Introduction
The concept of dissociation was first noted in 1845 by Moreau de Tours (Dorahy & Van der Hart, Reference Dorahy, Van der Hart, Vermetten, Dorahy and Spiegel2007). Originally dissociation was associated with splits and divisions of consciousness with consciousness being used interchangeably with terms like ego, personality, mind and psyche (Van der Hart & Dorahy, Reference Van der Hart, Dorahy, Dell and O'Neil2009). During the 19th century a link was also established between trauma and dissociation but there are now radically different views on the nature of dissociation. The main conceptual issue that is subject to intense debate is whether dissociation refers to a division of the personality or that it is simply an alteration of consciousness such as narrowing of the field of consciousness and lowering of the field of consciousness.
Since the 19th century there have been a multitude of conceptualizations for dissociation. Van der Hart et al. (Reference Van der Hart, Van Echten, Van Son, Steele and Lensvelt-Mulders2008) reviewed 53 empirical studies on the relationship between peritraumatic dissociation and post-traumatic stress and were surprised to find that not one study attempted to offer a definition of dissociation. Nijenhuis & Van der Hart (in press) suggest a return to the 19th century definition of dissociation which involves a lack of integration of the personality, manifesting in the existence of two or more dissociative parts of the personality. In order to assess the validity of this assertion, it will be helpful to briefly summarize other models of dissociation, including cognitive behavioural explanations.
Kennerley (Reference Kennerley and Grey2009) adopts the idea that dissociation is currently an umbrella term that encompasses various altered states of consciousness and that some of these are associated with trauma. Kennerley (Reference Kennerley1996) suggests that the phenomenon of dissociation can range from daydreaming to the extreme state of dissociative identity disorder (DID), in other words a spectrum of dissociation. Last, Kennerley (Reference Kennerley and Grey2009) concludes that so far, there is no model for dissociation that is well defined; in other words dissociation as a concept remains ill-defined.
Kennedy (Reference Kennedy2004) developed a cognitive model of dissociation noting that there is no coherent and fully developed cognitive model of dissociation. The closest comparison was Young et al.'s (Reference Young, Klosko and Weishaar2003) construct of schema avoidance. He suggested that unbearable affect could be associated with a pathological schema and that the person then makes vigorous conscious and non-conscious behavioural and cognitive efforts to avoid experiencing the unwanted affect.
Kennedy (Reference Kennedy2004) developed her model from Beck's (Reference Beck and Salkvoskis1996) cognitive theory of personality. The central proposition of her model is that dissociation is a result of decoupling of mental processes, which can occur at different stages. Beck's (Reference Beck and Salkvoskis1996) theory asserted that a person's personality is constructed of modes and these modes are a set of schemas that are responsible for encoding cognitive, behavioural, affective and physiological information. Orienting schemas then encode internal and external events which then trigger, or activate these modes in response to context. Kennedy's (Reference Kennedy2004) model suggests dissociation is the product of inhibitory decoupling of mental processes at three stages. The first stage is early, automatic processing, whereas stages two and three take place within modes and between modes.
Last, Holmes et al. (Reference Holmes, Brown, Mansell, Fearon, Hunter, Frasquilho and Oakley2004) identified two qualitatively different phenomena, detachment and compartmentalization. Detachment incorporates depersonalization, derealization and other similar phenomena such as out-of-body experiences. In these cases the person experiences an altered state of consciousness that involves a sense of separation or detachment from various aspects of everyday experience. This can involve their bodies (out-of-body experiences), their sense of self (depersonalization) or the external world (derealization).
Compartmentalization is a process whereby there is a deficit in the ability to intentionally control processes or actions that would normally be liable to such control. In such cases the functions that cannot be controlled deliberately and the information associated with them is said to be compartmentalized. There is the added suggestion that compartmentalization (like detachment phenomena) can be organized on a continuum which is defined by severity and functional impairment. There is also some evidence from laboratory-based studies that aid these definitions of detachment and departmentalization, but there certainly needs to be more rigorous scientific research if this distinction is to be confirmed (Holmes et al. Reference Holmes, Brown, Mansell, Fearon, Hunter, Frasquilho and Oakley2004). Nijenhuis & Van der Hart (in press) agree with this distinction but assert that to include conceptually and empirically different phenomena under one generic label (dissociation) is confusing to say the least.
