Sunday, February 22, 2009

Theories of Dissociative Personalities

The experts at The International Society for the Study of Trauma and Dissociation (ISSTD) are currently saying that we are not born with a discrete Self. Instead, a sense of self is an achievement over time as we acquire a self with a continuous sense of identity across a variety of contexts. They will tell you that this process, if allowed to develop normally, will bring the child to a state of acquired selfhood by about age five. If this process is interrupted significantly through chronic trauma, then the child is likely to develop a dissociative disorder. The most extreme case of such a dissociative disorder is Dissociative Identity Disorder (DID), formerly called Multiple Personality Disorder (MPD).

The most widely known developer of this theory is Frank Putnam, author of the 1997 book, Dissociation in Children and Adolescents. Putnam, anchors his theory in the writing and research of developmental theorists Wolff, Emde, Harmon, Prechtl and others. Putnam’s theory is biologically based. He says we are born with five “discrete behavioral states,” and add another at about the age of three months. These states are I: regular, non-REM sleep; II: “irregular or REM sleep;” III: “alert inactivity;” IV: “fussy;” V: “crying;” and VI: “alert activity.” Over time the child develops additional discrete behavioral states, but this development is too difficult to follow after about the age of one year. Putnam suggests that these states and the switches between them in infancy are the same sorts of states and switches as are found in the manic and depressive states of bipolar disorder, in the panic and normal moods of panic disorder and the alter personalities of DID.

I agree with some of what the experts have to say, and disagree with other things. We must always pay attention to the experts and give them their due. It is unfortunate, however, that the experts in this situation do not have certain missing, and crucial data. The experts dismiss without serious consideration the normal multiplicity (i.e., normal dissociation) about which much of this Blog is written. Consequently, they can never achieve an adequate theory of either Self or dissociation. Dissociatively normal persons are quite capable of accessing the normal subpersonalities that make up the total personality of the person. Normal persons are naturally multiple. The subpersonalities of normal persons are quite like the alter personalities of DID; and the states of consciousness found in panic, mania, and depression are carried by the subpersonalities of otherwise dissociatively normal persons. Further, when an individual accesses her or his internal parts, or subpersonalities, she or he maintains a sense of self, a sense that when separated from the parts with strong feelings, represents the Self. Until the experts examine more closely the work of John and Helen Watkins, Richard C. Schwartz, and others who write about this multiplicity they will always fall short of adequate theories of dissociation and Self.

Tuesday, February 17, 2009

Dissociation: Normal and Abnormal

Over the last several weeks I have sketched the internal worlds of both dissociatively normal and dissociatively abnormal persons. If you have read these posts you will have seen very little difference between the normal and the abnormal. Technically, when comparing whole inner systems, abnormal dissociation is present when subpersonalities act autonomously and take executive control of the body and then, when they give up that control and the primary self is once again in control, there is amnesia for what happened during the executive control by the other subpersonalities.

What is surprising to most people is that normals have an internal world so similar to dissociatively abnormal persons. There are part-selves, or, subpersonalities, that are sometimes named and sometimes not. They have their own discrete set of memories that may overlap with the memory sets of other part-selves, but nevertheless remain discrete as a totality. These part-selves generally have a sense of their own self representation (that is, their image of themselves), but sometimes these self representations are minimal. They have a sense of self and a desire to continue their existence. In all of these ways they are like the subpersonalities of people diagnosed with Multiple Personality Disorder.

Part of the problem with doing Parts Psychology is that we grow up with the idea that if we have parts of ourselves, or we hear voices, or have imaginary internal friends, then we are mentally ill. Introducing ourselves to the multiplicity within ourselves is a fairly simple task. It does not require hypnosis. All it takes is a willingness to explore ourselves in a new way. One simple technique that will produce an image of a part-self is to do the following: think of the person in your life who most irritates you. Notice the feeling of anger or irritation you feel when you think of that person. Maybe you can feel that irritation or anger in a part of your body, such as a tightness in your chest or a knot in your stomach. Then simply focus your attention on the emotion and direct your thoughts toward it, saying something like, "Let me you see you please; give me an image of you in my mind." In better than 50 percent of cases this simple exercise will give you an image of the irritated or angry part of yourself. You will discover that like all normals your mind is made of multiple part-selves.

Sunday, February 8, 2009

MPD/DID Treatment Episode

An example of a treatment episode for Multiple Personality Disorder (Dissociative Identity Disorder).

Alice is a 55-year-old married woman with two grown children. She fits the diagnosis for Dissociative Identity Disorder/Multiple Personality Disorder. Her relationships with her husband and children are currently not supportive. Each of them wants things from her which she cannot provide. In addition to these stresses she and her husband are currently experiencing significant financial stress. When the continued buildup of familial and environmental stresses did not abate Alice went away "inside" for about three weeks. Bettina, a previously unknown alter, possibly newly created, took executive control. Alice's husband named the new alter, "Bettina." When I met Bettina she had been in control for most of the last two weeks. She presents as a strong adult manager who is not troubled by Alice's family problems nor her work issues. She finds Alice's low-paying job a breeze.

