this theoretical stance, and to inquire into various aspects of such trauma-generated mental division of this kind, the paper reviews findings from a limited series of hypothesis-generating empirical studies which gathered data on lifelong consequences of childhood trauma in various clinical and non-clinical populations.

Such re-organization serves in buffering the traumatic breach in and between external reality and internal world. Although devoted to protection of the individual's unique psychological aspects i. In traumatic conditions, the barrier is suddenly and violently breached, overwhelming the nervous system with an influx of stimuli it cannot handle. Recent neurobiological research has documented the fact that traumatic stimuli trigger two types of reaction Lanius et al.

One is primarily avoidant , and constitutes emotional overmodulation based on excessive corticolimbic inhibition. This can lead to subjective disengagement from content of the traumatic memory. Stimulus modulation is an idea with diverse repercussions. From a physiological perspective, chronic overstimulation may lead to habituation or exhaustion. In contrast, denervation and other forms of stimulus deprivation cause an increase in the magnitude of subsequent responses a phenomenon commonly referred to as denervation supersensitivity.

Hence, stimulus modulation is essential for maintaining homeostasis and healthy adaptation; i. For instance, when confronted with an imminent life-threat for which flight-or-fight is no longer an option to counter danger, the organism may shift to immobility. In fact, intrusion and avoidance constitute a vicious cycle rather than totally independent phenomena. Suppressing thoughts can lead to an increase in behavior related to the formerly suppressed thought Erskine, ; Erskine and Georgiou, In a general population study, suicidality, substance abuse, dissociation, and problematic activities such as self-injury and dysfunctional sexual behaviors were all indicators of a robust latent variable; namely, dysfunctional avoidance Briere et al.

Avoidance and intrusions of traumatic mental content constitute the basic clinical components of PTSD. These usually co-occur on an individual basis as do the two types of response. Debate on the accuracy of these two stances is still ongoing. Alternatively, identity alterations observed in dissociative disorders may be considered an elaborated version of trauma-related mental intrusions and avoidance which correspond to the basic mechanism of PTSD. Namely, DID and PTSD may precede each other chrononologically or may be co-present depending on the status of the patient in the spectrum between avoidance or intrusion.

While acute trauma can induce peritraumatic dissociation, complex trauma leads to chronic dissociation more readily Ogawa et al. In a study on the general population, while childhood interpersonal complex trauma was related to altered self-capacities interpersonal conflicts, idealization-disillusionment, abandonment concerns, identity impairment, susceptibility of influence, affect disregulation, and tension reduction behaviors , non-interpersonal traumas and adult traumas were typically unrelated to the scales assessing these features Briere and Rickards, The main reason for this different effect is adaptation to trauma in the developmental years —a response of the whole organism—which has vital importance for the survival of the growing individual.

Bromberg , has proposed that dissociation could be considered as a proactive strategy used by children to protect themselves from developmentally traumatic interactions with caregivers that disrupt the sense of continuity in the self regardless of its natural multiplicity.

Hypothesis and Theory ARTICLE

A recent MRI study Mutluer et al. However, analyses within the PTSD group revealed a tendency of lateralization in findings showing significant negative correlations between clinical symptoms of Simple and Complex PTSD and volume changes of the right hemisphere subcortical structures. A significant positive correlation was shown between core dissociative phenomena depersonalization, derealization, and identity alteration which fit the dissociative subtype of PTSD or DID and left frontal cortical thickness.

These findings led the authors to support the idea that dissociation may be neuroprotective Ross et al. In the healthy group, the structures of right and left hemispheres were better correlated with each other. In support of the observations previously made by Farina et al.

Such disruption may lead to discontinuities in sense of self and agency which cause a disturbance of self-identity. Adaptive operations of the evolutionarily bestowed simple and complex psycho-biological action systems e. From a contrasting point of view, post-traumatic dissociation may disrupt both sensori-motor, and cognitive-emotional functions.

The so-called BASK behavior-affect-sensorium-knowledge model of dissociation underlines this separation of mental functions from each other Braun, In contrast to the BASK model, such parallel-distinction may have a vertical or horizontal character as valid for the organization of the nervous and mental system in general Echarte, The horizontal dissociation points to the altered relationship between higher and lower order brain structures, changing the status of the hiearchical control.

Vertical dissociation, however, points to the networks covering all levels of complexity in hierarchy; i. As well as compartmentalization, dissociation may also lead to detachment. Examples of symptoms of detachment are: Identity confusion, on the other hand, is a symptom that can be associated with either detachment or compartmentalization Brown, Recognition of detachment and compartmentalization as distinct types of dissociation has implications for treatment as well.