Summing up, the continuum model of dissociation has been the most widely used model since the 1980s, i.e. absorption at one end with DID at the other. However, this model is increasingly being rejected by various authors (e.g. Nijenhuis & De Boer, Reference Nijenhuis, De Boer, Dell and O'Neil2009) who suggest that many symptoms that are currently being included are not dissociative, i.e. lowering of consciousness. Furthermore, this model excludes symptoms that are dissociative, i.e. somatoform dissociative symptoms and two major symptom clusters of post-traumatic stress disorder (PTSD), i.e. numbing and intrusion (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006). DSM-IV (APA, 1994) describes dissociation as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment, which might be sudden, gradual, transient or chronic.
Method
The chosen method for this study is a critical literature review (Biggam, Reference Biggam2008). Reviews are important as they allow an understanding of key issues in specific fields (Hart, Reference Hart1998). The author aims to produce new insights by viewing the literature on the theory of structural dissociation of the personality (TSDP) in context and then synthesizing the findings (Aveyard, Reference Aveyard2007). TSDP to a large extent incorporates a phenomenological model of dissociation therefore personal experience is integral to understanding the subtle nuances of this theory. Ashworth (Reference Ashworth1987) narrates how human beings are actually intrinsically hermeneutic as interpretation is a regular aspect of all human activity. A quantitative approach to this study was deemed unsuitable as TSDP is a phenomenological individual experience that would be extremely difficult to measure empirically. Therefore the critical literature review, using a hermeneutic analysis within the constructivist paradigm was deemed the most appropriate way to analyse the text (McLeod, Reference McLeod2001).
Structural dissociation of the personality
TSDP is a relatively new theory of dissociation that synthesizes classical and contemporary theories of trauma and dissociation. Steele et al. (Reference Steele, Van der Hart and Nijenhuis2005) developed the theory because they believed that dissociation is the key concept to understanding trauma.
The theory suggests that there is a common psychobiological pathway for all trauma-related disorders and the key feature that separates this theory from others is structural dividedness. The theory originated from the work of Pierre Janet on hysteria and from the work of Charles Myers (Reference Myers1940) who described a basic type of structural dissociation in soldiers who had been traumatized in the First World War. The dissociation occurs when there is a division of the individual's personality into different prototypical parts, the so-called ‘apparently normal part of the personality’ (ANP) and the ‘emotional part of the personality’ (EP) (Van der Hart et al. Reference Van der Hart, Van, Van Son and Steele2000). The division of personality in trauma is an important distinction because once survivors have overcome this division, they have almost overcome their traumatization (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006).
As ANP, the person concentrates on trying to get on with normal life and therefore becomes involved in psychobiological action systems that direct daily life, i.e. caretaking, attachment and exploration, while intensely trying to avoid traumatic memories. These psychobiological action systems are innate and self-organizing. As EP, the person becomes fixated in the defensive action systems, i.e. defence, sexuality, hypervigilance, fight, flight, freeze, or total submission with severe hypoarousal, that were activated at the time the trauma took place (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006). Essentially, under the impact of chronic trauma these two types of psychobiological action systems (ones dedicated to daily life and ones dedicated to defence), become segregated and divided against each other (Howell, Reference Howell2005).
Structural dissociation has a wide range of presentations in that it can be very simple or extremely complex. The more complex structural dissociation is, the more deviation there will be from these prototypes, which are primary, secondary and tertiary dissociation. Primary structural dissociation is the most simple trauma-related division of the personality and when this occurs there is a single ANP and a single EP. The EP remains relatively unelaborated and does not have a wide degree of autonomy (Steele et al. Reference Steele, Van der Hart and Nijenhuis2005). An example of this would be simple PTSD or simple dissociative amnesia. In such cases ANP would present as being detached, numb and have partial or complete amnesia of the trauma, whereas EP re-experiences the trauma (Van der Hart et al. Reference Van der Hart, Nijenhuis, Steele and Brown2004). A clinical vignette illustrates primary structural dissociation and how survivors as ANP find it extremely hard to tolerate an EP.
