International Society for Traumatic Stress Studies

Book Corner Review: “The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization”

Posted 1 December 2007 in StressPoints by Warwick Middleton, MB, BS, FRANZCP, MD

Review of:
“The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization”
Onno van der Hart, PhD, Ellert R.S. Nijenhuis, PhD, Kathy Steele, MN, CS
W.W.Norton & Company, New York, 2006.

Reviewed by: Warwick Middleton, MB, BS, FRANZCP, MD
Chairman, The Cannan Institute

Editor's Note: Onno van der Hart is a past president of ISTSS, and Kathy Steele is a former member of the ISTSS board of directors.

The authors of this extensively referenced and substantive work, four years in the making, give dissociation an over-arching centrality in conceptualizing and classifying the syndromes of chronic or severe traumatization. The work draws heavily on the writings of Pierre Janet (1859-1947), a pioneer in conceptualizing dissociation, the “subconscious actions of the hysteric” (Janet, 1907), and the spectrum of traumatic neuroses, as well as on the observations of Charles Samuel Myers, a British clinician who coined the term, “shell-shock” in respect of the condition of traumatized soldiers fighting on the Western front in World War I (Shepherd, 2000).

A Janetian psychology of action is synthesized with a theory of structural dissociation, which seeks to provide a comprehensive model for conceptualizing severely traumatized individuals as being positioned at various points on a continuum defined by an organization of human personality that is likely to split along “rather well-defined, evolutionary metaphorical ‘fault lines’ ” (p. 3). Janet is aptly quoted in his observation that traumas “produce their disintegrating effects in proportion to their intensity , duration and repetition” (p. 84).

The text is organized into three major sections, which will be reviewed in turn:


Outlining a theory of structural dissociation

For the severely traumatized, the authors argue that a lack of cohesion and integration of their personality is manifested in the alternation between, and coexistence of, the re-experiencing of traumatizing events as well as an avoidance of reminders of the traumas and a focus on functioning in daily life. It is this division between action systems associated with avoiding or escaping events and those associated with everyday functioning directed towards survival and well-being, which forms the basis for the authors’ development of a theory of structural dissociation. Bridging the observations of those who worked with the survivors of combat trauma and those who have worked with the survivors of prolonged childhood trauma (exemplified by the phenomenology of patients with dissociative disorders), a division of personality, as a consequence of such traumas, is outlined.

Dissociative parts of the personality are conceptualized as being the components of a whole, each of which are self-conscious, have a rudimentary sense of self, and are seen as being generally more complex than a single psychobiological state. For the severely traumatized individual, it is conceptualized that the dissociative response is the co-existence of, and switching between, one or more Apparently Normal Personalities (ANP) and one or more Emotional Personalities (EP). “Survivors as ANP are fixated in trying to go on with normal life, thus are directed by the action systems for daily life (e.g., exploration, care-taking, attachment), while avoiding traumatic memories. As EP, they are fixated in the action system (e.g., defense, sexuality) or sub-systems (e.g., hyper-vigilance, flight, fight) that were activated at the time of traumatization” (p. 5). As EP’s, survivors “are stuck in the traumatic experience where they relive rather than retell their terror” (p. 41). The most threatening parts of the original traumatic experiences are defined by the authors as pathogenic kernels. “Because of the vehement emotions associated with these pathogenic kernels, or even amnesia, trauma survivors may be very reluctant or unable to report them initially” (p. 43).     

The authors conceptualize structural dissociation encompassing a range from very simple to extremely complex divisions of the personality, with the simplest division being a single ANP and a single EP (primary structural dissociation). Where traumatizing events were increasingly overwhelming or prolonged, more complex adaptations evolve, including secondary structural dissociation in which a single ANP coexists with more than one EP, and, tertiary structural dissociation associated with division of the ANP in addition to divisions of EP.

In secondary structural dissociation the ANP is described as being by far the most extensive part of the personality i.e. “the major shareholder”, while in tertiary dissociation there is more than one part active in daily life e.g. some parts are focused only on work, some on parenting, others on sexual activity etc. On occasions an ANP may hear the voices of EP’s as a dissociated form of auditory hallucinations. A basic premise of the theory is that all trauma-related disorders involve “some degree of structural dissociation, with acute stress disorder and simple PTSD being the most basic, and dissociative identity disorder (DID) the most complex” (p. 7). Structural dissociation is seen as occurring when an individual’s mental efficiency and mental energy are too low to fully integrate what happened. It is observed that there is no quantitative principle in the current literature that distinguishes dissociative parts of the personality in DID from dissociative personality parts in other trauma-spectrum disorders such as post-traumatic stress disorder (PTSD).

