I don’t know where to start with this important, exhaustive description of theory, etiology, description, and treatment of dissociative phenomena. I liked this book a lot. I was frequently frustrated in my reading. Only two other people attended the book group. Neither had finished the book. They found it interesting, and slow going. They had the same issues with the language that I did. One was skimming, one plodding through. I told them both not to miss the treatment chapters, in Part 3. I hope they get that far.
The Haunted Self: Structural Dissociation & the Treatment of Chronic Traumatization by van der Hart, Nijenhuis, and Steele (Norton, 2006) explains every part of every dissociative phenomenom through the lens of Pierre Janet’s theories. As I’ve been in practice for 26 years, and knowingly working with DID for 20, and have had great training and consultation from David Calof and others, there were few descriptions that I didn’t recognize. However, van der Hart, et al., gave names to things that I’d seen and not had words for or gave good and cogent explanations for terms I already knew. For instance:
Parallel dissociation (p.66) when parts (Emotional parts/EPs) "simultaneously experience the same moment of a traumatizing event, but may contain different aspects of it."
Sequential dissociation (p.67) when different EPs experience different temporal pieces of the same event.
Emancipation (p. 76) the degree to which a part develops more separation and autonomy from other parts of the personality.
Elaboration (p. 76) "the degree to which a dissociative part develops complexity and scope of the ‘ideals and function that constitute personality over time’ "(Janet)
Retraction of the field of consciousness (p.102) "The quantity of stimuli that held in conscious awareness at a given time . . . (ranging) from very wide to retracted, so the individual can be aware of a lot . . . or a little." In other words, when a "fight" EP is up, everything looks like an opponent. During a flashback, everything feels like a bad moment of the past. As an ANP (apparently normal part), there might be understanding and awareness of now and of an experience of back then, a broader field of consciousness.
Personification (p. 153) "the capacity to take personal ownership of our experiences." As in, "this happened to me, I felt it, I did it.’
Presentification (p. 157) "that complex human endeavor of simultaneously being and acting in the momment in a higly reflective manner." "Being present." ". . . when we synthesize and personify current internal and external stimuli that are critical for our current interests and adapt our (thoughts/feelings) and actions accordingly." (I’m finding these last two words creeping into my consultation explainations when discussing many clients with Axis II, PTSD, and other dissociative symptoms.)
Haunted Self is in 3 sections: "Structural Dissociation of the Personality", "Chronic Traumatization and a Janetian Psychology of Action" and Treatment of Chronically Traumatized Patients. If you are new to the concepts and treatments of dissociation, you could read every word of this book. I did. If you have been treating dissociation and are already using good models, you may want to read the first section, skim the middle the chapter intros, summaries, and topic headings to see if you know it already. Then read every word of the brief third section and the epilogue.
The Treatment chapters are great. They are written more clearly and concretely. They leave almost nothing out. Some chapters contain wonderful lists of nearly every intervention that a therapist would do with a dissociated client or almost any client, for that matter. The authors follow Janet’s simple and intelligent treatment goals. Phase 1: Stabilize the client and reduce symptoms; Phase 2: Treat the traumatic memories; Phase 3: Personality integration and rehabilitation.
Chapter 11 has a wonderful list of assessment targets, tools, and how to extract the information without blowing your client out of the water. Aside from these targets and gentle methods of doing the assessment, the authors begin their helpful discussion of the "experience of the therapist" (p 223), which continues throughout most of the treatment chapters. Their discussion goes beyond countertransference to explain what can happen with both client and therapist in dealing with dissociation.
Chapter 12 "Promoting Adaptive Action" discusses treatment in terms of Mental Economy (p.240) " 1. increase income of mental and physical energy; 2. decrease or eliminate unnecessary expenditures of mental energy; 3. reduce and eliminate debts (of) incompleted actions–old feelings, hx, traumas, etc.–that drain mental energy; 4. manage available income (energy) wisely by an increase in mental efficiency (by) investing in more adaptive actions." On pages 253-4, Table 12.1 has a wonderful list of all the skills you want your client to have or develop. These include psychophysical regulation, affect-tolerance and regulation, abilities to symbolize experience, relate to others, accurately perceive reality, manage time, organize oneself and one’s environment, pay attention, and solve problems.
Chapter 13, "Overcoming the Phobia of Attachment and Attachment Loss with the Therapist" looks at how we help our clients attach to us, despite wretched attachment histories. It contains another great list, this one on "Interventions to Overcome the Phobia of Attachment" (p. 271) "Phobia" is an oft-used word in this book. It means avoidance. Of memories, emotions, attachment, loss of attachment, parts, being whole, and change.
Chapter 14, "Phase 1, Treatment and Beyond, Overcoming the Phobia of Trauma-Derived Mental Actions" discusses how to deal with fears and avoidance of "what we feel, think, wish, need, and sense." (p. 281). We need to perceive, own, and know that they’re internal and may not reflect external reality. Survivors who inhibit these "mental actions", "eliminate an essential source of information that could help them integrate and live their lives more effectively and with greater meaning." Treatment techniques include psychoeducation; use of symbolism; focusing on physical sensations to build affect/body tolerance; use of medication; helping the survivor regulate affect by breathing, and connecting relational and spatially. (p.290). This chapter contains a thorough list of interventions for "Overcoming the Phobia or Trauma-Derived Mental Actions" (fear/avoidance of affect, thoughts, images, wishes, etc.)that I wish I could copy for you all.