Marie often compulsively rubbed her lips until they were raw and bleeding, which was incongruent with her meticulous efforts to look attractive. It became clear in therapy that this was a repetitive action by an EP that was trying to rub off red lipstick that she had been forced to wear by a perpetrator to make her look ‘sexy’. When this part of Marie could be introduced to present reality by the therapist, she wiped her lip with Kleenex and stared in wonder, ‘My lips are clean!’ From that moment forward, Marie no longer felt the compulsion to wipe her lips, and was able to fully integrate the EP that contained painful memories of sexual abuse. (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006, p. 55)
Secondary structural dissociation involves further division of EP, while there is still a single ANP. Examples include complex PTSD (Herman, Reference Herman1992), complex dissociative amnesia, complex forms of acute stress disorder, dissociative disorder not otherwise specified (DDNOS) and some personality disorders that are trauma induced, i.e. borderline personality disorder (Howell, Reference Howell2005).
Joyce, a client with complex PTSD, had this simple type of secondary structural dissociation. She had a single childlike EP who experienced abuse by her brother, and a single observing EP that ‘watched from the ceiling’ as she was being hurt, and an ANP that functioned well in daily life and was relatively amnesic for the abuse. (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006, p. 68)
Tertiary structural dissociation involves division of the ANP, in addition to a multitude of divisions of EP. Essentially, this is a formulation of DID. There may be many ANPs who perform different aspects of daily living and these ANPs may have a strong degree of elaboration, i.e. names, genders and preferences. Additionally they may also have a high measure of emancipation, which is a term used to describe actual or perceived separation and autonomy from other dissociative parts (Hart & Kritsonis, Reference Hart and Kritsonis2006).
Etty, a DID client with a history of childhood sexual abuse, became pregnant and needed prenatal examinations by an obstetrician (Van der Hart & Nijenhuis, Reference Van der Hart and Nijenhuis1999). These exams caused reactivation of her sexual trauma. To evade these reactivations, she developed a new ANP which was able to tolerate the physical examinations without any intrusion of traumatic memories. (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006, p. 75)
Controversies
Controversy abounds in that there is huge debate over whether complex PTSD warrants a separate diagnosis and if DID actually exists. Complex PTSD is characterized by problems of dissociation, loss of relational trust, affect regulation, somatic symptoms, self-destructive behaviour and abnormalities in sexual expression. The current controversy is whether it warrants a separate diagnosis and this issue will be revisited during the development of DSM-5 (Ford & Courtois, Reference Ford, Courtois, Courtois and Ford2009).
TSDP's basic position is that all individuals who are traumatized have a degree of structural dissociation which means that PTSD is essentially dissociative in nature and is not an anxiety disorder (Van der Hart et al. Reference Van der Hart, Nijenhuis and Solomon2010). There is not surprisingly widespread criticism of models that feature dissociative parts, including TSDP. In essence a number of authors believe, without citing empirical evidence, dissociative parts to be iatrogenic (Merskey, Reference Merskey1992), that is a suggestion that these dissociative parts have emerged as a response to inappropriate therapeutic pressures with the implication that if they do not receive attention or reinforcement, they will cease to exist. While commenting on some of the existing models of DID, Piper & Merskey (Reference Piper and Merskey2004) wrote a paper in which they concluded that the arguments used to support DID are illogical, and they also suggested that a reliable diagnosis of DID is impossible and unreliable.
There is some emerging tentative research that is attempting to prove the validity of TSDP and DID which extends beyond clinical evidence. Van der Hart et al. (Reference Van der Hart, Nijenhuis and Solomon2010) discuss an array of findings which they suggest is starting to build an evidence base for TSDP. This includes the studies of Reinders et al. (Reference Reinders, Nijenhuis, Paans, Korf, Willemsen and De Boer2003, Reference Reinders, Nijenhuis, Quak, Korf, Haaksma, Paans, Willemsen and De Boer2006) which suggest that ANPs and EPs engage separate neural networks when traumatic memories are activated, i.e. ANP does not perceive the trauma memory as a personal memory whereas EP does. The ANP relates to cortical areas whereas EP is associated with subcortical activity. The suggestion from Reinders et al. (Reference Reinders, Nijenhuis, Paans, Korf, Willemsen and De Boer2003, Reference Reinders, Nijenhuis, Quak, Korf, Haaksma, Paans, Willemsen and De Boer2006) is that ANP controls emotional reactions to traumatic memories, which is another way of saying that ANP fails to personify the trauma memory. However, it is important to recognize that TSDP will remain controversial for the foreseeable future.
