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Structure with Engagement: Toward anIntegration of Trauma and RelationalPsychoanalytic Models in the Treatmentof Dissociative DisordersHeather B. MacIntosh aa School of Social Work, McGill University, Montreal, Quebec, CanadaVersion of record first published: 27 Mar 2013.

To cite this article: Heather B. MacIntosh (2013): Structure with Engagement: Toward an Integrationof Trauma and Relational Psychoanalytic Models in the Treatment of Dissociative Disorders,Psychoanalytic Social Work, 20:1, 26-49

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Psychoanalytic Social Work, 20:26–49, 2013Copyright © Taylor & Francis Group, LLCISSN: 1522-8878 print / 1522-9033 onlineDOI: 10.1080/15228878.2012.749798

Structure with Engagement: Towardan Integration of Trauma and RelationalPsychoanalytic Models in the Treatment

of Dissociative Disorders

HEATHER B. MACINTOSHSchool of Social Work, McGill University, Montreal, Quebec, Canada

Trauma model approaches to the treatment of dissociative disor-ders may provide containment and direction and yet, these sameapproaches may be constricting and limit exploration. However,relational psychoanalytic approaches may allow for engagementand exploration while potentially failing to provide containmentand structure. This article provides an overview of key elementsof both models and considers the question of whether it is possi-ble to creatively resolve theoretical and clinical tensions betweentrauma model and relational psychoanalytic responses to dissocia-tion. A review of the history of the study of dissociation in the fieldof psychoanalysis and concerns about psychoanalytic practice inthe context of dissociation is followed by comparing contrastingconceptualizations of the assumptions of normality, definitions ofdissociation, theories of etiology, goals of treatment, and theorizedmechanisms of action. The review ends with a discussion of poten-tial possibilities for clinical integration.

KEYWORDS trauma, dissociation, dissociative identity disorder,psychoanalysis, relational psychoanalysis

INTRODUCTION

Empathic immersion with a tortured soul bearing a divided mind can be ter-rifying, dissociating, traumatizing, and disorienting for any therapist. Traumamodel approaches may provide containment for the distressing experience

Address correspondence to Heather B. MacIntosh, PhD, Assistant Professor, McGill Uni-versity School of Social Work, 3506 University Street, Room 300, Montreal, Quebec, H3A 2A7.E-mail: heather.macintosh@mcgill.ca

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Structure with Engagement 27

of proximity to these horrors and yet, these same approaches may also beconstricting and limit the exploration to within the margins of what is be-lieved to be known. However, relational psychoanalytic approaches mayallow for engagement and exploration while potentially failing to providecontainment and structure for the patient and may leave the analyst at timesperhaps longing for the containment of prescribed techniques. The objectiveof this article is to provide an overview of key elements of both modelswith the goal of understanding their key similarities and differences. Fromthere I examine the question of whether it is possible to creatively resolvetheoretical and clinical tensions between the technique-driven orientation ofthe trauma model and the expansive relational psychoanalytic responses todissociation.

HISTORY OF THE STUDY OF DISSOCIATION

Our Common Ancestors

“Psychoanalysis was founded upon the defeat of dissociation” (Whitmer,2001, p. 810). Freud and Breuer initially integrated and engaged with Janet’stheory of pathological dissociation where dissociation was seen as a defensethat was both a constitutional predisposition and a response to trauma. How-ever, Freud eventually abandoned the concept of dissociation in responseto external traumas, such as childhood sexual abuse, as an explanation forhysteria. This led to the development of his theory of neurosis where theinternal trauma of infantile wishes, fantasies, and Oedipal desires becamethe explanatory force (Davies & Frawley, 1994; Everest, 1999; Kluft, 2000).This represented a shift from identifying the source of disorder as beingexternal (trauma such as childhood sexual abuse) to internal (intrapsychicconflict). A number of authors would argue that this change in direction ledto a “legacy of mistrust and misunderstanding” (Davies & Frawley, 1992a,p. 8) between psychoanalysts and traumatologists and fostered the divisionin the study of psychopathology that is the focus of this exploration (Davies& Frawley, 1992b; Kluft, 1992; Loewenstein & Ross, 1992).

The psychoanalytic study of dissociation was not completely extin-guished by Freud’s dismissal of this concept. A group of diverse psycho-analytic theorists including Ferenczi, Jung, Balint, Rappaport, Sullivan, Gill,Brenman, Fairbairn, Bion, and Kohut continued to explore the role of dissoci-ation in psychological functioning and in the therapeutic process (Bromberg,2009; Davies & Frawley, 1992b; Everest, 1999; Loewenstein & Ross, 1992).Ferenczi explored the impact of the trauma of sexual abuse and dissociationon the process of psychoanalysis. His articulation of dissociation as a norma-tive aspect of human mental life, and its importance in the protection of themind in the face of trauma, foreshadows current thinking. His commitmentto the study of dissociation contributed to ruptures in his relationship with

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Freud (Davies & Frawley, 1992a). Jung, following his split with Freud, alsostudied dissociation, which he considered to be a normal phenomenon inpsychic life. In Sullivan’s development of interpersonal psychoanalysis heemphasized dissociation, and not repression, as a primary defense in re-sponse to traumatic events. He then articulated that these traumas remainunsymbolized, not hidden or repressed. These ideas laid the foundation forthe current emphasis of dissociation and trauma in the relational psychoan-alytic literature (Hirsch, 1997; Stern, 2004). From this foundation a relationalmodel of the mind has been built, one that emphasizes development in thecontext of early relationships with caregivers, and articulates the impact of achild’s need to maintain attachments at all costs (Schwartz, 1994).

