Aquarone, R., 2004. Dissociation and Power: A Dialogue with Voices. Reformulation, Summer, pp.15-19.
There are those clients or patients throughout our career that challenge our comfortable, relatively predictable mode of therapeutic work. This applies whatever our therapeutic orientation.
It is such clients that wake us up to ‘not knowing’, to feeling uncomfortable and often lost.
At those crossroad moments we have a choice, often unconscious. Do we stick to our known practice, which could mean referring the person to someone else, or do we learn, possibly adapt, our own therapeutic approach.
I hope that this brief talk will stimulate this dialogue in your own work.
Dissociation occurs in both minor non pathological and major pathological forms. It is used to some degree by most people and is so much part of our lives that this poses particular problems for therapists (and clients) in defining the point at which they diverge. The extent to which dissociation is embedded in our culture and everyday life is an important concept to understand. Without that understanding, we cannot as therapists begin to untangle the complex pathological processes involved and be in a position to intervene effectively.
The very lives and culture we live in encourages us to use this particular mechanism. For example, we all to some extent dissociate from the full impact of the dramas that unfold around us in the world, and which are brought to our television screen, such as Iraq and September the 11th.
Without that ability to dissociate from the full intensity of the emotional impact we are subjected to, we would be in a state of despair and utter dejection. The Americans during the first Iraq war had the uncanny ability to use technical language such as bombing of collateral targets as a way of distancing themselves from the reality that they were butchering human beings. It would help to give examples of dissociation in our everyday lives.
Some of these may be connected with some degree of stress and trauma while others are certainly not connected. In other words there is a pleasurable and creative side to this phenomenon as well as a painful desperate side when used unconsciously as a defence and means of survival:
A high school teacher after trying to resuscitate a dying child in the playground, later spoke of mechanically giving mouth to mouth ventilation and chest compression, “…but another part of me was horrified and just wanted to run away. I did all that I was trained to do, but I felt cut off from him. None of it was real”. These are just a few examples of minor non pathological forms of dissociation.
Young children often have incredibly vivid and persistent daydreams linked with play. These often coincide with periods of intense night dreams and nightmares.
These figures can be very real to the young child, often incorporating aspects of the child’s own personality. ‘It wasn’t me it was Fred’ syndrome.
The intensity of fantasy in young children coupled with a tentative grasp of reality creates a world where fantasy can seem as “real” as reality. Here the child inhabits two worlds. The self in reality and the self in fantasy.
Transitional Objects as Self
A transitional object used by the child to represent “mother” is by the very nature of the child’s incomplete emergence as a separate being, a representation of him or her self. The child is born with identity fused with that of the parent. The transitional object can assume more and more of the child’s own personality characteristics as the child grows older and the symbiotic ties are broken.
I shall now describe symptoms that suggest a point on the cline which would indicate a distinct pathological state. The word temporary is now replaced with the term habitual. Repeated use of the dissociated state creates a situation in which the client feels detached for most, if not all, of the time.
A clinical example is that of a young woman who spoke of sometimes catching a glimpse of herself in the glass of shop windows when she went shopping or in a mirror. “I suddenly think I might exist in my body. If I can see it, it stops that floating feeling”. The perpetual nature of the dissociation as in the above example can also be linked to the next point on the cline, in which dissociation is manifest in totally inappropriate contexts. One could argue that we can all drift out of our bodies when engaged in a tedious shopping trip, and suddenly feel surprised when catching sight of ourselves in a window, but what of the young mother who “cannot play with my children”. This young woman desperately talked of wanting to be able to: “feel I’m involved when I’m giving them a cuddle and playing hide and seek with them but I just watch myself and envy her (reference to self) being able to be with them”.
In this example there is no precipitating stress factor or any mechanical factor which leads to a chronic dissociative state. It has become a habitual part of the client’s world; it is also present in totally inappropriate contexts, i.e. in this case in a loving relationship with her children. It could also be expressed for some clients as a split between the client’s inner world and the outer world.
Ross, a middle aged mother, first came into therapy at the onset of severe depression. Her outer life for most of her adult life bore no resemblance to her inner self. She functioned in the world as a chameleon and described her physical body as a “sack” to move her around.
“I expect this sack to do the job it’s meant to do, if it fails me I take it to my doctor and request him, as the expert, to put it right in the same way as my car gets serviced or repaired at a garage. I have no feelings for it other than irritation when it lets me down.”
This outer body knew, well enough, till the onset of depression, how to perform as a parent in various social situations. Ross’ performance was habitual, ubiquitous and shell like. She blended well in most situations, too well, to the point where she became virtually invisible. Yet in therapy it began to emerge that this invisible side bore no relation to the dissociated internal real “self”.
We have reached the point at which dissociation can now be said to be incorporated deeply and pathologically in the internal framework of the client. Significantly it has become a habitual response and manifests in all contexts.
Taken to an extreme point on the cline, it can also result in more than one distinct identity. It can result in DID (Dissociative Identity Disorder) formerly MPD.
Daydreaming begins to intrude into real life
The child finds it hard to complete tasks, and adults are constantly prompting the child to pay attention. Children forget what they have done, where they might have left something, what they out to do. Chronic daydreaming prevents normal functioning. In some cases this is confused with low IQ.