Neurobiology of trauma
For a deeper understanding of some of the mechanisms underlying complex trauma it is essential to consider the neurobiology of trauma and the triune nature of the brain. Triune brain theory recognizes and distinguishes three levels and suggests the human brain is actually three brains in one. Each level has been established successively in response to evolutionary need. The primate or neocortex level consists of the thinking/rational, whereas the limbic level deals with feelings. Last, the reptilian level controls arousal and regulation. Each of the levels has separate functions but all three layers interact (Levine, Reference Levine2010).
In 1994, Van der Kolk published a seminal paper, ‘The body keeps the score’, in which he reviewed neurobiological research that suggested that trauma disrupts the stress-hormone system, the nervous system and stops people from processing and integrating trauma memories. In effect trauma memories remain unprocessed, specifically in the non-verbal, non-conscious, subcortical regions which are the amygdala, thalamus, hippocampus, hypothalamus and brain stem, where crucially they are not accessible to the frontal lobes, i.e. the rational, thinking parts of the brain. In other words it is our bodies not our minds that control how we respond to trauma. Van der Kolk (Reference Van der Kolk2002) suggests that psychological theories overemphasize the conscious, rational, cognitive aspects of trauma at the expense of omitting the body. However, caution is advised when making such claims which Fuchs (Reference Fuchs2009) describes as neurobiological reductionism. Van der Kolk's (Reference Van der Kolk1994) assertion is that people process trauma from the bottom-up body to mind, not top-down, mind to body. Somatic and emotional experiences may actually be stored in specific memory systems as proposed in Brewin and colleagues’ (Brewin et al. Reference Brewin, Dalgleish and Joseph1996; Brewin, Reference Brewin2001) dual representation theory. They posits that trauma memories are stored as situationally accessible memory (SAM) and that these memories have not been able to integrate into higher-order memory systems such as verbally accessible memory (VAM). These two memory systems operate in parallel but one can take precedence over the other in different circumstances. This theory also explains how survivors of complex trauma cannot make rational sense of traumatic memories because they are often stored as body memories which may be expressed somatically.
The role of the amygdala is highly significant in that it is a key component of recording painful memories, or what is sometimes referred to as emotion memories. An emotion memory, when triggered has the effect that the person experiences the feelings that they were experiencing at the time the memory was recorded (Stokes, Reference Stokes2009). These memories can last forever as shown by experiments from LeDoux (Reference LeDoux1998).
LeDoux (Reference LeDoux1998) in his seminal book, The Emotional Brain, describes a model that in effect explains two different paths of the amygdala. The so-called ‘low road’ is when external stimuli reaches the amygdala via the thalamus and the ‘high road’ includes the cortex. The low road or direct route is shorter and faster but cannot benefit from cortical processing and thus is fairly crude. This pathway serves an evolutionary purpose as people can respond to dangerous stimuli before they know what it is. Some stimuli are considered innate and are called unconditioned fear stimuli (Ruden, Reference Ruden2010). These stimuli being hardwired produce a fear response without conscious processing.
Much like Brewin and colleagues’ (Brewin et al. Reference Brewin, Dalgleish and Joseph1996; Brewin, Reference Brewin2001) dual representation theory, LeDoux (Reference LeDoux1998) explains how in traumatic events, both systems operate in parallel so that if exposed to stimuli that were present at the time of trauma, both systems will probably be reactivated. From the hippocampal system it is possible to remember facts about the trauma, whereas from the amygdala system, the stimuli will ensure tense muscles, increased heart rate, various hormones being released and various other bodily responses. This is another explanation for dissonance between ‘head’ and ‘heart’ responses or the rational vs. experiential system (Epstein, Reference Epstein1993).