The Divide

In spite of the work of this small group of analysts, the contemporary traumamodel of dissociation and traumatic stress evolved from the work of Janet,our common ancestor, with little psychoanalytic participation. While sev-eral psychoanalysts have contributed to the study of dissociation in thepast 20 years, this concept continued to exist primarily outside of the ana-lytic mainstream, and very little communication occurred across the traumamodel-psychoanalysis divide (Kluft, 2000). The field of trauma studies andthe world of psychoanalysis have remained essentially separate save for afew brave envoys navigating the spaces between bifurcated theories. In fact,the reintroduction of the concepts of dissociation and the devastating impactof childhood abuse into the psychoanalytic literature was met with contro-versy and conflict (Davies & Frawley, 1992a). This controversy continues insome corners of the literature, including those who continue to argue that itis fantasy and not trauma that leads to pathological dissociation. In addition,there are also those who argue that the dissociative disorder diagnoses arenot valid diagnostic entities.1

As a therapist, my training began within the trauma model, where themind of the dissociated patient was seen as fragmented and the work in-volved seeking out those divides and mapping out the structure within.Structural models have been built on a foundation of cognitive neuroscience,trauma research, and psychotherapy process studies. This perspective pro-vides clear, concrete, linear, and active techniques and offers guidance to aclinician attempting to work with patients whose internal worlds are chaoticand terrifying. However, working within a trauma-focused treatment center,I also found myself feeling constrained by structural models and fearful ofhow I was participating in what felt like the imposition of structure, albeiton a chaotic, unstructured mind. On the one hand, I felt contained by theprocess of piecing apart, mapping out, and coming to delineate an internalsystem; a predictable, linear process. On the other hand, I worried that by

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Structure with Engagement 29

engaging in this process I was, unwittingly, reifying internalized divides andconcretizing dissociative structures. Kluft (2000) assures critics of this modelwho share this fear that this does not occur and that, in fact, these approachesspeed up the process of integration. The focus is on structure and not onempathically engaging with the chaos and terror of my patient’s inner expe-rience and the mutative power of our moment-by-moment engagement witheach other. The making of these maps and models did appear to settle downoverwhelmed patients, but over and over again I witnessed them developless rather than more flexibility in their minds as a result. While patients werebecoming more functional, they were also becoming less internally flexible.Integration was elusive.

It was from this place of concern about the rigidity of working within thismodel that I turned to the analytic literature. It was my goal to broaden mytheoretical and clinical repertoire for working with dissociation and trauma.However, I found myself feeling more confused and disoriented as I at-tempted to integrate two approaches that, at times, appeared incompatible.

COMPARISON OF TRAUMA MODEL AND RELATIONALPSYCHOANALYTIC MODELS OF DISSOCIATION

Why is a comparison and discussion of integration important?

CONTEXT

Twenty years ago in the epilogue of one of the first psychoanalytic foraysinto discussing a psychoanalytic approach to dissociative disorders, authorsRoss and Loewenstein said,

Multiple personality and psychoanalysis are facing each other again aftera century. Are they destined to be incompatible and remain separate?We hope not. Can a rapprochement be achieved which might enrichour understanding of dissociative phenomena and mental functioning ingeneral? (Ross & Loewenstein, 1992, p. 172)

Kluft (2000), one of the pioneers of the trauma model who himself isa psychoanalyst, has called for psychoanalysis to be more integrative. Hedescribed the relationship between psychoanalysis and the study of disso-ciation and dissociative disorders as a “long, if uneasy, uncomfortable andoften mutually avoidant relationship” (Kluft, 2000, p. 259). In fact, many ofthe early pioneers of the trauma model of clinical practice were psychoana-lysts who, facing the challenges that an incomplete and inadequate psycho-analytic clinical theory presented, sought out knowledge from beyond theirown frontiers and became leaders in the trauma field. However, I know ofvery few traumatologists who have crossed the floor to the world of psy-choanalysis. Schwartz (1994), in discussing the divide between traumatology

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and psychoanalysis, accuses trauma model theorists of committing the samecognitive errors as the dissociated patients—exclusion, dissociation, andpolarization—and suggests that trauma models focus almost exclusively ontechnique without integrating potentially rich analytic perspectives. In thesame vein, Davies and Frawley (1992a) suggest that with Freud’s doubtthat sexual abuse could account for the distress of his patients, the field ofpsychoanalysis “cast aside” (p. 9) the potential to integrate a vast body ofknowledge on the prevalence, nature, and process of the impact of sex-ual abuse and trauma, and set the trajectory for the neglect of this area ofdiscourse for many years.

Over the past 20 years relational psychoanalysis has moved beyond therepudiation of dissociation and has begun to envision a new model of disso-ciation theory and practice. A number of psychoanalysts have attempted tointegrate aspects of traumatology into their work and have begun to publishtheir findings (Kluft, 2000; Lyon, 1992; Schwartz, 1994). Perhaps as relationalpsychoanalysis reclaims an understanding of trauma and dissociation, a newdialogue can enrich both sides of the divide and even begin to dissolvethe barriers that tend to dissociate the worlds of traumatology from that ofpsychoanalysis.

CONCERNS ABOUT PSYCHOANALYTIC APPROACHES TO DISSOCIATION

Three consistent concerns arise from a reading of the psychoanalytic lit-erature on working with dissociation. These include concerns about thetendency to pathologize patients who are not understood within the con-text of their dissociative response to their traumatic experiences, the useof interpretation, and taking a passive or neutral stance with dissociativepatients.

Patients with dissociative disorders rarely admit their dissociation, evento long-term therapists, unless they are asked directly about dissociativesymptoms and structures (Loewenstein & Ross, 1992). Reasons for this in-clude shame, a fear of labeling, an assumption that everyone experiencestheir mental life the way that they do, and amnesia for lost time. The vastmajority of patients do not present with dramatic displays of switching andreports of amnestic breaks from life, but rather are secretive and filled withshame (Kluft, 1992). Historically, unidentified dissociative patients mighthave been labeled resistant or borderline when psychoanalytic treatmentfailed or stalled, pathologizing the patient for the failure of the treatment.If such patients are not assessed for dissociation their symptoms may beoverlooked, resulting in treatment failures and the painful experience of apatient who is unable to regulate his or her overwhelming distress, in atherapeutic relationship with an analyst who is unable to identify the sourceof the patient’s (Bromberg, 2003a,b; Kluft, 1992; Loewenstein & Ross, 1992).