Imaginary friends take over from real friends
The child is actually isolated and friendless. They often refer to parts of themselves by name and can be observed talking to the “friends” or playing with them. The “friends” often play the role of companion/protector/forbidden types and adult carer. The child often refuses to play with real children and at home prefers to be alone.
In more severe cases the child has memory blanks. He or she cannot remember actions. They are often labelled as chronic liars. The memory blanks can be over mundane and trivial day life events as well as severe acting out.
Extreme Difference in Observed Behaviour
Teachers, parents, see an extremely different child at different times. These extreme mood swings are very disturbing to adults but not to the child. Adolescents do not fall into this category as within this age group it can be perfectly normal. Adolescents are also aware that this is happening and can become very upset by it.
Ability to Cut Off from Pain and an Awareness of Danger
The child doesn’t cry when hurt and takes extreme risks (putting him/herself in real danger). There seems to be little emotion present.
Dissociative Disorders Under DSM IV
The essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment. The disturbance may be sudden or gradual, transient or chronic. The following disorders are included in this section:
is characterised by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
is characterised by sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity.
Dissociative Identity Disorder (formerly Multiple Personality Disorder)
is characterised by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behaviour, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
is characterised by a persistent or recurrent feeling of being detached from one’s mental processes or body that is accompanied by intact reality testing.
Dissociative Disorder Not Otherwise Specified is included for coding disorders in which the predominant feature is a dissociative symptom, but that do not meet the criteria for any specific Dissociative Disorder.
Two Screening Instruments are used for assessing clients for levels of dissociative symptoms.
One: Dissociative Experience Scale (DES)
This is a 28 item self report instrument that can be completed in 10 minutes and scored in less than 5 minutes. It is easy to understand and the questions are framed in a normative way that does not stigmatise the respondent for positive responses.
Two: Somatoform Dissociation Questionnaire (SDQ-20)
Evaluates the severity of current somatoform dissociation
An audit was undertaken within a psychiatric hospital using the DES. We wanted to find out the number of patients with dissociative symptoms at a point in time on the acute admission unit and to correlate this with features that suggest that they may be inappropriately placed.
30.5% had significant high levels of dissociative symptoms;
5% were likely to have a dissociative disorder if further assessed using the SCID D (Structured Clinical Interview for Dissociative Disorders) This is in line with research results in other countries.
A Traumatised Part
(or alter) that wanted to tell her story and seek an attachment.
A Persecutory Part
(alter) that was partly the internalised abuser as well as the fury and murderous rage that was not possible to express outwardly at the time of the abuse.
A Protector Part
that doesn’t trust anyone and has an early built in template (through the dissociation) of keeping the status quo which means keeping the secrecy and making sure that no part of the system gets close to any human being.
The Presenter Part
(sometimes called the host) that deals with the outer world without much affect.
Themes in Therapy
I start from the standpoint that that Power is Power, whether abusive or helpful, whether passive or active. This applies both to us as therapists and to our clients. Internally, power will have had to be turned inwards and if necessary against herself or her body in order to keep the whole system safe and to deal with the outside world.
We have to negotiate with power and neither try to control it nor be intimidated by it. Again this applies to us as well as our clients.
Many of you will remember the years of Margaret Thatcher’s regime. It was a time of the cold war and a time when the world veered very close to possible annihilation.
Even Margaret Thatcher, in her dealings with Gorbachov (who controlled the Soviet Union) knew that she had to do business with him. Even she knew that they would have to find a common dialogue between them even though they represented diametrically opposite ends of the political and economic spectrum. There had to be respect for each others’ view point and power.
Importance of All Parts
All parts of a person need to be accepted and related to. Dissociative clients may well ask you to help them get rid of an unwelcome part (Jane referred to wanting to get rid of “those things going on in my head”). It is often easier for therapists to deal with the co-operative, pleasing part of a person but not the angry, verbally abusive or self harming side of them. Generally the angriest part of a person, once we find a way of relating to it, proves to be the greatest catalyst for positive change. That doesn’t mean that all parts have the same responsibilities.
[Issues of Dependency Versus Independence]
This is probably one of the most critical aspects of work with attachment issues and often misunderstood. This applies to both therapist and client.
In your role as therapist you are NEVER in an equal relationship. Just as in a family where the relationship between parent and child is never equal but, hopefully, enlightened and respectful.
The dissociative client has the family within themselves. He or she is both parent (to herself), and adult in an adult body, but also very childlike, easily led, naïve. Very often the dissociative client has parts (generally the traumatised part) that are regressed and may be age related to the abuse. These parts need to be listened to and allowed appropriate dependency on you as a therapist. Without that, there is no chance for them to experience Trust, Hope and Curiosity.
At the same time those parts do not carry decision making in the world outside. It is the adult parts of the system that need to take responsibility.
The balance as a therapist (and even more so within in-patient or psychiatric out-patient settings) is between encouraging a place for dependency and at the same time always returning the responsibility for decisions and safe actions back to the client. Clients can encourage either too much protection from therapists or angry rejection and negative verbal judgement from therapists, (especially within organisations, which I will turn to in a moment).