During the week preceding my meeting with Bettina, Candace, a powerful 8-year-old alter took executive control and began looking for her mother. She asked the husband where her mother was. The husband, although he knew Candace, did not know that Candace viewed Alice as her mother. He told Candace that her mother was dead, meaning that Alice's mother was dead. Candace was shocked "inside" where she 'hid" in her room playing with dolls and repeatedly asserted to herself that her mother was not dead. All of this information was provided by Bettina. By the end of the session we had agreed that we wanted to assure Candace that Alice was alive, and, perhaps, to facilitate a conversation between them. We also agreed that it would be a good idea to bring Alice back into executive control. When we ended the session I was comfortable that Bettina would do well in handling things until our next visit.
At our next meeting Diana, rather than Bettina, was in executive control. I had worked with Diana previously, but felt there was much more to do. She was the part of Alice who carried most of her depression. She was also the part who physically hurt Alice because she believed Alice was so weak. She was cooperative in our session and reported that Candace was now consoled. Bettina had arranged for two teenaged caretaker parts to reveal to Candace that Alice was not dead. They even managed to broker a short internal conversation between Candace and Alice. As a result, Candace, and the larger system, were no longer in pain.

The question now was how to bring Alice back into executive control. Alice is universally recognized as the Self by inside alters and outside family members. Diana revealed that Alice was stuck in the memory of an event from seven years ago in which she was threatened with rape. Although Diana and Bettina had both described Alice as having withdrawn into a bedroom setting in which she was looked after by the two teenage caretakers, the problem memory placed her on an outdoor bench where she sat shaken and overwhelmed with fear. I asked Diana to work with me in resolving Alice's current crisis through unburdening the powerful emotions that kept her trapped in reliving the traumatic memory. (Unburdening is a technique developed by Richard C. Schwartz in his "Internal Family Systems" model).

At first Diana objected, shocked that I would ask her to help since she was the one who had specialized in self harm. With a surprised face and tone of voice she asked "You want me to help? I'm the one who cut and burned her!" After some coaxing Diana agreed to allow me to guide her. I asked her to locate Alice on the bench where she sat in her trauma memory, and to speak to her with my words or to allow her to hear my voice as I suggested a powerful wind was blowing over, around, and through Alice, "carrying away her fear and other negative emotions, particle by particle, like grains of sand or dust." The intervention, with short repetitions, lasted no more than five minutes. At the end of the session Diana reported with a smile and a glowing face that Alice was fine now. When Diana left she was repeating aloud as she patted her chest, "She loves me! She loves me!" It was clearly new information that Alice loved her. The following week Alice was back for our next session.

Sunday, February 1, 2009

Normal Subpersonalities not MPD

In this blog I present a sketch of the internal world of a dissociatively normal person, in contrast to the patient diagnosed with Multiple Personality Disorder who I described in two previous posts. The point I want to make is that there is little difference in the ways the internal worlds are organized. The difference between them lies in the fact that with Multiple Personality Disorder, the individual subpersonalities sometimes take full executive control of the body and act according to their own agendas, and the person does not remember what happened during the interlude. That is not the case with those of us who are dissociatively normal. The internal world I describe below only became known through intentional separation of parts in therapy so that we could work with them. They do not take executive control of the body.

Rosalind is a 50 year old, divorced professional and mother of two children, now grown. Her score on the DES, a widely used test of dissociation, was only 5.4, low average when compared to the norm of 10.0. She originally came to therapy for help with a public speaking phobia and sexual issues. She identifies seven subpersonalities. Four are adults, two are teenagers, and one is a child. The child is Rosita, presenting as nine years old. She first appeared in Rosalind's life at around age three in the context of punishment for bedwetting. She began to have an important impact on Rosalind's life in the second grade following an incident when a teacher refused to permit her to go to the restroom, and then, while required to read aloud in front of her class, she peed her pants. This experience laid the foundation for the adult phobia of public speaking.

Rosa, a part who presents as age 19, first appeared in the context of carrying the pain of physical punishment by her father which lasted from early childhood through age 13. She is linked somehow to Rosita as the self-state who has experienced the difficulty with public speaking throughout Rosalind's life. She skipped her high school graduation so she wouldn't have to give the valedictorian address; she took college classes that would not require oral presentations, and she changed career goals twice in college to avoid public speaking. Rosa has been the dominant player in the unfolding of Rosalind's life, experiencing all the roles of wife, mother and professional. Not surprisingly, perhaps, she related to her husband as the good father she lacked while growing up.

The other parts have had important roles in Rosalind's adult functioning and all have an impact on the expression of her sexuality. Roseanne is a teenager part who serves as the adventurous explorer and uninhibited sex partner. Maryann, who presents as age 45, the age when Rosalind got her divorce, is the part who falls in love and lust with men. Rose presents as the same age 50 as Rosalind and is committed to conventional marriage, motherhood, and family. She is the caretaker when family and friends are in need of assistance. She enjoys her sexuality only in the context of a socially recognized, conventionally legitimate relationship. Sandy, who also presents as age 50, is a submissive sexual part who is drawn to abusive males. Finally, there is Sylvia, in her 30s, who functions to protect Rosalind through the suppression of sexual feelings. She especially doesn't like submissive Sandy.

At the time when we first spoke with each of them, most parts knew who Rosalind was and said she was "me," "an older me," or something similar. Parts did not have names prior to differentiation in therapy. They chose names for themselves during initial interviews, generally Rosalind's childhood nicknames. Sandy, the needy and sexually submissive part is the only one who made a point of insisting that her name was not Rosalind and neither was she. Sylvia didn't have a name nor a desire for one. We called her by a descriptive label, but I gave her a name when writing about her. I will say more about normal subpersonalities in another post. For now I merely want to illustrate that the internal worlds of dissociatively normal people are quite similar in structure to the dissociative worlds of those diagnosed with Multiple Personality disorder.