Those who seek to work psychoanalytically with dissociative patientsconsistently identify the use of interpretation as problematic. Kluft (2000)

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Structure with Engagement 31

indicates that in his extensive clinical and research experience with dis-sociative patients not only is the use of interpretation unlikely to resolvedissociative barriers but also patients are reported to experience a therapist’suse of interpretation negatively. Patients may experience interpretations asattacking, unempathic, and hurtful, as a sign that the therapist does not wantto know them or their experience, and reinforcing their belief that the thera-pist is only interested in having a relationship with their adult self (Bromberg,1994; Davies & Frawley, 1992b; Everest, 1999).

The third area of concern about a psychoanalytic approach to disso-ciation is related to assuming a neutral or passive stance in the treatmentof patients with dissociative disorders. While many psychoanalytic patientsmay benefit from a therapeutic environment where they enter into a spacewith an analyst who is open to exploring wherever they may go, the disso-ciative patient may become lost in the emptiness of silence. Not only mayan analyst miss the presence of severe dissociation if he or she relies upona passive, emergent stance, but also patients may feel lost, condemned, andconfirmed in their belief of their damaged status. The analyst’s silence willonly confirm the patient’s belief that his or her emotional and psychic isola-tion is warranted; his or her self-states may feel lost and uninvited into therelationship, not knowing how to begin to engage (Bromberg, 2006b; Davies& Frawley, 1992b; Everest, 1999; Gedo, 2000a,b; Loewenstein & Ross, 1992).These concerns call into question some of the core tenets of a psychoanalyticstance and suggest the need for alternatives and new ways of thinking aboutwhat psychoanalysis is and how we approach its practice with dissociativepatients.

Assumptions of the Normal Personality

A beginning point in a comparison of trauma models and psychoanalytictheories of dissociation must be the way normal personality is understood.These concepts will underpin theories of etiology and development, andframe treatment goals and models of therapeutic action. The trauma and dis-sociation literature is vast. A full review of this literature is beyond the scopeof this article, and would not likely progress the goal of providing a syn-thesized and clearly articulated overview of the tenets of the trauma model.In the process of making comparisons a certain reductionism is necessary,which does render the study somewhat rigid and dichotomous: the verything we are trying to avoid in enriching and broadening our understanding.It is important to bear this in mind as we explore these ideas.

TRAUMA MODEL

While there are certainly dissenting views and alternative theories, thereis also an established consensus within the trauma field. The International

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Society for the Study of Trauma and Dissociation (ISSTD) has recently pub-lished the third revision of the “Guidelines for Treating Dissociative IdentityDisorder in Adults” (ISSTD, 2011). This document represents the consensusof the leading experts in the field of traumatology regarding the etiology,assessment, and treatment of dissociative disorders.

Most adherents of the trauma model espouse the definition of nor-mal personality, that a normal personality is exemplified by an “enduringpattern of perceiving, relating to, and thinking about the environment andthemselves” (American Psychiatric Association, 2000, p. 686). This defini-tion, based upon the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), is based upon the assumption of a unitary mind and a unitaryconsciousness (American Psychiatric Association, 2000). Dissociative iden-tity disorder (DID) is viewed as a developmental psychopathology in whichvaried self-states emerge as a result of failure of developmentally normativeintegration, in response to trauma (ISSTD, 2011). This view presumes thatnormal personality development is exemplified by the development of a uni-tary sense of self and consciousness, out of the differentiated and isolatedself-representations in the minds of infants and young children (Carlson,Yates, & Sroufe, 2009, pp. 42–44).

RELATIONAL PSYCHOANALYTIC MODEL

Relational psychoanalysts’ theories of normal personality are based upon amodel of multiple selves, a nonlinear dynamic model of personality devel-opment (Mitchell, 1993). This model understands that personality begins asa constellation of selves shifting and changing over time, as does the traumamodel. However, in relational psychoanalytic theory this multiple state con-tinues. The multiple self-states are not isolated or exiled from one another,thus the model allows for intrapsychic conflict and resolution. Self-statesmay each contain a dominant affect or particular sense of self, and as thesestates shift and change they may have more or less continuous access to oneanother at different moments in time (Bromberg, 2001, 2006b). As a childdevelops within the context of a mutually regulating attachment relationship,the multiplicity of self-states grows into a feeling of coherence, where theperson is able to shift between self-states without losing a sense of continuityor cohesiveness (Bromberg, 1994, 2006a, 2009).

COMPARISON

The trauma model views the mind and the personality as normatively devel-oping toward unitary consciousness of self, while the relational psychoan-alytic model (developed primarily by Bromberg) views the normative per-sonality as one in which multiple selves coexist in a fluid constellation ofstates.

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Structure with Engagement 33

Defining Dissociation

TRAUMA MODEL

The trauma model consistently defines dissociation relative to the DSM-IV-TR(American Psychiatric Association, 2000). This understanding of dissociationfocuses on the DSM-IV’s concept of disruption of normal integration, andis defined as the failure to integrate information and self-attributions, andas alterations of consciousness characterized by a sense of detachment fromthe self and/or the environment. Dissociation is understood to be both asymptom (such as depersonalization or derealization), and a structural orga-nization of self-states. Some suggest that the term dissociation be limited tothe structural impact of trauma on the developing self, while others arguethat the term should include both the symptoms and structures of dissoci-ation (Bowman, 2011; Brown, 2011; Dell, 2011; Nijenhuis & van der Hart,2011).