Complicating the categorization, is the realistic observation by the authors that in low functioning DID patients, many ANPs and EPs may seem to be virtually indistinguishable from each other. This difficulty is addressed by the observation that “on closer scrutiny some dissociative parts — ‘ANP- biased’ — appear to be more orientated to functioning in daily life, while other parts — ‘EP – Biased’ — seem more oriented to defense” (p. 78-79).

Synthesis of a Janetian psychology of action with modern observations

Having outlined a theory of structural dissociation, categorized it, and examined the phenomenology of trauma-related disorders from its vantage point, the authors embark on outlining a Janetian psychology of action, which is synthesised with more modern observations on selfhood, memory, mentalization, learning, consciousness, cognitions self-organization, context evaluation, shame and mourning, etc. This leads to the third and largest section of the book which deals with assessment and stage-based treatment.

Assessment and stage-based treatment

On occasions theoretical points regarding treatment are given more immediate clinical relevance by useful illustrative clinical vignettes. Points made concerning therapy complement other modern texts focused on the treatment of complex psychological trauma/dissociative disorders, but no other modern texts gives such a complete synthesis of Janet’s psychology of action and none go as far in defining psychological trauma syndromes in forms of the sorts of dissociative splitting of personality that can be persuasively conceptualized as being influenced by developmental age, duration, type and extent of trauma, relationship to perpetrators etc. Given the manner in which a theoretical construct is developed to illuminate close similarities between conditions not always conceptualized that way, I am reminded of Janet’s book, “Major Symptoms of Hysteria,” (1907) based on fifteen lectures given in the Harvard Medical School in 1906, exactly 100 years before the publication of van der Hart, Nijehuis and Steele’s equally illuminating and thought-provoking synthesis.

Anyone who takes one of the parameters that have been used as one of the major axes in defining complex trauma and then reorients the rest of the landscape around the centrality of that chosen construct is inevitably going to give less prominence to issues or phenomena emphasized by other writers and it is likely that a certain degree of “rebranding” will occur as phenomena described by other names and associated with other constructs are subsumed, (in this case by an over-arching theory of structural dissociation). Thus, this book does not focus a great deal of attention on diverse but relevant issues such as boundaries, affective instability, somatization, or sexual transference/counter-transference issues in therapy.

An alternative, prominent conceptual model concerning complex psychological trauma, that of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) equated in the text with “Complex PTSD”, attracts limited discussion. Despite the oblique manner in which DESNOS is incorporated in DSM-IV-TR (APA, 2000; i.e., in the “associated descriptive features” of PTSD), it is not totally clear how the authors’ conclusion was arrived at: “We have proposed that complex PTSD involves secondary structural dissociation  a single ANP and two or more EPs … The presentation of these EPs tends to be more subtle in complex PTSD than in DID. In other words, these parts are usually not elaborated or emancipated” (p. 113). Van der Kolk et al. (2005) make the point that focussing on PTSD symptoms, relegates other post-traumatic sequelae to comorbidities. Dissociation/amnesia form part of the DESNOS items and unless such a patient is assessed in detail regarding their dissociation, it is hard to see how patients who would fulfill criteria for DID aren’t often described as having DESNOS/complex PTSD.

In their epilogue, the authors state their theory “needs further development and scientific scrutiny”, and that “controlled validation of the treatment based on the theory is yet to begin” (p. 355). Whilst this reader was in agreement with the very great majority of what was said about treatment, occasionally I was left to reflect on my struggles regarding particular patients where a hoped-for resolution was not seemingly as achievable as what was optimistically portrayed in this text, a case in point being the extreme attachment some very fragmented dissociative patients have to a chronic boundaryless perpetrator who is continuing regular sexual abuse into their adult life. “If the patient is currently being abused by the perpetrator, the therapist must support the patient in becoming safe. But this must be done without force, or a power struggle will likely ensue and the therapist will lose. Thus the therapist does not forbid the patient to have contact with his or her family, nor to confront perpetrators or even express anger in therapy prematurely. Instead, dissociative parts are encouraged to communicate their feelings and beliefs about the perpetrator to each other, and learn to be empathic with each other’s positions” (p. 320).