Within the field of cognitive behavioural psychotherapy various multi-level or multi-representational theories have evolved to suggest that there are indeed, two routes to emotion, one that involves automatic cognitive appraisal and one involving a controlled cognitive appraisal. Briefly, the two models that are most influential are the Schematic Propositional Associative and Analogical Representational System (SPAARS) which was developed by Power & Dalgleish (Reference Power and Dalgleish1999) and the Interacting Cognitive Subsystems (ICS) developed by Teasdale & Barnard (Reference Teasdale and Barnard1993). The beauty of these models is that they can explain that emotions can be produced without conscious processing. The SPAARS model uses the associative system to explain this process whereas ICS describes an interlock between propositional and implicational systems (Grant et al. Reference Grant, Townend, Mills and Cockx2008).
The emerging field of the neurobiology of trauma has enhanced understanding of some of the mechanisms underlying complex traumatization. The implications of these findings would suggest the need to develop a therapeutic framework that incorporates a wide variety of interventions. Bottom-up, and top-down processing have shown the importance of an integrative approach, especially in view of the different systems that are operating, i.e. rational, emotional and sensory.
The treatment of structural dissociation
The main treatment interventions for DID and other dissociative disorders are typically phase-oriented as first proposed by Janet (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006; Courtois & Ford, Reference Courtois and Ford2009). In addition to the phase-oriented model there are some important principles of treatment that are essential to be adhered to. Steele & Van der Hart (Reference Steele, Van der Hart, Courtois and Ford2009) outline six key principles. First, the therapy is conducted in a way that the therapeutic relationship is enhanced, i.e. secure attachment and equally activation of defensive behaviour in the therapist is minimized. Second, the client is encouraged to stay in the window of tolerance and over time to gradually expand the tolerance level. Third, the client is encouraged to develop both external and internal safety, i.e. self-harm or an active punitive dissociative part. Fourth, the client is encouraged to improve their every-day functioning. Fifth, the client is encouraged to develop effective coping strategies so that maladaptive behaviours are transformed into adaptive ones. Last, interventions that enable the integration of traumatic memories and therefore help the client to reduce and eliminate their conditioned responses to trauma are selected. At all times the therapist aims for graduated exposure so as to minimize avoidance and dissociation.
Phase-oriented treatment of structural dissociation
There are three phases to the phase-oriented treatment of structural dissociation and in all phases, it is crucial to raise the integrative capacity of ANPs and EPs that may be intrusive or possibly interfering with the therapeutic process (Steele et al. Reference Steele, Van der Hart and Nijenhuis2005). All three phases must be conducted within a relational approach (Courtois & Ford, Reference Courtois and Ford2009).
The phases do involve periodic returning to earlier phases as a key component of the treatment is that clients must learn skills to tolerate strong affect, thoughts and sensations, rather than avoiding them. These small steps raise their integrative capacity (Howell, Reference Howell2005). It is crucial during treatment that the therapist is aware that they are dealing with a whole person and consequently direct interventions to the individual rather than the dissociative part that might be in executive control at the time (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009). However, sometimes it is not feasible to target the whole personality so the therapist can work with a part or parts (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006).
Phase 1: Symptom reduction and stabilization
Phase 1 involves overcoming the phobia of attachment and attachment loss, the phobia of trauma-related mental actions and the phobias of dissociative parts. Overcoming the phobia of attachment and attachment loss is crucial as it is suggested survivors have developed malevolent internal representations of attachment figures and self that can be categorized as dissociative parts of the personality (Howell, Reference Howell2005). This means that they have no ability to self-soothe or to tolerate strong affect. There is a fear that attachment will be painful so there is a confusing pattern of alternating between relational approach and avoidance (Liotti, Reference Liotti2006).
Overcoming the phobia of trauma-related mental actions involves helping survivors to personify emotions, thoughts, body sensations, memories, body needs and fantasies that they have avoided (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009). Therefore they need to be taught specific skills to help them moderate and contain overwhelming affect (Kluft & Fine, Reference Kluft and Fine1993). It is also in this phase that cognitive errors, i.e. if/then assumptions can be explored and challenged as long as the survivor can remain in the present and learn to be more mindful (Steele et al. Reference Steele, Van der Hart and Nijenhuis2005).