PSYCHOANALYTIC MODEL

Until very recently the term dissociation was not included in psychoanalyticdictionaries. The Comprehensive Dictionary of Psychoanalysis (Akhtar, 2009)defined dissociation as “a defensive mental mechanism originally describedby Pierre Janet (1889), who used the term dissociation interchangeably withdisaggregation” (Akhtar, 2009, p. 82). Among analytic theorists, there ap-pears to be a lack of consensus as to what the term dissociation shouldmean. As the term is more generally used, it is difficult to discern whetherauthors are referring to similar concepts and clinical manifestations of trau-matic responses in their patients (Gullestad, 2005). There is some agreementin the literature that both the symptomatic and the structural aspects of adissociative response to trauma arise when normative mental capacity be-comes overwhelmed. Severity of trauma is related not to the content of theevent, but rather to the degree to which a person is unable to hold or con-tain the experience—without being overwhelmed by unintegratable affect(Bromberg, 2003a). Dissociation, then, is a form of creative adaptation whereconnections between states of self are decoupled by overwhelming affect.These states become rigidly divided and mutually incompatible, so that eachstate is able to maintain its role without being hampered by awareness ofthe others. The inner system of rules impairs the exchange of informationacross the mind (Bromberg, 2003a,b; Davies, 2006; Kluft, 1992).

COMPARISON

One aspect of the divide between the trauma model and psychoanalytic ap-proaches to the study of dissociation is the use of diagnostic terms and thelanguage of psychopathology. While the trauma model uses this languageas a means of professional communication, it emphasizes the adaptive role

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that dissociation plays in protecting the minds of those who seek to hidefrom their horrifying traumas. At the same time, this approach sets the tonefor a study of trauma and dissociation focused on disorder. On the otherside of the divide, while the lack of pathologizing and diagnostic languagemay seem refreshing, and encourages an understanding of the uniqueness ofeach patient’s experience, a common language would be helpful for profes-sional communication and for building an integrated psychoanalytic theoryof trauma and dissociation. When reading the psychoanalytic literature, it isoften unclear whether theorists are talking about the same thing when theyuse the term dissociation.

Both models emphasize the adaptive nature of the dissociative responseto trauma. Similarly, both models recognize the developmental aspects ofpersonality development and the impact of trauma upon the structure of themind. The trauma model appears to have gained greater consistency andconsensus in the use of the term dissociation, and while its language may bepathologizing and diagnostic, traumatologists use common definitions acrossthe literature, which allows for important comparisons and discussions withinthe field. Psychoanalysis does not yet appear to have a strong consensuallyagreed-upon definition of dissociation and dissociative response. It is difficultthen to compare and contrast the work of divergent writers within the field.

Understanding Etiology of Dissociative Disorders and DID

TRAUMA MODEL

Within the trauma model, the etiology of dissociative disorders and DIDis understood within a neuroscience and developmental perspective. TheISSTD posits that dissociative disorders develop when the personality fails tointegrate normally, as a result of severe and protracted trauma. In addition, itemphasizes that trauma within attachment relationships during critical peri-ods of development may lead to the development of separate self-states witha first-person perspective. The ISSTD further specifies that these disordersdo not arise in individuals who are already mature and have a stable unifiedpersonality (ISSTD, 2011).

In this model, neurobiological explanations account for failures in in-tegration. For example, high concentrations of stress-induced neurochemi-cals reduce the activity of brain regions related to execution of integrativemental actions including the hippocampus and prefrontal cortex; therefore,research participants with post-traumatic stress disorder (PTSD) are found tohave reduced hippocampal volume. Of course, the literature is replete withdiscussions as to whether this represents a consequence of the neurotoxiceffect of stress hormones or a predisposing factor for the development ofPTSD (Nijenhuis, van der Hart, & Steele, 2010). Findings from the vast neu-robiological research in PTSD find that traumatic experiences are encoded as

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Structure with Engagement 35

more or less complex sensorimotor and affective experiences, which remainrelatively unintegrated, and thus unavailable for the normal information pro-cessing that leads to episodic memory (van der Kolk, Hopper, & Osterman,2001).

The well-established Structural Dissociation Model (Nijenhuis et al.,2010) explains the etiology of dissociative disorders in relation to defensivesystems that result from evolution: severe threat may provoke a structuraldissociation of what the authors call the premorbid personality. This disso-ciation takes place between defensive systems required for survival and asystem that is involved in daily life, the emotional personality (EP) and theapparently normal personality (ANP). Thus the EP is stuck reexperiencingthe traumatic experience—which fails to become a narrative memory of thetrauma—while the ANP performs avoidance of the traumatic memories andengages in the matters of daily life (van der Hart, Nijenhuis, & Steele, 2005).

Nijenhuis et. al. (2010) explain further that when traumatic memoriesare activated, access to many other memories becomes obstructed. There-fore, when an EP that holds a specific traumatic memory is activated, thepatient loses access to a range of memories normally readily available tothe ANP. EPs are theorized to be organized around specific defensive re-sponses to danger, including fight, flight, and freeze responses. While theANP may possess some cognitive knowledge about the trauma and thatthe EP exists, said knowledge remains noetic while memories remain ina disconnected semantic form, lacking any kind of first-person quality. Thesystem of dissociative structuralization of the personality becomes reinforcedthrough classical conditioning, as the ANP becomes phobically avoidant ofthe traumatic memories held by the EP. Eventually the EP becomes theconditioned stimulus for the unconditioned stimulus of the involuntary andaversive traumatic memories. The ANP, having learned these associations,will try to avoid or escape from the conditioned stimulus, the EP. Thus pho-bia of traumatic memory maintains the structural dissociation of the ANPand EPs (Nijenhuis et al., 2010). This is not just a defensive barrier againstknowing, but a structural one.

RELATIONAL PSYCHOANALYTIC MODEL

Psychoanalytic explanations for the etiology of severe dissociation are lesscohesive than those of the trauma model. This likely reflects the early stageof development of this area of inquiry. While the literature is less cohesive,the neuroscientific literature is often referenced for explanatory purposes.Bromberg (2003b) references the work of neuroscientists and posits the ap-plication of an animal model to the human response to severe trauma. Thismammalian evolutionary response leads to a failure of cognitive modulatingsystems in response to life-threatening attacks. Bromberg argues that for hu-mans in the context of severe psychological trauma, the loss of a coherent,

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cohesive self and attachment relationships is life threatening. The need toprotect and sustain the self surpasses all else (Bromberg, 2009). In definingthis mammalian response, Bromberg turns to many of the same neuroscien-tific studies of trauma as the traumatologists. He also references the impact ofhigh levels of psychological stress in deactivating the hippocampus, leadingto traumatic experiences becoming stored as sensory and somatic traces thatcan return as physical symptoms or flashbacks without cognitive meaning(Bromberg, 2003b).