Namely, recent evidence suggests that cognitive behavior therapy, which utilizes an adapted anxiety-disorder model, is an effective treatment for pathological detachment Hunter et al. Other forms of treatment may be more appropriate for pathological compartmentalization Holmes et al. Narrowing or alteration of consciousness may also be considered as types of dissociation. These are time-memory e. Childhood traumata can arguably be classified into two types is proposed: This suggestion is consistent with contemporary understanding of the bimodal nature of neurobiological response to traumatic stress, where overmodulation and undermodulation of emotions are operative Lanius et al.

Both dichotomies correspond to the bipolar clinical character of all trauma-related syndromes including PTSD: Four issues seem to prevent researchers from identifying the distinct impacts of omission and intrusion. First, the naturalistic co-presence of these patterns for a majority of studied populations deflects attention from their distinct cognitive-emotional and sensori-motor consequences. Second, the discrepancies in results of self-report and clinician-administered assessment raise questions about the reliability of these tools.

The latter possibility would be consistent with the very nature of dissociation as an interpersonal experience sensitive to betrayal, attachment, and perception. Third, different tracks of post-traumatic processing may be pursued by sensori-motor and, alternatively, by cognitive-emotional dissociation.

Fourth, timing of childhood maltreatment Schalinski and Teicher, may account for considerable variance in psychological consequences. Therefore, distinct post-traumatic phenomena should be assessed and handled separately even if they occur concurrently. The partial phenomenological overlap between borderline personality disorder BPD and dissociative disorders -which both have a trauma-related origin- has been well-documented by empirical research Korzekwa et al.

Although some authors consider BPD a dissociative disorder Meares, , and others take an opposite stance by regarding dissociative disorders in the realm of BPD Lauer et al. The question arises whether such overlap is also related to co-existence of different types of developmental trauma.

Dissociative disorders, on the other hand, were predicted by childhood emotional neglect EN and denial minimization of trauma including idealization of parents of childhood adversities. Apparently, BPD was related to the intrusion both bodily and psychological and bodily omission whereas dissociative disorders were related to the psychological omission only. The two clinical response patterns did not markedly interact according to any childhood trauma measure.

Although both syndromes have their own important histories of conceptualization, the existing empirical data do not rule out the possibility that they represent two types of post-traumatic response. Apart from a potential personality disorder, a similar pattern can be observed at the more severe pole of the psychopathological spectrum. The first was characterized by childhood EA psychological trauma of intrusive type and predominantly had symptoms associated with DID and positive symptoms.

This group, who reported dissociation directly , had earlier age of onset and longer duration of the disorder. The latter group had more BPD criteria, somatic complaints, and general psychiatric comorbidity which represented dissociation indirectly. Among omission types of trauma, while PN was related to mean severity of the mood disorder episodes and psychotic features, EN was related to suicide attempts.

Hence, unlike the unipolar dissociative depression described below, omission type of trauma predicted the severity of the state. The childhood trauma total score was related to psychotic features, the number of lifetime comorbid psychiatric disorders and the number of courses of antidepressant drug treatment.

The latter was also associated with comorbid diagnosis of lifetime diagnosis of PTSD.

Unlike for the anticonvulsant treatment group, lithium non-responders were more common among patients with lifetime diagnosis of PTSD. Apparently, nosological fragmentation increased general psychiatric comorbidity is one of the outcomes of developmental traumatization which is facilitated by total severity of childhood abuse and neglect in bipolar disorder and bodily type of childhood adversity inschizophrenia. This phenomenon requires further addressing via epigenetical research. While reported observations on patients with schizophrenia replicated findings on the relationship between EN omission and dissociation in non-clinical populations Ogawa et al.

While bodily intrusion may lead more readily to indirect symptoms of dissociation, emotional intrusion, however, seems to be related to positive symptoms e. While dissociative depression was related to a combination of omission and bodily intrusion of sexual type, PA bodily intrusion of non-sexual type added sensori-motor dissociation to this condition possibly due to unassimilated sensori-motor reactions; i.

The diagnosis of lifetime depressive disorder a trait measure was predicted by sensori-motor dissociation whereas cognitive-emotional dissociation was related to current severity of depression a state measure. The former track was associated with childhood neglect while the latter was related to abuse. While similarly leading to depression as the final common pathway, the consequences of childhood neglect omission and abuse intrusion were associated with distinct trajectories. The question arises whether the relationship between childhood adversity and its consequences follow a different track among patients with a somatic illness.