Overcoming the phobia of dissociative parts involves initially working with the ANPs and for the survivor to recognize and accept various parts and in particular those parts that are avoided. This is essential, especially with aggressive and persecutory parts as these remain engaged in the protective fight defensive subsystem. Persecutory EPs are not able to regulate their anger, pain, shame, and fear so they fight against fearful EPs in a way that a vicious cycle of fear and rage/internal punishment develops (Steele et al. Reference Steele, Van der Hart and Nijenhuis2005). The therapist needs to remain wary as premature engagement with these parts can result in increased dissociation, decompensation or leaving therapy (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009). When a survivor is able to maintain an awareness of ANPs and key EPs in the present, tolerate and regulate overwhelming affect, phase 2 can be started.
Phase 2: Treatment of traumatic memories
This phase that involves overcoming the phobia of traumatic memories is complex and full of potential pitfalls. If done well the therapist enables the survivor to synthesize and realize their traumatic memories so that they are shared among ANPs and EPs. Their memories then become transformed into symbolic verbal accounts that are personified and presentified (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006). The result of this process is that the survivor develops an autobiographical narrative memory of the trauma and in effect, the past is no longer the present. Presentification assures the survivor that the present can now be different in that while the present may be shaped by the past, it is not dictated by it.
The actual treatment of traumatic memory involves both guided synthesis and guided realization. Guided synthesis involves controlled exposure to the traumatic memory so that it is not experienced as overwhelming. The survivor is encouraged to remain in the present while exposed to the memory. Synthesis on its own is not enough in that it is critical that the memory becomes autobiographical so that the survivor realizes that the traumatic event happened to them. Guided realization helps the survivor to realize their history, to grieve for the losses and slowly move towards increased levels of personification and presentification (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006).
It is absolutely crucial that exposure to traumatic memories is not implemented before a capacity to modulate arousal is developed, otherwise the survivor risks being destabilized (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009). The therapist needs to be aware that not all dissociative parts will have access to particular traumatic memories, the implication being that the ability to tolerate a memory will vary among the dissociative parts. If during graded exposure to the memory arousal becomes too high, then the survivor may respond with further dissociation in an attempt to self-regulate (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009).
Phase 3: Integration and rehabilitation
The final phase begins when the majority of a survivor's traumatic memories have become autobiographical narratives. The survivor is encouraged to let go of unhelpful beliefs and behaviours, and to engage in the world with new coping skills. This phase can be just as difficult as the other phases as the survivor continues to grieve for cumulative losses due to the traumatic events and finds that life in the present continues to be difficult and painful (Steele et al. Reference Steele, Van der Hart and Nijenhuis2005).
The importance of staying within the window of tolerance at all stages cannot be underestimated as Ogden et al. (Reference Ogden, Minton and Pain2006) specify that survivors of trauma are prone to hyperarousal (too much activation) or hypoarousal (too little arousal) and often oscillate between these two extremes. Traumatic reminders then trigger these autonomic tendencies leaving clients at the mercy of dysregulated arousal. For the past to be past, it is suggested that traumatic experiences be processed in an optimal arousal zone. Between these two extremes of hyper- and hypoarousal is a zone known as the window of tolerance. Siegel (Reference Siegel1999) argues that clients work within this window of tolerance as information from internal and external environments can then be integrated. In this optimal arousal zone, cortical functioning is kept going, which allows and assures integrated top-down and bottom-up processing. As a client's integrative capacity increases so does the window of tolerance (Ogden et al. Reference Ogden, Minton and Pain2006).
Recommendations for CBT
Before listing some of the key principles of treating complex trauma it should be noted that there is a major difficulty in that complex trauma or complex PTSD (C-PTSD) is not as yet, a condition that is formally acknowledged in the mental health field. It is suggested that classifying this disorder would lead to treatments that are informed by current scientific and clinical knowledge bases (Herman, Reference Herman1992; Ford & Courtois, Reference Ford, Courtois, Courtois and Ford2009; Van der Kolk, Reference Van der Kolk2009).
Currently CBT has a long history of using prolonged exposure (PE) for the successful treatment of PTSD but its efficacy has not been tested for clients with complex structural dissociation (Steele & Van der Hart, Reference Steele, Van der Hart, Courtois and Ford2009). PE helps clients repair, organize and elaborate a fragmented or partial trauma narrative (Foa & Rauch, Reference Foa and Rauch2004). There are problems with PE in that there are several studies that have a high percentage of drop-out rates, with rates ranging from 34% to 46% (L. S. Katz, unpublished data). Van der Kolk et al. (Reference Van der Kolk, McFarlane and Weisaeth1999) also suggest that adults who were abused as children may react adversely to PE and that it is instead essential to focus on self-regulatory deficits. Other CBT interventions for the treatment of dissociation include grounding strategies, use of metaphors, and imagery reprocessing and re-scripting therapy (IRRT).