Gedo (2000b) writes of the important adaptive defensive purpose ofdissociation, fulfilling the traumatized person’s need to “not know” (Gedo,2000b, p. 195). When the defense of dissociation fulfills its function, it maybecome a central organizing principle of psychic operations, constantly pro-tecting against the recurrence of trauma (Bromberg, 2006a). As long as thereis a constant watch for future traumatic repetitions, little psychic life is avail-able for the development of the personality. As a result, the mind becomesan insulated constellation of discrete and concrete self-states, living in thetraumatic moment of the affects and sensations held within them. Brombergevocatively writes of the “thought without a thinker” (Bromberg, 2001, p.386) as each self-state lives a lonely life of dissociated isolation and nopart of the self holds more than one piece of the puzzle of their existence(Bromberg, 1994, 2001, 2006a).

COMPARISON

Both the trauma model and the preliminary psychoanalytic understandingof the etiology of dissociative disorders reference the burgeoning neuro-science and trauma literature. In fact, there is significant overlap betweenthe two models, in the research cited, in spite of differences in how thesefindings are interpreted. As we explore more deeply the explanations thetwo theories provide for the same phenomena, their roots begin to show.Trauma model explanations are structural, concrete, linear, and derived frominterpretations of behavioral principles and neuroscience that support theirstructuralization of the dissociative experience. Meanwhile, psychoanalyticexplanations remain nonlinear, phenomenological, and utilize the principlesof neuroscience to support their nonlinear dynamic model of etiology.

Goal of Treatment

TRAUMA MODEL

The goal of treatment for DID is identified by the ISSTD as integrative func-tioning (ISSTD, 2011). This is seen to be achieved when the dissociativebarriers between self-states have dissolved, and the patient is able to ex-perience his or her self as one unified entity (Kluft, 1999). Traumatologistsidentify final fusion or unification—the existence of a unified consciousness

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Structure with Engagement 37

and personality—as the ideal and most stable outcome of treatment, whileadmitting that this is not possible in all cases. Alternately, negotiated co-consciousness and cooperation between self-states is seen as a less stablebut also desired outcome. If unification is achieved, the goals of ongoingtreatment include the integration of residual dissociated ways of thinkingand experiencing (ISSTD, 2011).

RELATIONAL PSYCHOANALYTIC MODEL

Integrative functioning is also identified as an important goal in the relationalpsychoanalytic work with dissociative patients. Because these analytic theo-rists do not use diagnostic language, it can be difficult to know whether thedissociative phenomena treated by these analytic writers is, in fact, compara-ble to DID and other dissociative disorders. However, this integration is notdefined in the same way as the integration espoused in the trauma model. Asmay be inferred from the assumption of normal personality held by psycho-analytic theorists, an analytically derived integration forms the basis for thecapacity to “feel like one self while being many” (Bromberg, 1993, p. 166).Through the therapeutic relationship, the patient develops the capacity tohold more than one idea in mind at the same time, to fluidly move betweenself-states that cease to be isolated, to tolerate knowing symbolically andemotionally all of one’s own life story and traumas, to reflect upon one’sown mind and self, and to be able to feel internal conflict between self-states without dissociation—all facets of the overarching goal of integration(Bromberg, 2001, 2006b, 2009; Whitmer, 2001).

COMPARISON

While both models espouse integration as a goal in the treatment of disso-ciative patients, the understanding of that integration diverges significantly.Trauma models focus on dissolving dissociative structure, while psycho-analytic models seek to shift rigidity and concreteness in the divides be-tween multiple self-states (that are assumed to be normal in themselves),to assist the patient to develop the capacities for self-reflection and affectregulation.

Mechanism of Action and Process of Change

TRAUMA MODEL

While many opposing views and conflicting positions have been histori-cally articulated within the field of trauma research, significant consensushas emerged on how to treat dissociative disorders. The current guidelines(ISSTD, 2011) present structured, clear, and concise guidance to clini-cians working with patients with dissociative disorders; little is left to the

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imagination. This treatment process is based upon a linear framework thatemphasizes safety, containment, clarity, predictability, and technique.

Treatment frame. The ISSTD and leading researchers in the field pro-mote stage-oriented treatment models for DID and other complex traumaand dissociative disorders (ISSTD, 2011; Kluft, 1999; Lebowitz, Harvey, &Herman, 1993; Steele, van der Hart, & Nijenhuis, 2005).

Stage one includes establishing safety for the patient, promotingstabilization, and encouraging symptom reduction. Processing of traumaticmemories is held off during this initial stage, until the patient can tolerate theemotional tasks of the treatment without compromising his or her personalsafety. It is essential that all self-states make a commitment to behavesafely, refraining from self-harm and suicidality. A number of specific goalsare integrated into this stage; the specific tasks may include mapping thesystem, building trust and safety within the therapeutic alliance, encouraginginternal communication and acknowledgment among self-states, gatheringpatient history, as well as building affective tolerance, and regulation in thepatient (ISSTD, 2011; Kluft, 1999; Loewenstein & Ross, 1992).

Stage two focuses on confronting, working through, and integrating trau-matic memories. The primary tasks in this stage involve remembering, toler-ating, processing, and integrating traumatic memories that had been lost inthe battle for psychic survival. Within this second stage fragmented and disso-ciated elements of traumatic memories are integrated into a comprehensibleand coherent narrative through repeatedly re-accessing and re-associatingthem. This is painful work for the patient and necessitates experiencing andexploring grief, loss, and pain for all that was done to them and, often morepoignantly, all that was not done for them.