However, the special relationship between childhood neglect and body perception was reported in a non-clinical college population as well: I know that, in the weeks following the birth, I asked myself a lot of questions about it. I felt betrayed by my body. I felt like my body was a part of me that I can't control. I thought that if my body did this to me, and hid all these things from me, I could not be certain about anything that I felt, or anything that I thought about me.

The main feeling that I had, was to not trust myself anymore. Kierkegaard, while inquiring mind-body relationships, was inspiring about the potential protective nature of mental division and dissociative depression.

Man does not think with his soul, as the Philosopher imagined. He thinks as a consequence of the fact that a structure, that of language—the word implies it—a structure carves up his body, a structure that has nothing to do with anatomy. This shearing happens to the soul through the obsessional symptom: Thought is in disharmony with the soul. Nevertheless, one has to be careful in interpreting Lacan's usage of the word unconscious which he anchores in external reality: Indeed, trauma explicitely disrupts the capacity to develop consistent narratives of experiences Van der Hart et al.

According to the multiple code theory of emotional processing, inhibition of a transition from the subsymbolic patterns of sensory and visceral sensations and motoric activity associated with states of emotional arousal to the symbolic images and words level of thinking Bucci, which hinders the integration between emotion and cognition. This is shown in his Clinical Diaries Kirschner, Lacan's approach to trauma as the presence of the effect of unsymbolized real physical experiences seems to be in accordance with Ferenczi's notion of the unprocessed foreign body in the psyche Garon, cited by Kirschner, This is the point at which therapist and patient meet each other.

Dissociation is not only an intrapsychic and psychosomatic embodied but also an interpersonal phenomenon Liotti, The latter contributes to the dynamism of dissociation in terms of the contextual factors affecting the condition of the individual. Hence both Liotti and Barach have underlined the role of interpersonal attachment disturbances in DID.

Additionally, early defenses against attachment-related dissociation may lead to interpersonal controlling strategies that further inhibit the attachment system. Dissociative symptoms emerge as a consequence of the breakdown of these defensive strategies when exposed to events that activate the attachment system. In the view of Liotti , it was Bowlby who first hinted at the relationship between attachment processes and dissociation. Namely, Bowlby proposed that inadequate care-seeking interactions with primary caregivers could lead the infant to develop multiple internal representations of self and attachment figures which he called Internal Working Models; IWM.

One IWM becomes dominant in regulating interpersonal relationships in a certain context, while the other IWMs remain separated from mainstream conscious experience. The latter surface in stressful situations to regulate emotions and cognitions in a way that may be perceived as alien to the person's usual sense of self.

In addition, sense of agency is influenced by this alteration. Liotti suggests that the shifts among the multiple IWMs correspond to the drama triangle elaborated by Karpman ; i. The link between attachment theory and the drama triangle is represented in the model of attachment to the perpetrator Ross, which allows the victim to achieve a subjective sense of control in the abusive condition.

Hence, according to Liotti , psychotherapy for pathological dissociation should be a phase-oriented process focused primarily on achieving attachment security, and should only secondarily deal with trauma. Disavowal of the attachment to the perpetrator, however, may require some type of trauma work.

Although the therapist would try to act as a secure base to improve alliance and symptom control Cronin et al. Before treating trauma, the theapist cannot know what the client may perceive as sufficiently safe Bromberg, This may limit their potential to trust in themselves and to improve the quality of their relationship including the relationship with the therapist. Hence, if developmental trauma is not processed; i. The aspect of self desribed by this term is prone to fragmentation due to the conflictual demands of the external world.

Multiple Selves, Multiple Voices: Working With Trauma, Violation, And Dissociation

Projective identification serves as a regulator of interpersonal distance e. In fact, projective identification is based on interpersonal dissociation where the subject of emotions, thoughts, and behavior becomes contentious Howell, The capacity of fusion may turn to a threat to individual autonomy in certain conditions, leading to loss of boundaries. Individuals who become members of a cult or terrorist organization e. They are perceived as external entities controlling the person.

Creating a cultural equivalent of the dissociative subtype of PTSD, they seem to be a way of coping with environmental threat. The concept of trauma refers to a stressor located in the external world. The traumatized psyche becomes self-traumatizing Kalsched, , p. Hence, the healing process has to be navigated from within. Neurosis is self division. Such relationships are also trasferred to the external world. However, internal phobias trigger distance to the content of the internal worldin the subject, rendering the dissociative amnesia noticable to the observer e.