For the treatment of DID and other dissociative disorders the most well known CBT intervention is the Tactical-Integration model which has a foundational blueprint which is a modified cognitive therapy module (Fine, Reference Fine1999, Reference Fine and Luber2009). In this model attention is given to cognitive-affective distortions and dysfunctional schemas that help to maintain false beliefs about reality as it is now. This model attempts to restructure the thinking of various personalities so that lengthy cognitive restructuring is implemented with various alters. The cognitive restructuring involves the alters noticing the connection between how they think and how they feel. This part of the process, and there are other aspects to the model, is similar to the cognitive restructuring programme for treating PTSD developed by Mueser et al. (Reference Mueser, Rosenberg and Rosenberg2009).
Eye Movement Desensitization and Reprocessing (EMDR) has also been used to treat DID and there are many protocols now available (Beere, Reference Beere and Luber2009; Luber, Reference Luber2009; Paulsen, Reference Paulsen and Luber2009). EMDR correlates with the triune nature of the brain (neocortex, limbic, reptilian) and therefore fits working with complex trauma. Briefly, Shapiro's Adaptive Information Processing model hypothesizes that a neurobiologically based information processing system attempts to transform disturbing events into narrative memories so that the past is no longer present (Forgash & Copeley, Reference Forgash and Copeley2008). EMDR makes it easier to ‘dose’ the moment a patient experiences intense affect which helps avoid extreme physiological arousal that often accompanies full-blown prolonged exposure (Van der Kolk et al. Reference Van der Kolk, McFarlane and Weisaeth1999).
Herbert (Reference Herbert, Corrigall, Payne and Wilkinson2006) notes the limitations of traditional CBT for the treatment of complex trauma, and especially cautions that clinicians do not treat all types of trauma in the same manner or re-traumatization may occur. She is also in agreement with the view that cognitions are only part of the picture, in that complex trauma clients have information confined to their sensory motor and limbic systems that is disconnected from their rational systems.
Van der Kolk et al. (Reference Van der Kolk, McFarlane and Weisaeth1999) states that it is critical that survivors of trauma learn to understand the meaning of their physical sensations. The ability to name and tolerate sensations, feelings and experiences enables a person to own these experiences, or personify them as Van der Hart et al. (Reference Van der Hart, Nijenhuis and Steele2006) suggests. Van der Kolk et al. (Reference Van der Kolk, McFarlane and Weisaeth1999) is adamant that these skills need to be in place before the treatments aimed at tackling traumatic memories are implemented, otherwise they are likely to resort to pathological self-soothing behaviours, i.e. binge eating, self-harm, or substance abuse. It becomes critical to label and process these somatic experiences. This leads to an important element of trauma therapy which is the creation of narratives. Creating a trauma narrative enables a survivor to gain emotional distance from the trauma and to observe from a variety of analytical vantage points.
Another essential skill that is useful for those who have trauma-related disorders is mindfulness. Trauma survivors use a wide variety of avoidant behaviours and are unable to be mindful or present. This results in attempts to suppress intrusive thoughts, to remove themselves from situations that trigger strong affect, substance abuse and emotional numbing. This is the antithesis of mindful behaviour. Follette et al. (Reference Follette, Palm and Pearson2006) suggest this inability to remain in the present without engaging in avoidance could be regarded as a skills deficit and that the inclusion of mindfulness skills for the treatment of trauma may be beneficial. Linehan (Reference Linehan1993) has integrated mindfulness into her Dialectical Behaviour Therapy (DBT) so that clients can learn to tolerate distress and intense emotional affect. Mindfulness skills may help a client to increasingly focus on the present rather than be stuck in the past or fear for the future.
An examination of the literature has revealed key principles in the treatment of complex trauma. First, they occur within a secure therapeutic relationship where it is essential that the client stays in the window of tolerance and then slowly expands the tolerance level over time. Second, the aim when treating traumatic memories is to use graduated exposure so as to minimize avoidance and dissociative reactions (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006). This is crucial as currently CBT relies heavily on PE for the treatment of trauma memories. Using PE for complex trauma could lead to re-traumatization and would mean that the conditioned fear response is not extinguished.