Stage three includes integration and rehabilitation, where further gainsin internal cooperation, coordinated functioning, and unification of self-statesare made. Patients are guided in developing a more stable and solid sense ofself. Therapy begins to address social, vocational, and emotional challengesthat are normative with many processes at later stages.

Mechanism of information transfer and dissolution of dissociative barri-ers. Through the development of an internal narrative between self-states,learning how to listen to each other and communicate with the therapist,dissociative barriers begin to dissolve and semantic and somatic memories,feelings, and personality traits that were once rigidly dissociated and di-vided slowly become more available to one another. Amnestic barriers breakdown; information about the self, and lived experiences, become shared bythe whole person. Traumatologists posit that as traumatic experiences areintegrated between self-states the self-states may experience themselves asless separate. Hypnosis is often used to facilitate fusions between self-states,when the separateness no longer serves any meaningful function and thepatient is no longer invested in maintaining the separateness (ISSTD, 2011;Kluft, 2000).

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Techniques. The trauma model provides clear, prescriptive techniqueswith which to approach this challenging work. Guidelines assist the clinicianin helping patients to map the self-state system, to develop affect regulationcapacities and grounding skills, to facilitate work between and within self-states, and to stabilize the system by responding to the needs of protectiveself-states. Direct work is recommended with the self-states in the personalitysystem. The self-states will, in a divided way, describe the structure, conflicts,and coping mechanisms available to the patient. Kluft (2006) argues that, un-less the therapist works directly with self-states, the psychotherapy processwill fail. In fact, he indicates, contrary to the concern that direct parts workwill reify and concretize the self-states, that this process facilitates and expe-dites the dissolution of the sense of separateness (Kluft, 2000). He suggestseliciting self-states by asking to speak to them, inviting other parts that wouldlike to communicate to speak or communicate within the system, suggestingthat whatever is heard inside the head be communicated if it is safe to do so,and acknowledging the patient’s felt experience of separateness while sug-gesting the gradual thinning of boundaries toward an eventual integration.

Hypnosis is suggested to relieve anxiety, to create a safe place for self-states that feel threatened, to explore the self-state system, to contain affect,to control the abreactive process, and to facilitate integration. Other recom-mended techniques include group therapy, creative therapies, and the use ofEye Movement Desensitization and Reprogramming (EMDR) by specificallytrained clinicians (ISSTD, 2011; Kluft, 1999).

RELATIONAL PSYCHOANALYTIC MODEL

This is a literature still early in its development. Only a few theorists arefocusing their attention on the psychoanalytic approach to treating DID anddissociative disorders. These authors do not suggest a linear model of stagesand steps, although they certainly emphasize the importance of the treatmentframe and the safety of the patient. Bromberg (2006a, p. 131) suggests that itis necessary to envision therapeutic action in terms of a nonlinear relationalmind. Compared to the trauma model, the process of relational psychoanal-ysis is more emergent: nonlinear, unpredictable, unstructured, and dynamic.

Treatment frame. While stages and steps are not articulated in thepsychoanalytic approach to treating dissociative patients, safety and con-tainment are emphasized as important elements early in treatment, alongwith the importance of building affect regulatory capacities in traumatizedpatients.

The therapeutic relationship comprises one of the most important ele-ments in ensuring the safety of the process. Saakvitne (2000) conceptualizesDID as a disorder of attachment, and emphasizes that a core element oftherapeutic work is the conscious development of a secure attachment inthe therapeutic relationship, through carefully navigating the echoes of the

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past in the present relationship. She highlights the importance of holding therealities of separation and loss in mind throughout the therapeutic process,so that each session is seen as an opportunity for “reconnection, connectionand separation” (Saakvitne, 2000, p. 253) in an effort to assist traumatizedpatients in developing object constancy. Bromberg (2006b) argues that trau-matized and dissociative patients struggle with trust in relationships and theirown capacity to heal in a relational context, and that it is this challenge whichleads to challenging patient behaviors. “The experience of trust in the conti-nuity of human relatedness must be restored as part of the analytic process”(Bromberg, 2006b, p. 893).

The therapeutic relationship must include all parts of the patient’s self.This process of relationship building may be slow, as the therapist comes todiscover the different parts of a patient and begins to build a relationship.Each self-state will have its own sense of reality, its own needs, and itsown particular attitudes toward the therapy and therapist. These must berespected (Bromberg, 2006b). Paying more attention to some parts, avoidingthose parts that the therapist would prefer to ignore, or failing to recognizeand validate the divergent needs of different self-states, may communicateto the patient a lack of acceptance, attachment, and welcome to their wholepersonality (Bromberg, 2003a, 2006a; Davies & Frawley, 1992b). It is notclear whether the development of connections with the patient’s self-statesoccurs simply as self-states emerge into the treatment frame, or whetheranalysts elicit the participation of unknown or silent self-states. This is notclearly articulated in the literature.

A successful treatment process also requires attention to emotionalsafety. The challenging material requires of the therapist an empathic stance,attending to the patient’s need to balance emotional engagement with therisk of emotional dysregulation and flooding. The patient’s capacity for af-fect regulation and ability to engage in intersubjective relating are to developthrough the attunement of the therapist, and the relational negotiation of af-fective engagement in this new attachment context (Briere, 2006; Bromberg,2006a, p. 134).

Mechanism of information transfer and dissolution of dissociative barri-ers. An adequate theory of therapeutic action, in the context of dissociativedisorders, must articulate how the treatment process will facilitate the sharingof affects, memories, and aspects of the self that are divided and dissociateda priori, and how dissociative barriers will begin to become more fluid andmove toward dissolution. Navigating enactment and working with dreamsare identified by relational psychoanalysts as key mechanisms in this processof change.