In purely descriptive screening studies, the most frequently seen personality disorders in DID are borderline, paranoid, compulsive, avoidant, and dependent types Ellason et al. This somewhat contradictory combination of traits which carry components of all three DSM-5 personality disorder clusters i. This dilemma has been proposed to describe the immense need of the autistic schizophrenic individual for interpersonal contact but also the simultaneous anxiety and feeling of being threatened by close and intimate relationships Burnham et al. Hence, threats against a sense of security and control may also originate from the internal world of the patients.

Such experiences may constitute a chronic source of anxiety, and lead to diverse symptoms accompanying the strivings of the individual to ameliorate this fear. Howell conceptualized pathological narcissism as a trauma-related condition and the interpersonal aspect of dissociation. The presence of overblown self-object representations in the internal world may be a consequence of non-availability of appropriate relationships in the external world.

This corresponds to childhood neglect. This problem is also valid in the opposite direction; i. It can not be solved without an intervention from the external world ; i. This work is the essence of the treatment of the post-traumatic self. A recent survey documented that experienced therapists reported that some type of boundary modification occurred in their treatment of post-traumatic conditions Sachs, Careful assessment of the dynamics of such modifications requires the highest level of skill in psychotherapeutic practice.

In fact, dissociative disorders indeed have sociocognitive origins as do several psychiatric disorders and psychological trauma itself. The influence of the observer on the subject to be assessed is recognized even in exact sciences such as physics and computer programming. This cannot be expected to be different in clinical psychology and psychiatry, which work on subjectivities as well as objectivities. One may also have different experiences about oneself when alone or in the presence of others.

Discrepancies in self-report and clinician assessment have been reported for BPD Edell et al. Compared to dissociative disorders, BPD was related to an awareness of dissociative amnesia, depersonalization, and identity alteration in self-report more readily than the clinical interview. Hiddenness of the selected dissociative symptoms in BPD during clinical interview may be interpreted in two ways; i. Such fluctuations in assessment may pertain to the self-system of the individual with a dissociative disorder with or without BPD.

This may involve hidden influences of non-executive personality states, or which may cause covert switching of distinct mental states during assessment contingent on perceptual alterations to traumatic memories Beere, a , b. Beere b has demonstrated that as the dissociative psychopathology entered the DID range the most severe end of the dissociation spectrum , reports of amnesia appeared to decrease although it is known clinically that there is more amnesia among those manifesting DID than manifested in this particular subgroup.

The presence of an interviewer clearly represents a situation that is the model setting of interpersonal attachment, which has a crucial importance for the studied population Liotti, Apparently, the presence of a clinician interpersonal situation or aloneness during assessment may have distinct effects on the mental status of the evaluated subject. If so, what is the relationship between this effect and the two diagnostic patterns? This is a measure of capacity to discriminate the mental state of others from expressions in the eye region of the face Fertuck et al. Antidepressant medication status, PTSD co-occurrence, current vs.

This would lead to a preponderance of memory continuity in the self-system during a clinical interview, e. They also had smaller left anterior cingulate while right anterior cingulate was larger in coitus group i. Both these psychological and neurobiological phenomena may point to a possible strivings of the organism to manage the psychological pain e. Psychological trauma represents a breaking point in human life characterized by a drastic change in reality which requires the re-adaptation of the affected individual to the emerging condition.

Interpersonal developmental trauma occurs in context of distortion of reality by the perpetrator; i. According to pioneering trauma clinician and researcher Janet, mental health is characterized by a high capacity for integration which unites a broad range of psychological phenomena within one personality Van der Kolk and Van der Hart, Traumatic stress jeopardizes these abilities, thereby leading to dissociation with diminished awareness, comprehension, and self-control. In both normal and abnormal functioning, reflexive self-awareness is crucial but can be disturbed by the tension that arises from coordinating subjective and objective perspectives about oneself.

Paradoxically, he considers dissociation primarily as the means through which the individual maintains personal continuity, coherence, and integrity of the sense of self in front of the unbearable reality. Dissociation allows the existence of several different subjective versions of reality within one person.

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An intriguing aspect of such trance-logic that has important behavioral consequences is related to variations in the belief that dissociative identities are separate. This may even lead to a completed suicide due to failure to comprehend that both parts belong to the same person. From an external vantage point, this would look like a delusion of persecution unless the dissociative identities involved are identified as the source of the experience.

The American Psychiatric Glossary defines reality testing as the ability to evaluate the external world objectively and to differentiate adequately between it and the internal world Stone, Impaired reality testing is one of the major hallmarks of psychosis. Reality testing is intact in patients with dissociative disorders except during dissociative psychotic episodes where the latter may constitute crisis states superimposed on the ongoing dissociative pathology or those conditions when the patient's belief on the separateness of personality states takes a delusional scope.