Lastly, Communication Between the Parts
This is facilitated if you, as the therapist, accept and talk or address the various parts or voices as directly as you can.
You become, as therapist, the container and acceptor of all the parts even if there is amnesia within the system. For a DID client, it is not enough to hear from the ‘presenter part’ about the voices inside and what they are saying. You have to, generally, by-pass the presenter and talk to those parts directly. As you know, there is a vast difference for us as individuals between talking about how angry we feel inside and hearing ourselves expressing anger!
Treatment, Power and Dialogue within Organisations
There are strong parallels between the work with individual clients at a micro level, and its mirroring within the Psychiatric System, in the UK at any rate.
Dissociation, when no longer needed as a survival defensive mechanism, can become an enslaving entanglement within the interior world of the client whose default position is the ‘entrapment and infantalisation’ of the individual’s capacity to be a self-regulating, independent and creative individual.
The very nature of a psychiatric system encourages infantalisation and a negative reliance on a power hierarchy that dictates rules, regulation and behaviour. This feeds into the client’s deep longing for parenting BUT also repeats a familiar pattern of dysfunction and abdication of self-worth and responsibility. This can apply equally to patients with general trauma backgrounds or issues of early attachment difficulties.
There are three components of this pattern:-
1. Loss of sense of self: Hospital/Prison: behaviour that leads to negative attention or compliant victim role.
2. Loss/Abdication of responsibility for decisions taken.
3. Antennae finely tuned to splits/discords within the system and can capitalise on this.
There follows a brief example of the situation that can so easily occur when dealing with highly dissociative patients.
Crisis leads to Hospital Admission
Diagnosis given which often can contradict early diagnosis (with patients suffering from a dissociative identity disorder or other dissociative disorder).
CPA team set up which can encourage splits in both the team and the patient.
In general circumstances changes are made, often unilaterally by individual professionals involved, according to the patient’s perceived behaviour and interpretation according to the professional involved. The patient will on the one hand quickly adapt to fit into the perceived role but then change behaviour according to the next professional or peer he or she is in contact with.
All of this can lead to:-
Them/Us culture by both patient and professional.
The patient can end up being discussed in either a derogatory or combative way.
Positive Family Model
A positive family model needs encouraging, where there is appropriate responsibility by the parental authority (the professionals) and the patient.
All discussions and decisions should be taken at CPA meetings with the patient present. Elicit the patient’s views respectfully … they know themselves at some level better than we do.
If things go wrong … ‘We have a problem’. The more the patient is brought into solutions, problems etc. the less likely acting out or self-harm over a period of time.
It is important not to become the equivalent of a child minder. The children are dumped to be picked up again at the end of admissions.
So right from the start we are encouraging the adult patient to take responsibility for the child within. It is a creative flow between dependency and independency.
With a strong CPA team in place, multi-agency involvement can be reduced (reduction in costs), and there can be positive moves to out-patient treatment (cost reduction). With a strong plan in place IN CASE of admission the diagnostic roller coaster is less likely to restart.
Without a sustainable holding environment from the professionals involved, no positive prognosis is possible for the clients involved. In fact we believe the holding environment is of equal importance to the therapy offered, irrespective of the model used.
© Remy Aquarone,
Pottergate Centre for Dissociation
26 Princes Street,
Norwich NR3 1AE
States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features
Ryle, A., 2007. States Characterisation Procedure (SCP) for supporting the reformulation of patients with borderline/dissociative features. Reformulation, Winter, pp.9-11.
The â€˜Human Givensâ€™ Fast Trauma and Phobia Cure
Jenaway, A., 2008. The â€˜Human Givensâ€™ Fast Trauma and Phobia Cure. Reformulation, Summer, pp.14-15.
Process Issues in Conducting CAT with Dissociative Identity Disorder
Kellett, S., 2004. Process Issues in Conducting CAT with Dissociative Identity Disorder. Reformulation, Autumn, pp.11-15.
Clarifying an ethical dilemma with CAT in work with children and adolescents
Marie-Anne Bernardy-Arbuz, 2013. Clarifying an ethical dilemma with CAT in work with children and adolescents. Reformulation, Summer, p.28,29,30,31.
Are there Limitations to the Dialogical Approach to Psychotherapy?
Pollard, R., 2004. Are there Limitations to the Dialogical Approach to Psychotherapy?. Reformulation, Summer, pp.8-14.
Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple
Ardern, M., 2004. Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple. Reformulation, Summer, pp.28-29.
Summary Report on ACAT Training and Trainer Development Conference
Bennett, D., 2004. Summary Report on ACAT Training and Trainer Development Conference. Reformulation, Summer, p.6.
The Procedure Tracking Form (PTF): A Possible New Tool for CAT
Kingerlee, R., 2004. The Procedure Tracking Form (PTF): A Possible New Tool for CAT. Reformulation, Summer, pp.25-27.
What Do Cognitive Approaches Have To Contribute To CAT?
Llewellyn, S. and Cooper, M., 2004. What Do Cognitive Approaches Have To Contribute To CAT?. Reformulation, Summer, pp.20-24.
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