Enactment. As early as the 1990s, relational psychoanalysts began dis-cussing the role of enactment in the process of change in severely dissocia-tive patients. Writers discussed the externalization of the patient’s internalexperience in the form of enactment, and began explicating a theory of

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therapeutic action focusing on working within enactments (Bromberg, 2001;Davies, 2006; Schwartz, 1994). In working with a dissociated patient, enact-ment is described as a natural means of communication. There is a consensusamong analytic writers in the field of trauma and dissociation that enactmentis a primary route of access to the dissociated experiences of the traumatizedself-states, for analyst and patient alike. Where processing of symbolic in-formation occurs at the level of language, affect, body sensations, emotionalschemas, and other dissociated aspects of self are processed subsymboli-cally (Bucci, 2011). Traumatic experiences and their associated sensory andaffective content remain unsymbolized and dissociatively unavailable to theanalytic process. These dissociated experiences are referred to as unformu-lated experiences by Stern (2004). Unsymbolized experiences can only bebrought into symbolic existence through the “dyadic dissociative process” ofenactment (Bromberg, 2006a, p. 136). Thus, the enactment is a behavioralexpression of the aspects of self and experience that are unavailable forself-reflection and verbal exploration (Bromberg, 2006a, 2009; Stern, 2004).

In the context of an enactment, repetition of past experience occurswhile the patient’s historically related affective response is activated. Theenactment struggle between patient and analyst paints the patient’s internalobject world into the therapeutic relationship. This enacted space betweenthe analyst and patient lacks intersubjectivity, as the patient engages trau-matic rigid assumptions of repetition and inevitable irreparability of the re-lationship, while the analyst, caught in his or her own dissociated moment,places the locus of the problem in the patient. However, the mutative im-pact of an enactment rests upon something new, surprising, and differentoccurring within the analytic relationship. This something new allows for thedevelopment of a new co-constructed experience (Bromberg, 2001, 2003a;2006a; Davies, 2006; Stern, 2004).

The process of change does not, however, end with the shifting ofenactment into a new experience, but rather with the achievement of thecapacity for the experience of internal conflict (Bromberg, 2006a, p. 136).Stern (2004) indicates that during an enactment there is no awareness ofconflict; in fact, absence of conflict is the essential quality of an enactment.Conflict that cannot be experienced within one mind is held between two,where both participants are stuck with a rigid and concrete experience of theother. Enacted experience becomes less frozen in dissociated space: throughthe mutative effect of the analyst’s efforts at creating a new and differentexperience, the patient becomes more able to use language to describe hisor her own experience and becomes aware of the full range of his or herown mind within his or her own mind. No longer must these aspects ofself-experience be held in or by the analyst. From this space, new narrativesof the self, greater intersubjective relatedness, and capacity for intrapsychicconflict emerge. The patient can hold more than one experience of his or herself in his or her own mind at the same time (Bromberg, 2006a; Stern, 2004).

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To be fully engaged in an enactment requires that the analyst also enterinto the dissociative field. Stern (2003) speaks of analysts’ vulnerabilities thatpredispose them to dissociating with their patient, involving something oftheir own story. With this vulnerability an analyst must willingly share in theconsciousness with the patient, who requires of the analyst that he or shehold unacknowledged states of mind and participate in the gradual bringingof these states into awareness (Bromberg, 2003b, 2006a). As the analyst holdsand responds to these disavowed states, the analyst begins to experience thepatient as more integrated and whole in his or her own mind and the patientcan gradually begin to inhabit this self.

Working with dreams. “When a patient brings in a dream, the analytictask is to enable him to bring in the dreamer” (Bromberg, 2003b, 2006a).Dreams represent another way to bridge dissociative divides in traumatizedpatients, and allow for the voices and experiences of other self-states to bebrought into the analytic space. It is recommended that clinicians invite theirpatients to enter the dream freely. Rather than share the narrative of thedream, they are encouraged actively to daydream a reliving of the dream,to draw the analytic dyad into a relational enactment. As the analyst en-gages and responds to all aspects of the dreamer, greater understanding andknowledge of all of the patient’s self-states will emerge (Bromberg, 2006a).

In summary, this model posits that, within a safe and contained treat-ment frame and therapeutic relationship, the analytic dyad will navigate thedissociated experiences and states of both analyst and patient through enact-ments and the exploration of dreams, to create in the patient the capacity forintersubjective relating and intrapsychic conflict. Without these capacities,analytic inquiry will end up focusing on the very limited and concretizedaspects of the self that the patient is able to verbalize and represent cogni-tively. Without the capacity to experience and tolerate intrapsychic conflict,traditional analytic strategies such as interpretation not only will fail but willpotentially be re-traumatizing.

COMPARISON

The first question that comes to mind in attempting to draw any compar-isons between models which have grown more and more divergent over thecourse of this review is, are we talking about the same phenomena? While thedecreased use of pathologizing DSM language opens up the space for cre-ative exploration of ideas, it makes it difficult to really know if these analyticauthors are writing about dissociative structuralization at the level of suchsevere forms as DID, or whether they are discussing levels of fragmentationthat are less severe.

In spite of the beautiful prose and clearly articulated case descriptionsin the literature of relational psychoanalysis, this reader is left with a reactionsimilar to one when a brilliant magician performs a mind-boggling trick;how’d he do that? There is no how-to manual available. On the other hand,

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the trauma model comes with a fully articulated treatment manual, and yethas left this author feeling as though she was engaged in a technique-driven,concretizing, and reifying process that did not shift dissociative barriers orallow for the emergence of new relational experiences and capacities.

PULLING IT TOGETHER

Regardless of the model from which a therapist originates, working withpatients who have experienced severe, prolonged, and often vicious abuseis challenging. These challenges require that therapists of any model worktoward creating a safe therapeutic environment; not only for the patient butalso for the therapist (Bromberg, 2003b). Trauma models are clearly defined,providing structure and guidance on the specifics of how to do the therapy.These models offer a safe space of containment for therapists, who neednot lose their footing away from the dry ground of technique and structure.Relational models, meanwhile, allow for flexibility, surprise, and a depthof affective engagement in the therapeutic relationship that may be deeplyhealing to both patient and analyst. Entering into the process, however,requires the therapist to engage with dissociated experience and to navigatethe stormy undertow of the therapist’s own vulnerabilities; the dry land oftechnique and structure is far away. Is there a way to manage the tensionsbetween these two worlds, where one may provide refuge against dangerousundertow and the other offers a voyage into the depths of engagement withthe experiential worlds of our patients?