Loss of insight due to chronic or acute dissociation can also have forensic implications in criminal cases McFarlane, Concerns about security and control may lead to a crisis for dissociative patients which may interrupt their daily functioning including transient impairment of reality testing. Two syndromes may dominate the frontline clinical picture of a patient with DID in this regard: The two conditions represent the most dramatic versions of sensori-motor and cognitive-emotional dissociation.

Both may co-occur and, even, may be superimposed on DID Nijenhuis et al. They are frightening for the affected patients as well as for their close social network. Many patients with DID are admitted to psychiatric services subsequent to treatment-resistant and dramatic conversion symptoms including non-epileptic seizures Tezcan et al. Severe acute dissociative reactions with psychotic features have been known as hysterical or as reactive dissociative psychosis Van der Hart et al. Such crises may also occur in context of power struggle or a threat to attachment. Regaining a sense of security and control requires at least a temporary balance between them usually obtained by interventions in both spheres.

Interaction between internal and external worlds occurs in the context of the cultural environment. The concurrent diagnosis of BPD dropped as well. These findings contradict the reports on North American dissociative patients who appear to have a predominantly internally focused coping style Armstrong and Loewenstein, The change in Rorschach responses of this patient is in accordance with impaired impulsiveness after treatment.

Namely, Turkish patients reported intense anger and lack of control of this emotion, chronic feelings of emptiness and boredom, efforts to avoid abandonment, and intense but unstable relationships more frequently than Dutch patients. In turn, Dutch patients reported frequent mood swings, physically self-damaging acts, identity confusion, and impulsive and unpredictable behavior more frequently than Turkish patients.

Some type of affect dysregulation was common to both groups Chefetz, The dichotomy of internal and external phobias seems to be operative here. These differences in predominant post-traumatic response types may be related not only to cultural factors affecting symptom presentation e. Awareness about the traumatic nature of life experiences may be affected by the cultural environment. This is apparent in a study of women with somatization disorder living in a semi-rural region of of eastern Turkey Taycan et al.

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Participants in this study had been exposed to every type of trauma endemically but had limited awareness of the nature of their environment. As well as functional somatic complaints, possession i. This is known to be relatively common in Turkey, including among the well-educated middle and middle-upper class. However, the dissociative group had more comorbid separation anxiety disorder compared to controls possibly due to attachment disturbances. The instrument used to assess childhood trauma did not cover overprotection—overcontrol by parents.

In fact, this self-compensatory behavior of traumatized parents leads to intergenerational transition of trauma. This style not only threatens interpersonal boundaries and private individual spheres, but is overwhelming for the rising generation due to implied control by feelings of guilt Kogan, Both the experience and expression of traumatic stress may be influenced by sex and gender. The latter is heavily shaped by culture.

A recent study documented examples of these differences as observed in variability of reaction types of traumatic stress among male and female Yazidi refugees with PTSD in Turkey Tekin et al. Both genders had been exposed to war-related trauma. Women reported flashbacks, hypervigilance, and intense psychological distress due to reminders of trauma undermodulation of emotions more frequently than men.

On the other hand, men reported feelings of detachment or estrangement from others overmodulation of emotions more frequently than women. More depressive women than men reported feelings of guilt or worthlessness. It is not yet known whether such differences between women and men are based on gender socio-culturally formed roles or sex biologically formed differences.

Working with Trauma, Violation and Dissociation

The shape and functions of crisis episodes superimposed on a trauma-process constitute a further culture-sensitive sphere. Both the prevalence of non-epileptic seizures as well as acute dissociative reactions with psychotic symptoms seem to differ widely in different parts of the world. The book draws upon the exciting and illuminating understanding of trauma and dissociation that has developed within the last decade and shows how this can transform our view of many severe personality disorders.

MPD is presented as a disorder based upon trauma and pretence - a pretence which structures the personality. The author explores the implications of working with The book draws upon the exciting and illuminating understanding of trauma and dissociation that has developed within the last decade and shows how this can transform our view of many severe personality disorders.

The author explores the implications of working with personalities structured around trauma and pretence. The many complex and bewildering aspects of the therapeutic process are discussed. Hardcover , pages.

Published June 19th by Wiley first published May 8th Working with Trauma, Violation and Dissociation. To see what your friends thought of this book, please sign up. To ask other readers questions about Multiple Selves, Multiple Voices , please sign up. Be the first to ask a question about Multiple Selves, Multiple Voices. Lists with This Book. Jan 28, Halo rated it it was amazing.

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