Chapter 15 is about "the development of internal empathy and more cooperation among parts of the personality, and more realization each part belongs to a single I." (p.301) It contains another comprehensive table of interventions.
Chapter 16 elucidates the treatment of traumatic memory, or Phase 2. It illuminates treatment for different kinds of trauma targets and then gives explains three kinds of Guided Synthesis during which the "therapist guides dissociative parts in a series of experiences win which dissociated aspects of the traumatic memory are evoked and shared. And exposure is conducted such that its intensity and duration are adapted to the survivor’s mental level." This includes "gathering all parts together, while the therapist facilitates a strong feeling of connection and empathy among them. . .Then connection with safe present and the therapist, and then a slow introduction for parts to remain together and in the present." It’s a lovely step-by-step instructions for synthesis and trauma processing, while holding the "dual attention" of past and present.
Chapter 17, Phase 3 treatment, is the "Integration of Personality and Overcoming the Phobias of Normal Life." It discusses integration of parts and overcoming resistance to the new experiences in boring, normal life: routines, monotony, grieving the past, taking healthy risks, becoming intimate, becoming healthily sexual, and functioning at the highest levels. It talks about the termination of long-term therapy.
As a consultant, I’m often asked, "how long will it take?" Nowhere in this book does it warn therapists that these phases, from the initial assessment to relationship building to creating function and tolerance to clearing trauma and then integration can take several years, in some secondary, and almost every tertiary dissociative clients. I think it ought.
EMDR is mentioned a few times. It’s recommended for simple PTSD and carefully in the trauma treatment stage. Joanne Twombly is cited (once from her chapter in EMDR Solutions–the first citation of my book I’ve actually seen) as is Denise Gelinas.
My advice. Read this book. Skim if you have to. Read every word of the treatment chapters. Swear at the language if you must. If you know it all, you’ll be validated and supported. If you didn’t know it, you’ll be glad that you do now. Then get a great consultant before you tackle tertiary dissociation.
I like looking at the personality disorders and PTSD as dissociative disorders. It makes them much easier to treat, when you can see the rigid "parts" in clients. Even mood disorders can contain parts. In the group, we discussed that ADD, could be extra-mobilized EP states, in some people. I love this model, and the treatment that arises from it. I still wish the book was easier to read.
I had some difficulty with these authors’ use of phrases like “higher mental energy” or “higher mental level,” “higher order actions,” and sometmes I believe “higher cognitive” this or that. After working with this language (on top of the many other wonderful but less dissimilar layers), I was able to extricate myself from associations I felt confident were irrelevant, but still the language seemed different from the more descriptive language taken from Janet, Myers, Bowlby and so on.
This language confused me in that it introduced independent elements into the whole trauma dynamic that seemed to confuse it at least for me and revert to “resilience” kind of implications.
This for me makes the whole “trauma” foundation of the whole volume wobble and threaten to revert to blaming the victim and praising the apparently UN-traumatized survivor, which some people’s use of the “resilience” concept can lead to.
The other layers seemed like a lot of work just because of the ambition and thoroughness of the theoretical synthesis undertaken, but the “higher” language seemed to involve me in speculation and hypothesis until I gradually felt I might have tracked down what they meant, though I remained a bit uneasy.
Perhaps none of this happened for you and this language, opaque or confusing for me, was something you took right in stride.
Ahah, now I check back into the review Roman Numeraled “I” of a few days earlier and see that you also struggled with the Janet language. I didn’t equate as you seem to have “action systems” with just behavior.
It seemed to me the concept or dynamic was more along the lines of a built-in pattern or tendency somewhat like “instinct” or what Jung calls “archetypes” (also an even more opaque term or concept).
But all these languages had issues partly coming from the effort to synthesize them all in one theoretical model and partly coming from the innate difficulty of understanding the phenomena implied and the concepts themselves.
The “higher” stuff seemed differently difficult to me. It confused me by introducing concepts I felt fairly confident were NOT intended, like high IQ or better patient or individual/worse patient or individual (i.e. person of stronger “self” or “superior” character). I wondered if the European authors were less Puritanical than I and the American literatures I am more accustomed to reading and able to use value terms like “higher” without experiencing judgments that disrupt diagnostic continuity and lucidity. I was glad the publishers had included photographs of the authors, who seem so benign and thorough, weaving together this account of what can be deeply harrowing material. It was just nice to SEE them.
Thank you for calling attention to this warm, riveting, sort of forest or mountain range of a book.
It seems almost more of a SET of volumes compressed into a single strenuous yet heartfelt book, a dissociation LIBRARY (which of course the massive and partly unavailable [e.g. most of the Janet] bibliography DOES comprise). I was not at all as able to take all the formidable synthesis in stride as you. It gave me a LOT to think about and a sense I would have to keep reading it over and over, and a sense I was going to learn a LOT that way.
I was especially grateful to have the opaque and impenetrable quality of the word and concept DISSOCIATION acknowledged and so heroically addressed.
Thanks again for your double review of it, and thanks to the authors for their long, hard, foundational work, here.
I didn’t like the language, but I’ve met van der Hart and seen videos of him working. He’s a dear. And he was very connected to the clients. I wonder how much of the problem was translation issues. I wonder if “higher” is different in Dutch. I love the ANP-EP breakdown. It makes perfect sense to me.
Thanks for writing!