Conceptually ,I found that very many patients I have seen could be usefully positioned within the structural model of dissociation, but there were those whose fit was not as precise as others. How best to conceptualize a severely traumatized Vietnam Veteran, who over the years has repeatedly been triggered into self-harming/angry/suicidal emotional parts in the context of triggers or flashbacks, but who really has no apparently normal personality and lives a pervasively isolated, constricted and depressing life? In terms of the model of structural dissociation, I ponder also about how to best conceptualize identity states associated with DID in which an adult identity state encompasses sexual functioning, both at the level of finding some way in which to have a sexual relationship, but also incorporating forms of erroticisation conditioned by their original abuse? I have had the experience where the original “host state” in a patient with DID has disappeared (never to reappear) and where two of the emotional identity states that initially were particularly in evidence (against a background of other emotional identities) over an extended period of the time evolved to a cooperative duo that functioned more and more in the realm of ANPs.

Summary

In sum, this is a well-written, well-structured and thought-provoking book that challenges us to think very seriously about the multiple trauma derived states that we encounter so frequently in our patients. Further, the text reinforces and elaborates on the observations of others on the way in which severe trauma in a wide spectrum of individuals produces very predictable and congruent effects.


References

American Psychiatric Association (2000). "Diagnostic and Statistical Manual of Mental Disorders, 4th Edition – TR." Washington DC: American Psychiatric Press.

Janet M.D. (1907). "The Major Symptoms of Hysteria." New York: The Macmillan Company.

Shephard B. (2000). "War of Nerves." London: Jonathan Cape.

van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J. (2005). Disorders of Extreme Stress: the empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18:5, 389-399

 

November Book Corner

“The Book Corner” will feature 1) listings of new titles from ISTSS members; and 2) ISTSS member reviews of relevant new titles. To be considered a “new title,” books must have been published in the last 12 months.

Listings of new titles
ISTSS members who have written or edited a book in the last 12 months are invited to send titles and publication information to Matthew Lesh (mlesh@istss.org) for inclusion in "The Book Corner."

Member reviews of relevant new titles
Members are invited to submit reviews of relevant titles (published in the last year) for consideration for publication in StressPoints. Reviews should be approximately 500-700 words; please include all relevant publication information.

November Selection

Carll, E. K. (Ed.). (2007). "Trauma Psychology: Issues in Violence, Disaster, Health, and Illness, Two Volumes." Westport, CT: Praeger. (Volume 1: Violence and Disaster, Volume 2:  Health and Illness)

Previous Book Corner Selections

Cloitre, M., Cohen, L.R., & Koenen, K.C. (2006). "Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life." New York: Guilford Press. 

DePrince, A.P. & Cromer, L.D. (Eds.) (2006). "Exploring Dissociation: Definitions, Development, and Cognitive Correlates."  New York: Haworth Press.  Published simultaneously as a Special Issue of the Journal of Trauma and Dissociation and as a Haworth book.

Follette, V.M. & Ruzek, J.I. (Eds.) (2006). "Cognitive Behavioral Therapies for Trauma - Second Edition." New York: Guilford Press.

Friedman, M.J., Keane, T.M., & Resick, P.A. (Eds.) (2007). "Handbook of PTSD: Science and Practice." New York: Guilford Press. 

Greenwald, R. (2007). "EMDR within a Phase Model of Trauma-Informed Treatment." New York: Haworth Press.

Halpern, J. & Tramontin, M. (2007). "Disaster Mental Health: Theory and Practice." Belmont CA: Thomson Brooks/Cole.

Richard, D. & Lauterbach, D. (Eds.) (2006). "Handbook of Exposure Therapies." Academic Press.

Weine, S. (2006). "Testimony After Catastrophe: Narrating the Traumas of Political Violence." Evanston, Illinois: Northwestern University Press.

van der Hart, O., Nijenhuis, E. & Steele, K. (2006). "The Haunted Self: Structural Dissociation of the Personality and the Treatment of Chronic Traumatization." New York: W. W. Norton.