Third, it is recommended that CBT adopts the phase-oriented model for the treatment of complex trauma. Integration is a major treatment goal, so it is critical to raise the integrative capacity of dissociative parts. Therefore the therapist must at times work with a part or parts of the personality and recognize that this can result in increased dissociation. The client must learn skills to tolerate strong affect, thoughts and sensations. Part of this process is personification which helps the client take ownership of their experiences in order that presentification can then occur. Once this has occurred memories become autobiographical and the past is no longer the present.
Discussion and conclusions
Contemporary neuroscience is helping to lead the way as it becomes apparent that treatment needs to involve learning how to modulate arousal, learning to tolerate strong affect and sensations. The evolving field of the neurobiology of trauma has demonstrated that when the brain is under threat, the area responsible for executive functioning goes offline so that trauma survivors lose touch with a sense of time and the knowledge that sensations have a beginning, middle and end. Consequently they remain stuck in a terrifying, seemingly never-ending present where they cope by shutting down, adopting a dealing but not feeling mode (Van der Kolk et al. Reference Van der Kolk, McFarlane and Weisaeth1999). It is suggested by the author that it is essential that CBT integrates the latest neurological research that highlights how the brain responds in trauma and then target and develop new interventions accordingly. Ideally this would take place within a phase-oriented model with the recognition of the importance of structural dividedness.
The implications and following recommendations are based on the assumption that cognitive therapy in particular overemphasizes the role of cognition and that top-down vs. bottom-up processing is now being reflected in various new models. Le Doux's (Reference LeDoux1998) model of two different paths to the amygdala; Brewin and colleagues’ (Brewin et al. Reference Brewin, Dalgleish and Joseph1996; Brewin, Reference Brewin2001) dual representation theory; Epstein's (Reference Epstein1993) cognitive experiential self theory; SPAARS (1999); ICS (Teasdale & Barnard, Reference Teasdale and Barnard1993) and Herbert's (Reference Herbert, Corrigall, Payne and Wilkinson2006) integrated three-systems model all infer two routes to emotion. These models explain how clinically it is often the case that a client will remark that they know one thing but they cannot feel it. There is a dissonance between their head and heart or rational vs. experiential (Epstein, Reference Epstein1993).
Last, it is clear that the debate over what constitutes dissociation will continue. TSDP offers a radically different model with structural dividedness at its heart. If TSDP is accepted, some symptoms that are currently defined as dissociative, i.e. a lowering of consciousness will no longer be seen as part of a continuum model of dissociation. PTSD would also need to be re-categorized as a dissociative disorder rather than an anxiety disorder. In terms of treatment, TSDP would help cognitive behaviour therapists to understand the complexities and subtle nuances of dissociative disorders and the principles that apply not just to the less commonly seen DIDs. It is the author's assertion that TSDP, neurological research, and the multi-level theories from within CBT also start to explain why sometimes cognitive therapy (CT), and specifically cognitive restructuring, seldom works for this client group. TSDP also recognizes the critical role of the body in treating trauma (Van der Hart et al. Reference Van der Hart, Nijenhuis and Steele2006) and perhaps it is time for CBT to integrate this more fully into its theoretical framework. The importance of helping people to listen to the unspoken voice of their own bodies and for them to feel emotions that helped them to survive without being overwhelmed by them cannot be understated (Levine, Reference Levine2010).
Acknowledgements
I thank and acknowledge Onno van der Hart for his helpful feedback on an earlier draft of this paper and also the reviewers in the development and revision of this paper. I also acknowledge Claudia Herbert of the Oxford Development Centre, and Michael Townend and Jill Schofield of the University of Derby.
Declaration of Interest
None.
Learning objectives
• To explore whether dissociation is simply an alteration of consciousness or a structural division of the personality.
• An overview of the TSDP and the neurobiology of trauma.
• Provide a detailed analysis of the treatment of structural dissociation leading to recommendations for CBT.
• To highlight the importance of emotions without conscious processing.
Comments
No Comments have been published for this article.