Pearlman (2001) articulates treatment guidelines that quietly integratepsychoanalytic sensibility for treatment of Dissociative Identity Disorder in-formed by the trauma model while more recently Howell (2011) has writtena volume of treatment guidelines for DID that appear to integrate her exten-sive training in both psychoanalysis and trauma model interventions. Theseauthors are not explicit in their attempts at integration. A small group ofanalytic authors have written about the need for more active psychother-apeutic interventions in the treatment of patients with severe trauma anddissociation. Some of these went so far as to suggest that while grounding ina theoretical orientation is a valid space to begin, analysts must utilize theirown empathic engagement with their patients to make decisions about howto approach treatment with any given patient based on his or her particularneeds and vulnerabilities (Howell, 2011).

When examining possible considerations for analysts working with dis-sociative patients, potential problem areas include the development of a safeand contained treatment frame, issues related to assessment, and specificconcerns about the analytic approach to treatment.

In developing a safe and contained treatment frame, clinicians mustconsider the emotional demands of this work on their own well-being aswell as their clients’. Understanding your own dissociative vulnerabilities,

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and seeking support in working through traumatic events in your own life,is essential for this work to be successful and safe. The emotional impactof working with clients with dissociative symptoms and structures is muchmore challenging than with non-traumatized patients. Therefore, it is essen-tial that the treatment frame be clearly delineated and articulated (Bromberg,2001; Gedo, 2000b; Loewenstein & Ross, 1992). This allows both patient andanalyst to understand and know limits and have clear expectations aboutwhat will and will not comprise the therapeutic relationship. Creating a safecontaining space for a traumatized patient may, at times, require negoti-ated adaptations to the treatment frame such as double sessions, additionalsessions, and extratherapeutic contact with the analyst (Davies & Frawley,1992b). Assessing for the presence of dissociative symptoms and structuresis a practice that all analysts should incorporate into their therapeutic work.Shame, fear of labeling, the assumption that dissociation is normal, and am-nesia may all interfere with a patient’s readiness to bring these parts of hisor her self into the therapeutic milieu (Chefetz, 2000).

There is strong consensus among the writers in this limited literaturethat a passive or neutral stance from the therapist may be ineffective at bestand re-traumatizing at worst. Evocative questioning, not leaving patients inlong spaces of silence, physical contact if required to bring the patient backto the present in the case of severe flashback or to stop him or her fromengaging in self-injury in sessions, active eliciting of all parts of the patient’sself, evocative responding, and affective containment in the context of emo-tional distress, are some of the suggestions provided by writers seekingto work analytically with dissociated patients. Interestingly, those providingcase studies to illustrate an integrative approach described the inclusion oftechniques and strategies from the trauma model, but did not speculate onthe impact these inclusions might have on the analytic process (Chefetz,2000; Kluft, 2000). This is an area for ongoing exploration.

A model of the dissolution of dissociative structures through the nav-igation of enactment articulates a method of bringing dissociative states,memories, affects, and expectations into the therapeutic process. However,it does not address how to work with self-states that emerge directly withinthe therapeutic setting. An analyst may find it helpful to explore the rolesand needs of self-states, to refer to them by name if they are named, not toplay favorites or neglect parts of the patient that are difficult for the analyst,to help patients to build a dialogue in their inner world, to negotiate withself-states that are interfering with treatment or the patient’s safety, and tobe a part of the negotiation and relationship-building process in the innerworld of the patient (Davies & Frawley, 1992b; Dutra, Bianchi, Siegel, &Lyons-Ruth, 2009; Everest, 1999; Gedo, 2000b; Howell, 2011; Kluft, 2000,2006; Lyon, 1992; Rothschild, 2009).

In pulling these two models of treatment together, the analyst maydraw from trauma model techniques earlier in the treatment when affect

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dysregulation, safety, and traumatic memory processing needs to be clear,contained, and direct. This technique-driven work allows for processing oftrauma memories and developing skills in affect regulation and self-capacitiesthat may obfuscate a patient’s capacity to engage in any psychoanalytic work.At later stages of treatment, opening up into the expanses of relational psy-choanalytic possibilities of working with dreams and engaging dissociatedaspects of self through enactments may allow for building trust in the selfand another and building new relationships inside of a divided mind. Thesemodels may be flexibly held and balanced based on the needs of the pa-tient at any given moment. As the analyst and patient build a new kind ofrelationship—a safe, boundaried, healing relationship—the need to returnto the safe base of technique may diminish as the therapeutic dyad buildssafety in the vast pool of potential analytic exploration.

CONCLUSION

Structural trauma models and relational psychoanalytic models of workingwith severely traumatized and dissociative patients share certain importantqualities: a desire for the patient to be safe, a goal of increased communi-cation and decreased dissociation within the mind, an interest in assistingpatients in processing traumatic memories and experiences, and a belief inthe powerful healing potential inherent in the therapeutic process. Thesetheories diverge in their understanding of the normal personality, goals oftreatment, and of how exactly the previously dissociated memories and self-states evolve toward sharing information, become fluid, and gradually losetheir discrete and isolated qualities.

Psychoanalytic theorists and clinicians working with severely trauma-tized and dissociative patients appear to be in consensus that modificationsto the therapeutic frame and approach to the therapeutic process are im-portant for the success of the therapy. Maintaining safety in the process andtherapeutic relationship, assessing for the presence of dissociative symptomsand structures, avoiding the use of interpretation early in the therapeuticprocess, and taking an active stance, drawing techniques and strategies fromthe trauma model, have been identified as potentially viable approaches.

NOTE

1. For a full discussion of these controversies, please see Gleaves, May, and Cardena, 2001, andDalenberg et al., 2012.

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